A case report of CMV lymphadenitis in an adult kidney transplant recipient.

Cytomegalovirus (CMV) infection following kidney transplantation is associated with increased morbidity and mortality. In this case report we describe a case of a 23-year-old woman with an unusual presentation of diffuse CMV lymphadenitis following kidney transplantation that did not respond to gangiclovir therapy. This case highlights the atypical presentation of CMV disease in a kidney transplant recipient, the importance of CMV hypergammaglobulin in the treatment of CMV infection post kidney transplantation, and the difficulties in transitioning care from pediatric to adult transplant programs.

Cross-specialty linkage of resource-based relative value scales. Linking specialties by services and procedures of equal work.

This article describes methods used to combine into a common scale resource-based relative values from separate specialties. The key to producing a common scale is identifying pairs ("links") of services from different specialties that require approximately equal amounts of intraservice work. We distinguished two kinds of pairs of link services, those judged to be the same and those judged to be equivalent, usually within a narrow category of medical activity. Working with a cross-specialty panel of physicians and with data on time factors from a national survey, we selected sufficient links to connect each specialty to others by at least four links. We then used the weighted least-squares method to locate all the links optimally on a single, common scale. Analyses of the accuracy of this scale showed that the typical disagreement between specialties about where to locate the intraservice work of a given service was only 7%. Other analyses showed that the accuracy of the common scale was not sensitive to different classes of links.

Evaluation and management services in the Resource-Based Relative Value Scale.

Evaluation and management (E/M) services, which include making diagnoses, counseling and educating, developing strategies of care, and following up on treatment, are common to all medical specialties. Surveys of a variety of specialists using the magnitude-estimation method show that physicians agree closely in rating the work of particular E/M services. Regardless of the type of E/M service, the site at which it is performed, or the specialty performing it, work per unit of time varies only slightly. Comparison of work and time for services to which experts assigned billing codes in our consultative process indicates, however, that there may be large differences in the way different specialties use these billing codes. In some instances, work entailed by some of the E/M billing codes within specialties also appears to vary substantially. If empirical studies of physicians' coding and billing practices support our findings, possible responses might include (1) developing specialty-specific resource-based relative values for E/M services and (2) redefining the Physicians' Current Procedural Terminology, edition 4, codes for these services in terms that include time specifications.

Extrapolation of measures of work for surveyed services to other services.

A national survey of physicians produced detailed data on the work involved in performing 372 different services. This article describes methods developed to extrapolate the study data to a larger universe of services, defined by the Physicians' Current Procedural Terminology, edition 4. Because data measuring work inputs for nonsurveyed services presently are unavailable, we devised an extrapolation method that makes use of available charge data without building their inherent distortions into the extrapolated scale. To neutralize the effect of these distortions, we used small, homogeneous families of services as the basic units for the extrapolations and assumed that charges are reasonable indicators of relative work within such families. To produce extrapolated work values within each family, we multiplied an estimate of work based on survey data for a benchmark procedure by charge-based ratios that represent the relationships between surveyed and nonsurveyed services. These extrapolations can be used in constructing a Resource-Based Relative Value Scale.

Results and policy implications of the resource-based relative-value study.

The resource-based relative-value scale (RBRVS) is a measure of relative levels of resource input expended when physicians produce services and procedures. It is a function of the physician's work input, the opportunity cost of specialty training, and the relative practice costs for each specialty. This paper presents resource-based relative values (RBRVs) for selected procedures of four major specialties--family practice, internal medicine, general surgery, and thoracic and cardiovascular surgery. We compare RBRVs with current charges and find several general patterns. Invasive procedures are typically compensated at more than double the rate of evaluation-and-management services, when both consume the same resource inputs. Imaging and laboratory procedures fall between invasive and evaluation-and-management services. We analyze the financial implications of the RBRVS by developing a simple model and simulating the effects of an RBRVS-based fee schedule on physicians' revenues in various specialties. We use Medicare data to perform the simulation under the "budget-neutral" assumption. Results show that an RBRVS-based fee schedule affects specialties differently. The average family practitioner could receive 60 percent more revenue from Medicare, whereas the average ophthalmologist could lose 40 percent of current revenues. The effects on other specialties fall between these two.

Relaxation: its effect on the nutritional status and performance status of clients with cancer.

Relaxation was used to promote normal food consumption patterns among persons with cancer. As part of a larger study, 22 persons with cancer were randomly assigned to receive instruction and reinforcement in a relaxation technique to be used preprandially. The relaxation procedure included four components: (a) deep abdominal breathing, (b) tensing and relaxing of various body parts, (c) relaxation by autosuggestion, and (d) voluntary image control. Twelve clients complied with relaxation instructions in part, and 10 did not. Among compliers, 75% experienced desirable weight change over a six-week period. Performance status, measured by the Karnofsky scale, improved for 33% and worsened for 17% over eight weeks. Research has shown relaxation to be an effective measure in relation to pain, hypertension, and other conditions. These preliminary results now suggest that relaxation may also be effective in treating the eating problems of the person with cancer, leading to improvement in weight and performance status.