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Biomedical subjects

C Z Margolis

Publications and source records attributed to C Z Margolis.

At least 19 recordsLinked to original sources
PubMed1992

Computerized algorithms and pediatricians' management of common problems in a community clinic.

In 1987, a microcomputer clinical algorithm (CA) system for constructing and using CAs for patient care was designed and implemented for six common primary care pediatrics problems. Six community clinic pediatricians agreed to use the system for several months. Length of patient's visit, completeness of data collection, antibiotic use, and appropriateness of clinical plan were measured before the computers were introduced (without CAs) and after the computers were introduced (both with and without CAs). All performance measures improved after the introduction of CAs. However, CA implementation had to be discontinued after five weeks because the CAs were too tedious for the physicians to follow during routine care. The authors conclude that CAs cannot be successfully sustained with physicians for common problems, even though their design and use can significantly improve the process of care.

Adolescent↗
PubMed1991

Cryptosporidium in Bedouin and Jewish infants and children in southern Israel.

We conducted a 1-year prospective study in two clinics and a hospital in the Negev region of southern Israel to determine the epidemiological and clinical patterns of Cryptosporidium diarrhea among Jewish and Bedouin infants and children living in the same geographical area. A total of 612 episodes were studied: 398 in Bedouins and 214 in Jews, of which 449 occurred in patients with diarrhea and 164 in controls. Cryptosporidium was detected in 13 of 382 patients (3.4%) with diarrhea and in 1 of 138 controls (0.7%) (P = 0.078). In 5 of 13 Cryptosporidium-positive patients (38%) another pathogen was detected. No significant difference in Cryptosporidium detection rates was observed between Jews and Bedouins or between hospitalized or nonhospitalized patients. The frequency of Cryptosporidium detection did not differ significantly when three age-groups were compared (less than 6 months old, 7-12 and 13-36 months old). The rate of Cryptosporidium detection was similar among malnourished and well-nourished patients, as determined by weight-for-height percentiles. Cryptosporidium was detected more frequently during the summer months (8.3%) than during the rest of the year (1.2%) (P less than 0.001). Patients with Cryptosporidium diarrhea did not differ clinically from patients with other causes of diarrhea. However, they were characterized by the absence of fecal leukocytes. Cryptosporidium is not a rare cause of diarrhea in southern Israel. It is more prevalent during the hot and dry season and can be detected in a relatively high prevalence among very young infants. Its clinical features are indistinguishable from those of patients with non-cryptosporidial diarrhea.

Child, Preschool↗
PubMed1990

Clinical practice guidelines at an HMO: development and implementation in a quality improvement model.

Harvard Community Health Plan (HCHP) is adapting to clinical medicine the managerial principles and methods of quality improvement theory that were originally developed and successfully applied in industrial settings. An essential step in applying the quality improvement cycle to clinical medicine is the setting of standards or specifications for clinical care. HCHP has chosen to focus its standard-setting efforts on the development of clinical algorithms, which provide an excellent basis for specifying and communicating optimal care processes and for evaluating actual clinical care. When implemented effectively, clinical algorithms may improve quality and decrease costs by guiding clinicians toward more standardized, high-quality, cost-effective clinical strategies and by facilitating more valid measurement of clinical process and outcomes. This article describes the evolution, structure, methods, and future agenda of the Algorithm Based Clinical Quality Improvement Process (ABCQIP) at HCHP.

Algorithms↗
PubMed1990

Rotavirus diarrhea in Jewish and Bedouin children in the Negev region of Israel: epidemiology, clinical aspects and possible role of malnutrition in severity of illness.

We conducted a 1-year prospective study in the Negev region of southern Israel to determine the epidemiologic and clinical patterns of rotavirus diarrhea. A total of 605 patients were studied, 392 Bedouins and 213 Jews, 441 of whom had diarrhea (449 episodes) and 164 did not. Rotavirus was the most common organism detected in children with diarrhea (63 of 444; 14%) but was rarely found in controls (3 of 163; 2%) (P less than 0.001). In 22% (12 of 54) of the rotavirus-positive patients, at least one other organism was also detected. The rate of rotavirus detection decreased as age increased, from 18% in the first year to 8% in the third year of life. Hospitalization with rotavirus diarrhea occurred more frequently in the summer. However, during winter, when diarrhea was less prevalent in the community, the proportion of cases associated with rotavirus was higher. Compared with controls, malnourished children were more likely to be hospitalized. However, rotavirus was detected in similar proportions among well-nourished and malnourished cases with diarrhea. The most prevalent rotavirus serotype was type 1 (in 69%), followed by types 4 and 2 (18 and 13%, respectively). We estimated that during the study period, approximately 2% of all Bedouin infants vs. only 0.2% of Jewish infants were hospitalized with rotavirus disease in their first year of life. Clinical signs and symptoms and stool appearance were not useful in predicting rotavirus detection. Malnutrition seems to be an important indicator of disease severity, which may explain why the toll of rotavirus-associated morbidity and mortality is particularly high among children in developing countries.

Acute Disease↗
PubMed1990

Rheumatology algorithms for primary care physicians.

Primary care physicians were trained on three rheumatology topics to assess the effectiveness of an educational strategy for continuing medical education. Algorithm training was shown to be at least as effective as that based on standard prose monographs. Both training groups improved their knowledge of patient management skills but there were no statistically significant differences between groups in the amount learned. When algorithms were used to design text materials, the designed texts required less study time than did the annotated clinical algorithms alone. That difference was significant for the shoulder pain materials (P less than 0.05) but not for the osteoporosis materials. The ratio of knowledge gained to study time was significantly higher for the algorithm group on the low back pain topic (P less than 0.05) but not for the other topics. Taped interview problems tests were studied as a method for assessing patient management skills related to problem-specific indicator conditions and were found to produce interrater reliability greater than 0.80 on five of the six tests.

Clinical Protocols↗
PubMed1989

Physician dropout.

Explore the source record for details and available documents.

Clinical Protocols↗
PubMed1989

Clinical algorithms teach pediatric decisionmaking more effectively than prose.

Despite the rapidly increasing volume of medical literature, little attention has been paid to the appropriate printed format for teaching clinical content. This study attempted to determine whether a clinical algorithm (CA) or prose is more effective for teaching clinical decisionmaking. Clerkship students, preclerkship students, and pediatric house officers in five medical centers in the USA and Israel were presented with clinical algorithms and prose describing management of fever in a child under 2 years of age, and management of meningitis in children. Knowledge of decisionmaking was measured before and after learning, using audio-taped clinical problems and learning time as measured. It was concluded that CAs are more effective and more efficient than prose for teaching clinical decisionmaking. When writing about clinical decisionmaking, the use of CAs should always be considered, especially if a series of interdependent decisions is being described.

Algorithms↗
PubMed1985

Criteria map audit of scorpion envenomation in the Negev, Israel.

A criteria map audit is a medical record audit in which quality of care is evaluated according to algorithmically arranged criteria. Thus, a particular criterion is applied to the patient record only if other criteria have been met. For example, if a stung child's condition is severe but not life threatening and if he has had a positive skin test for antivenom sensitivity then he should receive antivenom only after receiving adrenaline and hydrocortisone. We used a modified criteria map audit to determine both the clinical picture of scorpion envenomation and quality of care process in 94 children. Related outcomes of care measured included mortality, persistent morbidity, allergic reaction to scorpion antivenom and length of stay in hospital. Scorpion stings in the Negev region are usually due to the yellow scorpion, L. quinquestriatus, and usually occur in the summer months on the extremities in exposed male children under 10. The clinical picture is more severe when the scorpion is yellow, when the child is younger and when the sting is on the trunk or head. Symptoms apparently mediated by the central nervous system (2.6 findings/child) were more frequent than parasympathetic symptoms (2.3 findings/child). Treatment with antivenom and specific therapy for complications led to very low persistent morbidity and mortality in symptomatic cases, but was also accompanied by a longer hospital stay (64% equal to or greater than 3 days) than for asymptomatic cases (18% equal to or greater than 3 days). Testing for antivenom sensitivity was omitted in an unacceptably high percentage of cases (69%) and its omission led to an allergic reaction in 4 out of 40 cases (10%). Inadequacy in treatment of 7 secondary clinical problems ranged from 71% for hypertension to 29% for seizures (mean 46%). Persistent morbidity was negligible and mortality was 1.2%. We conclude that criteria map audit can be used to describe the clinical and epidemiological picture of a clinical problem while at the same time providing an audit of the process of care.

Adolescent↗
PubMed1979

Problem-oriented record. A critical review.

After 10 years of experience using the problem-oriented record (POR), Weed proposed that both patient care and clinical education could be improved by changing traditional medical records to a problem-oriented format. The problem-oriented system of record keeping has since been attempted or adopted by many physicians in the United States and abroad. This article will review four aspects of the POR. First, it will define the format of the POR in an ambulatory and ward setting. Second, it will discuss POR implementation. Third, it will attempt to assess the extent to which POR is in use currently. Fourth, it will review the studies that have attempted to evaluate the effectiveness of the POR.

Ambulatory Care↗
PubMed1979

Reliability of the middle ear examination.

Interobserver reliability of physical signs elicited and diagnoses made on middle ear examination were studied. Effect on reliability of variation in observer knowledge, patient age and instrument were defined. Two board-certified, color-seeing pediatric specialists who worked in the same clinic examined consecutively 350 ears with the same otoscope for each case. Over a period of four months, four different otoscopes were used to examine at least 50 ears with each. The following groups of findings were graded independently by the pediatrician according to pre-set criteria: color, landmarks and light reflex. Diagnosis was also recorded. At no time did the observers discuss their findings or diagnoses. Degree of interobserver agreement was expressed by the reliability coefficient (values given below) and the K coefficient. Overall agreement on findings ranged from 0.50 for landmarks to 0.85 for air-fluid level. Overall agreement for diagnoses was 0.72. Specific agreement on physical findings ranged from 0.0 for presence of air-fluid level to 0.85 for absence of air-fluid level. Specific agreement on diagnoses ranged from 0.08 on serous otitis to 0.56 on otitis media and 0.61 on normal. After the age of one year, agreement did not increase with age. Agreement did not change significantly with different instruments or as the study progressed. We concluded that equivalence of observer knowledge strongly increases agreement, while patient age less than one year decreases agreement, and type of instrument does not affect agreement. Clinicians should be trained to recognized middle ear signs and diagnoses according to specified criteria to maximize interobserver agreement.

Age Factors↗
PubMed1978

Problem acuteness and medical record utility.

We studied the usefulness of having the patient's medical record available to the pediatrician at the time of the patient's visit. For most acute problems, the medical record had no effect on the management of the patient, whereas the record frequently affected the handling of chronic or recurrent problems. These results suggest a means of improving the effectiveness of pediatric emergency room management and also a means for defining empirically criteria for evaluation of care by record audit.

Acute Disease↗
PubMed1975

A review of pediatric inpatient care.

Between 101 and 188 medical records of children hospitalized in each of three community hospitals and one major teaching hospital were examined to determine need for admission and quality of care administered. Two of the hospitals had been similarily studied two years before. Twenty-five percent of all admissions and 17% of all patient days were considered unnecessary. The smallest number of inappropriate admissions was found in the major teaching institution, but one of the community hospitals without any teaching affiliation was notably better than the other two. The teaching hospital and the same community hospital also achieved the lowest questionable management rates. Significant (P less than 0.5) but minimal reduction had occurred in number of unnecessary admissions when first and second utilization studies in these two hospitals were compared.

Child↗