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Objectives: We examined the relationships among depressive symptoms, physician diagnosis of depression, and charges for care., Study Design: We used a prospective observational design., Population: Five hundred eight new adult patients were randomly assigned to senior residents in family practice and internal medicine., Outcomes Measured: Self-reports of health status assessment (Medical Outcomes Study Short Form-36) and depressive symptoms (Beck Depression Inventory) were determined at study entry and at 1-year follow-up. Physician diagnosis of depression was determined by chart audit; charges for care were monitored electronically., Results: Symptoms of depression and the diagnosis of depression were associated with charges for care. Statistical models were developed to identify predictors for the occurrence and magnitude of medical charges. Neither depressive symptoms nor diagnosis of depression significantly predicted the occurrence of charges in the areas studied, but physician diagnosis of depression predicted the magnitude of primary care and total charges., Conclusions: A complex relationship exists among depressive symptoms, the diagnosis of depression, and charges for medical care. Understanding these relationships may help primary care physicians diagnose depression and deliver primary care to depressed patients more effectively while managing health care expenditures.

Background: There are differences in styles of care among primary care physicians. The purpose of our study was to determine whether differences in physician practice styles and patient health status generate different medical charges., Methods: New adult patients (N = 509) were randomized to primary care physicians, and use of medical care services and associated charges were monitored for 1 year., Results: Controlling for baseline patient health status, a technically oriented style of care was associated with significantly higher specialty care, emergency department, diagnostic, and total charges. Some practice behaviors, however, were associated with lower charges; for example, a practice style emphasizing patient activation was associated with significantly lower primary care charges. Both a lower baseline patient health status and a health status that declined over the study period predicted higher charges., Conclusions: Measurable differences in practice style are associated with differing medical care charges. Patients' health status was also an important determinant of medical charges and had implications for the assessment of physician utilization patterns.

Background: The rate of admission for avoidable hospital conditions (AHCs) has been proposed as a measure of the ability of a population to access health care. The purpose of this study was to determine the relationship between the availability of primary care physicians and the rate of avoidable hospitalizations., Methods: Statewide hospital discharge data for general acute care hospitals in Pennsylvania were used to determine age- and sex-adjusted AHC rates in the 26 health service areas (HSAs) in Pennsylvania. The number and type of primary care physician as well as the per capita income for each HSA were obtained from the Area Resource File. Correlations of number and type of physician with AHC rates were obtained., Results: Only the number of family and general practice physicians (FPs/GPs) per population was significantly correlated with adult and pediatric AHC rates. As the number of FPs/GPs in each HSA increased, the AHC rate decreased. The significant relationship between FPs/GPs and the AHC rate remained after controlling for the effect of per capita income. No significant correlation was found between either the number of general internists and the adult AHC rate or the number of general pediatricians and the pediatric AHC rate., Conclusions: The availability of FPs/GPs is related to lower rates of hospitalization for certain conditions. Family physicians may provide more effective first-contact access to health care than is provided by either general internists or pediatricians in Pennsylvania. Future studies should address whether care by family physicians is more cost-effective as a result of this reduction in avoidable hospitalizations.

Background: This study applies the concept of economic efficiency to primary health care physicians. Comparisons of charges made by family physicians and general internists would provide evidence of "optimal" health care delivery of primary care services., Methods: A list of all active licensed primary care physicians was obtained from the office of the Oregon State Board of Medical Examiners. Two thousand eight hundred forty-three questionnaires were sent to Oregon primary care physicians. Of the 1365 responses, 484 were family physicians and 341 were general internists., Results: The study found that family physicians had significantly lower mean office visit fees than general internists, while both groups had essentially similar patient mixes. This difference in fees could not be explained by patient case mix., Conclusions: The findings of this study and the body of literature available support the concept that family practice physicians provide economically efficient primary health care. If two similarly trained physicians provide a comparable level of medical care, with the same or similar outcome (or output), the physician who provides the care for the lowest cost should be used.

Background: It is not known whether differences exist between the use of inpatient resources by family medicine and internal medicine physicians when patient demographic and complexity variables are statistically controlled., Methods: The study population was all patients in 13 higher volume diagnosis-related groups (DRGs) discharged from the family medicine (n = 306) and internal medicine services (n = 2374) of the University of Cincinnati Hospital during 1985 and 1986. The dependent variables were length of stay and inpatient readmission within 2 weeks. Stratification by DRGs was used to control for the effects of age and case mix on these variables., Results: With the exception of findings regarding one DRG, the results do not indicate that differences exist in average length of stay between patients of family medicine and internal medicine physicians after adjustment for other variables. Furthermore, almost all of the explained variance in length of stay was attributed to patient complexity and not to physician specialty or patient race or sex. For all discharges, the proportion of patients readmitted within 2 weeks was about 4% higher for the internal medicine service. However, multivariate analysis did not support the importance of physician specialty (family medicine or internal medicine) as a predictor of whether readmission occurred within 2 weeks., Conclusions: General indicators of resource use (such as length of stay or readmission occurrence) without adjustment for patient case mix, demographics, and complexity are inadequate for comparison of health care providers. Further research regarding interspecialty differences should use longitudinal data from large populations, which would permit more detailed examination of resource utilization.

Background: Rapidly changing Medicare reimbursement policies since 1983 have affected every primary care physician. This study has attempted to quantify the attitudes and behaviors of Ohio primary care physicians toward these changes., Methods: In Ohio, 1758 primary care physicians were surveyed by a mailed questionnaire about their attitudes toward recent changes in Medicare reimbursement policies and the resulting changes in their practices., Results: More than 80% of respondents termed most Medicare policies as "objectionable" or "very objectionable." Fifty percent were limiting the number of Medicare patients in their practices. Family physicians and physicians who perceived their income to have decreased and their staff workload to have increased were also more likely to limit the number of Medicare patients in their practices., Conclusions: Ohio primary care physicians have a negative opinion of Medicare reimbursement policies and have limited their practices significantly as a result.

Five hundred twenty new patients were randomly and prospectively assigned to receive care in the Internal Medicine Clinic or Family Practice Clinic of a large university hospital. Previous analyses of outpatient data demonstrated that the frequency of visits to the clinic of primary care, acute care clinic, emergency room, and consultant clinics were all significantly higher for patients randomized to internal medicine compared with family practice. In the present study, patients' charts were reviewed for information regarding hospitalizations. During the 3.4-year study period, there were a total of 61 hospital admissions for internal medicine (35 of 249 patients), and 58 for family practice (27 to 271 patients). Age (mean 47 years) and sex of patients in both groups were equivalent. The average total cost of hospitalization for each patient was greater for those randomized to the Internal Medicine Clinic: $7,193 for internal medicine patients as compared with $5,764 for family practice patients. The professional costs per hospitalization showed greater variation: $913 for Internal Medicine Clinic patients and $629 for Family Practice Clinic patients. Internal Medicine Clinic patients had a longer mean length of hospitalization (7.5 days) when compared with that of Family Practice Clinic patients (6.3 days). It can be concluded that in this clinical environment the hospitalization patterns are different for patients assigned to the Internal Medicine Clinic compared with the Family Practice Clinic: both cost and length of care for hospitalization are less for those followed by the Family Practice Clinic.

Encounter forms for all patient visits to a small group practice (two internists, three family physicians, and one Medex) were examined retrospectively for October 1979 and January, April, and July 1980. A total of 5,694 patient encounters (2,327 male, 3,367 female) were recorded during the four months studied. Diagnostic and therapeutic procedures were performed on 592 patients (9.6 percent), 321 male and 271 female. The family physicians performed fewer procedures on their patients (6.1, 7.5, and 8.6 percent of the total patients seen). The Medex did 18.4 percent of all office procedures for that time period. The ten most commonly performed procedures included electrocardiogram (ECG), rhythm strip or ambulatory ECG, splint application, suture removal, pulmonary function test, suturing, exercise treadmill test, wart removal, removal of skin lesion or punch biopsy, application or removal of plaster cast, and application of ace wrap, sling, or collar. The majority of the procedures performed by the family physicians were also done by the Medex; however, the diversity of the procedures performed by the family physicians was comparable with that of the internists. There were large economic differences between groups, with the internists having the highest total billings and the Medex the lowest average charge per procedure performed.