Implementation of a Web-Based Tool for Shared Decision-making in Lung Cancer Screening: Mixed Methods Quality Improvement Evaluation

BackgroundLung cancer risk and life expectancy vary substantially across patients eligible for low-dose computed tomography lung cancer screening (LCS), which has important consequences for optimizing LCS decisions for different patients. To account for this heterogeneity during decision-making, web-based decision support tools are needed to enable quick calculations and streamline the process of obtaining individualized information that more accurately informs patient-clinician LCS discussions. We created DecisionPrecision, a clinician-facing web-based decision support tool, to help tailor the LCS discussion to a patient’s individualized lung cancer risk and estimated net benefit. ObjectiveThe objective of our study is to test two strategies for implementing DecisionPrecision in primary care at eight Veterans Affairs medical centers: a quality improvement (QI) training approach and academic detailing (AD). MethodsPhase 1 comprised a multisite, cluster randomized trial comparing the effectiveness of standard implementation (adding a link to DecisionPrecision in the electronic health record vs standard implementation plus the Learn, Engage, Act, and Process [LEAP] QI training program). The primary outcome measure was the use of DecisionPrecision at each site before versus after LEAP QI training. The second phase of the study examined the potential effectiveness of AD as an implementation strategy for DecisionPrecision at all 8 medical centers. Outcomes were assessed by comparing absolute tool use before and after AD visits and conducting semistructured interviews with a subset of primary care physicians (PCPs) following the AD visits. ResultsPhase 1 findings showed that sites that participated in the LEAP QI training program used DecisionPrecision significantly more often than the standard implementation sites (tool used 190.3, SD 174.8 times on average over 6 months at LEAP sites vs 3.5 SD 3.7 at standard sites; P<.001). However, this finding was confounded by the lack of screening coordinators at standard implementation sites. In phase 2, there was no difference in the 6-month tool use between before and after AD (95% CI −5.06 to 6.40; P=.82). Follow-up interviews with PCPs indicated that the AD strategy increased provider awareness and appreciation for the benefits of the tool. However, other priorities and limited time prevented PCPs from using them during routine clinical visits. ConclusionsThe phase 1 findings did not provide conclusive evidence of the benefit of a QI training approach for implementing a decision support tool for LCS among PCPs. In addition, phase 2 findings showed that our light-touch, single-visit AD strategy did not increase tool use. To enable tool use by PCPs, prediction-based tools must be fully automated and integrated into electronic health records, thereby helping providers personalize LCS discussions among their many competing demands. PCPs also need more time to engage in shared decision-making discussions with their patients. Trial RegistrationClinicalTrials.gov NCT02765412; https://clinicaltrials.gov/ct2/show/NCT0276541

Natural Resources Research Institute Technical Report

The potential to develop a viable crayfish industry in Minnesota currently exists. Crayfish biomass in our inland lakes can greatly exceed that of fishes; existing harvest techniques appear to have very little impact on the year-to-year crayfish population. Thus, Minnesota's crayfish appear to be an abundant and resilient resource. There are markets for soft and hard shell crayfish for food, soft and hard shell crayfish for bait, and peeled tail meat. A Minnesota crayfish product could currently be inserted in any of these markets, but crayfish as a bait appears to be the most attractive market. There is a very high seasonal demand for bait crayfish and the wholesale prices can be in the range of $15 to$25 per lb for soft shells. In addition to bait markets, large hard shell crayfish for food have a strong international export market, but this market requires that sufficient quantities be shipped at the right times. Also, there is local interest in peeled tail meat for retail sale. We examined four widely distributed Orconectes species (O. virilis, O. propinquus, O. rusticus, O. immunis) to assess commercial soft shell production potential. Crayfish were held in production-sized shallow trays with 2 cm of water at constant temperature similar to that used for commercial soft shell production. Molting success was examined as a function of capture date, sex, and stage of maturity. The timing of life cycle events dictates to a large extent the availability and soft shell production potential of wild caught crayfish, particularly in northern latitudes where market-sized crayfish are often nonjuveniles. Adults typically molt two to three times per growing season, associated with reproductive cycles. Molting rate in the laboratory was highest when crayfish were captured just prior to the wild molt. The first molt of the season was much more synchronous than the second molt. Molt timing varied by sex. Premolt Orconectid crayfish did not change color like Procambarus sp. but could be identified by the decalcification of the cheliped merus. The harvest of several species may be required to optimize soft shell production since synchronous molts occur at different times for different species. Our economic assessment of the crayfish food market suggests that it is relatively flat. This is due to: continued high production costs (including the lack of a proven tail meat separator); regional consumption (primarily in the south-central and Pacific states); unsophisticated packaging and marketing; and seasonally available supply. Crayfish are used in much of the Midwest for fishing bait. Since it is illegal to sell live crayfish for bait in Minnesota, markets in other states will have to be targeted. Problems to overcome include reducing mortality of crayfish shipped to out-of-state markets and drops in sales when crayfish are available closer to the markets. We have analyzed the economic feasibility of food and bait soft shell crayfish production facilities using flow-through and recirculating systems for the first two years of operation. Bait crayfish production in a recirculating system appeared to be the most profitable operation and food crayfish production in a flow-through system appeared to be the least profitable operation. The processing of large quantities of crayfish for a commercial tail meat operation in Minnesota requires that an inexpensive, automated system be developed in order to maintain the product's economic viability. We have evaluated the necessary engineering design components for developing a relatively inexpensive automated crayfish processing system, which could be linked to extant tail meat extruders. We feel that such a system is feasible, and could cost less than $15,000 retail

The Effects of Interlocking a Universal Hip Cementless Stem on Implant Subsidence and Mechanical Properties of Cadaveric Canine Femora

OBJECTIVE: To determine if an interlocking bolt would limit subsidence of the biological fixation universal hip (BFX(®)) femoral stem under cyclic loading and enhance construct stiffness, yield, and failure properties. STUDY DESIGN: Ex vivo biomechanical study. ANIMALS: Cadaveric canine femora (10 pairs). METHODS: Paired femora implanted with a traditional stem or an interlocking stem (constructs) were cyclically loaded at walk, trot, and gallop loads while implant and bone motions were captured using kinematic markers and high‐speed video. Constructs were then loaded to failure to evaluate failure mechanical properties. RESULTS: Implant subsidence was greater (P = .037) for the traditional implant (4.19 mm) than the interlocking implant (0.78 mm) only after gallop cyclic loading, and cumulatively after walk, trot, and gallop cyclic loads (5.20 mm vs. 1.28 mm, P = .038). Yield and failure loads were greater (P = .029 and .002, respectively) for the interlocking stem construct (1155 N and 2337 N) than the traditional stem construct (816 N and 1405 N). Version angle change after cyclic loading was greater (P = .020) for the traditional implant (3.89 degrees) than for the interlocking implant (0.16 degrees), whereas stem varus displacement at failure was greater (P = .008) for the interlocking implant (1.5 degrees) than the traditional implant (0.17 degrees). CONCLUSION: Addition of a stabilizing bolt enhanced construct stability and limited subsidence of a BFX(®) femoral stem. Use of the interlocking implant may decrease postoperative subsidence. However, in vivo effects of the interlocking bolt on osseointegration, bone remodeling, and stress shielding are unknown