Appendix Table.

Characteristics and Findings of Reviewed Studies on the Association Between Health Care Cost and Quality

Study, Year (Reference), by Analysis Level	Participants (Years of Data Collection)	Cost Measure Description and Type	Quality Measure and Type	Methods to Control Confounding	Findings of Association Between Cost and Quality	Association Type
Area-level
Area

Baicker and Chandra, 2004 (7)	FFS Medicare beneficiaries in 50 U.S. states (2000–2001)	Average annual Medicare payments per beneficiary. Type: expenditure	24 process quality measures developed by Medicare QIOs for treatment of AMI, breast cancer, diabetes mellitus, CHF, pneumonia, and stroke. Type: process	Multivariable regression model	$1000 additional Medicare spending per capita was associated with 10 positions lower in overall state quality ranking (P <0.001). The association between spending and individual quality measures was significant and negative for 15 of 24 measures (P <0.050) and nonsignificant for 9 of 24 measures (P >0.050).	Negative

Baicker et al, 2006 (41)	10.2 million births in counties with populations >250 000 (1995–1998)	Risk-adjusted cesarean delivery rate. Type: care intensity index	Maternal mortality; neonatal mortality. Type: outcome	Multivariable regression model	Small and insignificant association between county cesarean delivery rate and neonatal or maternal mortality rate. Decreasing cesarean delivery rate by 1 SD was associated with a decrease of 0.2 neonatal deaths per 10 000 births at normal birth weight (P <0.97), a decrease of 0.2 neonatal deaths per 10 000 births at low and very low birth weight (P <0.28), and a decrease of 0.096 maternal deaths per 10 000 births (P <0.100).	Imprecise or indeterminate

Byrne et al, 2007 (28)	22 VA geographic networks (1998–2003)	Average risk-adjusted funding in VA networks. Type: expenditure	3-y mortality rates. Type: outcome	Multivariable regression model	A $1000 increase in average risk-adjusted funding was associated with non–significantly lower odds of mortality for males (OR, 0.943 [95% CI, 0.880–1.010] and females (OR, 0.950 [CI, 0.839–1.076]).	Imprecise or indeterminate

Cooper, 2009 (10)	FFS Medicare beneficiaries in 50 U.S. states (2000 and 2004)	Total health spending per capita; total Medicare spending per capita. Type: expenditure	State ranking of health system performance (composite of 24 Medicare QIO measures and Commonwealth Fund scale). Type: process	2000 Medicare spending was adjusted for age, sex, race, and cost of living; 2004 results unadjusted	Higher 2004 total per-capita spending was associated with lower state quality ranking, where lower quality ranking means better quality (Pearson correlation coefficient = −0.34 using Medicare QIO measures and −0.51 using Commonwealth Fund ranking, P <0.050). However, Medicare spending per capita was associated with higher (worse) state quality ranking (Pearson correlation coefficient = 0.65 using Medicare QIO measures and 0.41 using Commonwealth Fund ranking; P <0.050).	Positive

Doyle, 2007 (34)	Patients visiting Florida from other states hospitalized for AMI, cardiac dysrhythmias, or CHF, in 44 of 67 counties with at least 30 such cases (1996–2003)	County end-of-life expenditure index (EOL-EI; hospital and physician spending during last 6 mo of life) Type: care intensity index	Inpatient mortality. Type: outcome	Natural experiment examining outcomes of patients exposed to health systems not designed for them by focusing on visitors to Florida and multivariable regression model; alternative specification using instrumental variables analysis	A 10% increase in county EOL-EI was associated with a 0.3–percentage point decrease in mortality, or 5% of the mean.	Positive

Fisher et al, 2003 (5)	Medicare FFS beneficiaries aged 65–99 y hospitalized between 1993 and 1995 for hip fracture (n = 614 503), colorectal cancer (n = 195 429), or AMI (n = 159 393) and a representative sample (n = 18 190) drawn from the MCBS (1992–1995)	HRR EOL-EI and AC-EI = spending on physician and hospital services provided during the first 6 mo after index hospitalization. Type: care intensity index	Percent of "ideal" AMI patients that received recommended treatment; percentage of the general Medicaid population that received recommended preventive services. Type: process	Natural experiment using area EOL-EI as a measure of spending due to physician practice rather than illness or price; multivariable regression models	In regions in the highest-spending compared with the lowest-spending quintile, patients with AMI were less likely to receive acute reperfusion (49.8% vs. 55.8%), aspirin at admission (83.9% vs. 87.7%) or discharge (74.8% vs. 83.5%) and ACE inhibitors at discharge (58.5% vs. 62.7%), and were more likely to receive β-blockers in the hospital (61.5% vs. 63.9%; test for linear trend, all P <0.050). Association between spending and receipt of β-blockers at discharge was not significant (53.7% vs. 52.7%, P >0.050). Flu immunizations (48.1% vs. 60.3%), pneumonia immunizations (19.7% vs. 29.4%), and Pap smears (33.6% vs. 40.8%) were provided less frequently in higher-spending regions (test for linear trend, all P <0.050). Association between mammography tests and spending was not significant (47.6% vs. 48.7%; P >0.050).	Mixed-negative

Fisher et al, 2003 (5)	Medicare FFS beneficiaries age 65–99 y hospitalized between 1993 and 1995 for hip fracture (n = 614 503), colorectal cancer (n = 195 429), or AMI (n = 159 393) and a representative sample (n = 18 190) drawn from the MCBS (1992–1995)	HRR EOL-EI and AC-EI = spending on physician and hospital services provided during the first 6 mo after index hospitalization. Type: care intensity index	Usual source of care; health problem but did not see physician; trouble getting care; delaying care due to cost; waiting for visits. Type: access	Natural experiment using area EOL-EI as a measure of spending due to physician practice rather than illness or price; multivariable regression models	In regions in the highest-spending compared with the lowest-spending quintile, patients were less likely to report a usual source of care (86.5% vs. 87.8%) and more likely to report having a health problem but not seeing a physician (10.1% vs. 8.7%, test for linear trend, both P <0.050). There was no significant association between reporting trouble getting care (3.1% vs. 2.5%) and delaying care because of cost and spending (8.9% vs. 9.3%, test for linear trend, both P >0.050). Compared with patients in the lowest-spending areas, those in the highest-spending areas were more likely to report waiting >30 min for an ED visit (34.0% vs. 28.4%), outpatient department visit (39.3% vs. 22.9%), and physician visit (31.9% vs. 24.8%, test for linear trend, all P <0.050).	Mixed-negative

Fisher et al, 2003 (6)	Medicare FFS beneficiaries aged 65–99 y hospitalized from 1993 to 1995 for hip fracture (n = 614 503), colorectal cancer (n = 195 429), or AMI (n = 159 393) and a representative sample (n = 18 190) drawn from the MCBS (1992–1995).	HRR-level EOL-EI; AC-EI. Type: care intensity index	5-y mortality rate; change in functional status. Type: outcome	Natural experiment using area EOL-EI as a measure of spending due to physician practice rather than illness or price, multivariable regression models	Each 10% increase in regional end-of-life spending was associated with the following RRs for death: hip fracture cohort, 1.003 (95% CI, 0.999–1.006); colorectal cancer cohort, 1.012 (CI, 1.004–1.019); AMI cohort, 1.007 (CI, 1.001–1.014); and MCBS cohort, 1.01 (CI, 0.99–1.03). No significant difference in functional status index decrease between the highest- and lowest-spending regions (−1.96 [CI, −2.36 to −1.55] vs. −1.96 [CI, −2.42 to −1.50]).	Mixed

Fisher et al, 2003 (6)	Medicare FFS beneficiaries aged 65–99 y hospitalized from 1993 to 1995 for hip fracture (n = 614 503), colorectal cancer (n = 195 429), or AMI (n = 159 393) and a representative sample (n = 18 190) drawn from the MCBS (1992–1995).	HRR-level EOL-EI; AC-EI. Type: care intensity index	2 summary scores of general satisfaction with care (global quality and accessibility) and 3 summary scores focused on satisfaction with a usual physician (technical skills, interpersonal manner, and information-giving). Type: patient experience	Natural experiment using area EOL-EI as a measure of spending due to physician practice rather than illness or price, multivariable regression models	EOL-EI was negatively associated with global satisfaction and positively associated with satisfaction with interpersonal aspects of care (specific magnitude not reported, P >0.050). Associations with patient experience of access to care, information giving, and technical skills were not significant (specific magnitude not reported, P <0.050).	Mixed

Fowler et al, 2008 (44)	2515 community-dwelling Medicare FFS beneficiaries responding to a survey	HRR-level mean per-capita Medicare Parts A and B spending. Type: expenditure	Perceived unmet need for care. Type: access	Multivariable regression model	There were no significant differences between highest- and lowest-expenditure areas in perceived unmet need for tests or treatment (5.0% vs. 3.9%; P = 0.25 for linear trend) and cardiac tests (14.2% vs. 12.5%; P = 0.14 for linear trend). Respondents in highest-expenditure areas reported perceived unmet need for specialists more frequently than those in lower-expenditure areas (8.0% vs. 3.3%; P <0.001 for linear trend).	Article-level: mixed. This comparison: mixed-negative

Fowler et al, 2008 (44)	2515 community-dwelling Medicare FFS beneficiaries responding to a survey	HRR-level mean per-capita Medicare Parts A and B spending. Type: expenditure	Perceived quality of ambulatory care; perceived quality of overall care. Type: patient experience	Multivariable regression model	There was no significant difference between highest- and lowest-expenditure areas for 5 of 7 measures of perceived quality of care (physicians always or usually spent enough time, 87.0% vs. 88.7%, P = 0.94; physicians always or usually explained new medications, 86.1% vs. 90.3%, P = 0.75; physicians knew medication adverse effects, 89.8% vs. 97.3%, P = 0.27; health care better than average, 32.1% vs. 33.3%, P = 0.67; community care better than average, 29.7% vs. 29.8%, P = 0.33). Respondents in highest-expenditure areas were more likely to report that physicians knew about pain (97.8% vs. 93.2%, P = 0.01 for linear trend) and less likely to provide an overall rating of care of 9 or 10 out of 10 (55.4% vs. 63.3%, P = 0.008).	Mixed

Landrum et al, 2008 (45)	Medicare beneficiaries in the national SEER database, aged >66 y, and with first diagnosis of colorectal cancer (1992–1999)	HRR-level EOL-EI; AC-EI. Type: care intensity index	Stage at diagnosis; adjuvant chemotherapy for colon cancer; adjuvant chemotherapy for rectal cancer; receipt of surveillance colonoscopy; complete diagnostic colonoscopy; surveillance testing for carcinoembryonic antigen; receipt of chemotherapy within 6 mo. of colon cancer diagnosis. Type: process	Multivariable regression model	A $1000 increase in area-level EOL-EI was associated with 0.3% higher probability of being diagnosed with late-stage cancer (95% CI, 0.1–0.4), 1.6% higher probability of adjuvant chemotherapy for stage III cancer (CI, 0.8–2.5), and 2.5% higher probability of surveillance testing for carcinoembryonic antigen (CI, 1.3–3.7). There was no significant association between EOL-EI and adjuvant chemotherapy for rectal cancer ($1000 increase associated with 0.3% higher probability [CI, −0.7 to 1.2]), diagnostic colonoscopy (0.2 [CI, −0.2 to 0.7]), or surveillance colonoscopy (0.3 [CI, −0.9 to 1.4]). Increased EOL-EI was associated with increased use of chemotherapy among patients for which it is recommended, not recommended, and discretionary (among all patients, $1000 increase in spending associated with 0.9% higher probability of chemotherapy [CI, 0.5–1.3]).	Mixed

Landrum et al, 2008 (45)	Medicare beneficiaries in the national SEER database, aged >66 y, and with first diagnosis of colorectal cancer (1992–1999)	HRR-level EOL-EI; AC-EI. Type: care intensity index	Overall and colorectal cancer-specific mortality at 3 y after diagnosis. Type: outcome	Multivariable regression model	EOL-EI was not significantly associated with cancer or all-cause mortality but was significantly associated with increased noncancer mortality (magnitude not reported, P <0.001).	Mixed

Sirovich et al, 2006 (26)	10 577 physicians who provided care to adults in 51 metropolitan and 9 nonmetropolitan areas of the United States and a supplemental national sample (1998 or 1999)	HRR-level EOL-EI; AC-EI. Type: care intensity index	Physician-perceived ability to provide high quality care, perceived availability of clinical services, and career satisfaction. Type: access	Multivariable regression model	The proportion of physicians who felt able to obtain elective hospital admissions ranged from 50% in high-intensity regions to 64% in the lowest-intensity regions (P <0.001); the proportion of physicians who felt able to obtain high-quality specialist referrals ranged from 64% in high-intensity regions to 79% in low-intensity regions (P <0.001). Compared with low-intensity regions, fewer physicians in high-intensity regions felt able to maintain good ongoing patient relationships (62% vs. 70%; P <0.001) or able to provide high-quality care (72% vs. 77%; P = 0.009).	Negative

Wennberg et al, 2009 (40)	Random sample of patients hospitalized at 2473 hospitals; care intensity measure based on 20% national Medicare sample (2006–2007)	HRR hospital care intensity summary measure based on number of days in hospital and number of inpatient physician visits (not EOL-EI). Type: care intensity index	10 patient experience measures from the HCAHPS. Type: patient experience	All measures adjusted for age, sex, race, and comorbid conditions	The proportion of patients reporting a negative overall experience and care intensity were positively associated (r = 0.51; P <0.001).	Negative

Yasaitis et al, 2009 (46)	National sample of 64 088 respondents aged 19–69 y to an online interactive patient assessment (2003–2008)	HRR-level EOL-EI. Type: care intensity index	Patient satisfaction with care efficiency, continuity, access, and overall quality; patient-centeredness; physician–patient communication; safety. Type: patient experience	Multivariable regression model	Compared with patients receiving care in lower-intensity regions, patients receiving care in higher-intensity regions reported lower satisfaction with the efficiency (61% vs. 72%), continuity (75% vs. 76%), accessibility (45% vs. 49%), overall quality of care (33% vs. 40%), and patient centeredness (23% vs. 32%) than patients in lower-intensity regions (all P <0.001).	Negative
Health plan

Roski et al, 2008 (47)	Patients with diabetes aged 18–75 y insured by a volunteer sample of 35 health plans (2005)	Relative resource use defined as actual vs. expected price-standardized annual health plan spending for patients with diabetes. Type: expenditure	Composite measure based on percentage of diabetics with evidence of annual hemoglobin A_1c screen, LDL screen, eye exam, nephropathy care. Type: process	Indirect standardization of costs for age, sex, diabetes type 1 or 2, and comorbid condition	No significant association between health plan total diabetes relative resource use and quality (magnitude not reported). No significant association for inpatient facility, procedure and surgery, or evaluation and management subcategories of resource use and quality (magnitude not reported). Significant positive association between pharmacy resource use and quality (Pearson correlation coefficient = 0.513; P <0.003).	Imprecise or indeterminate
Provider-level
Disease management programs
Mangione et al, 2006 (29)	8661 adults with diabetes sampled from 63 physician groups nested in 11 health plans (2000–2001)	Disease management intensity measured by use of physician reminders, performance feedback, and structured care management. Type: care intensity index	Dilated retinal examination, nephropathy screening, foot examination, hemoglobin A_1c testing, serum lipid panel, recommendation for influenza vaccine, and recommendation to take aspirin and quit smoking. Type: process	Multivariable regression model	The association between disease management intensity and process quality measures was positive and significant for 6 of 8 measures (difference between 3rd and 1st tercile, 8–15 percentage points, P <0.050) and positive but nonsignificant for 2 measures (difference between 3rd and 1st tercile, 4 and 2 percentage points, P >0.050).	Article-level: mixed-positive. This comparison: positive

Mangione et al, 2006 (29)	8661 adults with diabetes sampled from 63 physician groups nested in 11 health plans (2000–2001)	Disease management intensity measured by use of physician reminders, performance feedback, and structured care management. Type: care intensity index	Serum LDL cholesterol level, hemoglobin A_1c level, systolic blood pressure. Type: outcome	Multivariable regression model	No significant association between disease management intensity and intermediate outcomes (difference between 3rd and 1st tercile in hemoglobin A_1c level, 0.1 percentage point [95% CI, −0.2 to 0.4]; systolic blood pressure, 2 mm Hg [CI, 0–4]; serum LDL cholesterol, 0 mmol/L [0 mg/dL] [CI, −4 to 4]).	No difference

Hospitals
Auerbach et al, 2010 (27)	81 289 patients cared for by 1451 physicians at 164 hospitals participating in Premier Perspective, admitted for coronary artery bypass graft, aged ≥18 y (1 Oct 2003–1 September 2005)	Premier Perspective hospital cost per discharge from hospital accounting systems or cost/charge ratios. Type: accounting costs	Antimicrobial use to prevent surgical site infection on the operative day, discontinued antimicrobial use within 48 h, serial compression device use for venous thromboembolism prevention in 2 d after surgery, use of aspirin, β-blockers, and statin drugs in 2 d after surgery. Type: process	Multivariable regression model	Individual quality measures had inconsistent associations with costs but patients who had no quality measures missed (composite measure) had lower costs than those who missed ≥1 (1 missed quality measure associated with 7.8% higher cost than none missed, P <0.001).	Mixed-negative

Barnato et al, 2010 (39)	1 021 909 patients aged ≥65 y, incurring 2 216 815 admissions in 169 Pennsylvania hospitals (April 2001–March 2005)	Index of hospital end-of-life treatment intensity calculated by empirically weighting 6 Bayes' shrunken case-mix standardized treatment ratios (ICU admission, ICU LOS, intubation or mechanical ventilation, tracheostomy, hemodialysis, and gastrostomy) among admissions aged >65 y at end-of-life (care intensity index)	30- and 180-d mortality. Type: outcome	Multivariable regression model	Compared with admission at an average intensity hospital, admission to a hospital 1 SD below vs. 1 SD above average intensity resulted in an adjusted OR of mortality for admissions at low PPD of 1.06 (95% CI, 1.04–1.08) vs. 0.97 (CI, 0.96–0.99); average PPD, 1.06 (CI, 1.04–1.09) vs. 0.97 (CI, 0.96–0.99); and high PPD, 1.09 (CI, 1.07–1.11) vs. 0.97 (CI, 0.95–0.99), respectively. By 180 d, the benefits to intensity attenuated: low PPD, 1.03 (CI, 1.01–1.04) vs. 1.00 (CI, 0.98–1.01); average PPD, 1.03 (CI, 1.02–1.05) vs. 1.00 (CI, 0.98–1.01); and high PPD, 1.06 (CI, 1.04–1.09]) vs. 1.00 (CI, 0.98–1.02), respectively.	Positive

Birkmeyer et al, 2012 (48)	All hospitals performing selected surgical procedures for FFS Medicare beneficiaries (number of hospitals: coronary artery bypass graft, 1060; colectomy, 1227; abdominal aortic aneurysm repair, 728; hip replacement, 1839) (2005–2007)	Medicare payments for all services from admission date to 30 d after discharge. Type: expenditure	Mortality within 30 d of index surgical procedure; Complications selected from the Complication Screening Project. Type: outcome	Multivariable regression models	Compared with hospitals in the lowest complications quintile, hospitals in the highest quintile had higher spending for all studied procedures (highest vs. lowest complications quintile: coronary artery bypass graft, $46 024 vs. $40 671, P <0.001; colectomy, $28 199 vs. $25 481; abdominal aortic aneurysm repair, $33 002 vs. $27 723; hip replacement, $22 051 vs. $19 615). Small, inconsistent differences in spending by quartile of mortality (highest vs. lowest mortality quintile: coronary artery bypass graft, $43 249 vs. $43 583; colectomy, $26 756 vs. $27 530; abdominal aortic aneurysm repair, $30 334 vs. $30,612; hip replacement, $21 092 vs. $20 907).	Mixed-negative

Bradbury et al, 1994 (49)	43 Pennsylvania hospitals (1989–1990)	Total hospital charges per discharge, ancillary charges per discharge. Type: charges	In-hospital mortality and morbidity, defined as continued clinical instability determined by presence of MedisGroups key clinical findings. Type: outcome	Multivariable regression model	Total charges showed a positive, significant (P <0.050) association with morbidity (all patients) and mortality (patients with LOS ≥4 d); nonsignificant association between charges and mortality for patients with LOS 1–3 d; insufficient information presented to abstract magnitude of associations.	Mixed-negative

Bradbury et al, 1997 (50)	10 043 cholecystectomy patients treated by 218 surgeons in 43 Pennsylvania hospitals (1990–1991)	Total hospital charges per discharge, ancillary charges per discharge. Type: charges	In-hospital morbidity, defined as continued clinical instability determined by presence of MedisGroups key clinical findings. Type: outcome	Multivariable regression model	Total charges showed a positive, significant (P <0.010) association with morbidity; insufficient information presented to abstract magnitude of associations.	Negative

Carey and Burgess, 1999 (51)	Nonpsychiatric patients at 137 VA hospitals (1988–1993)	Total variable cost from VA hospital accounting data. Type: accounting costs	Observed or expected 30-d mortality; observed/expected 14-d readmission rates. Type: outcome	Instrumental variables analysis	A 1-unit increase in observed or expected mortality index was associated with 24%–44% higher cost in instrumental variables regressions for each of 4 y (P <0.100). A 1-unit increase in observed or expected readmissions was associated with 25%–29% higher cost in instrumental variables regressions for each of 2 y (P <0.100).	Article-level: mixed. This comparison: negative

Carey and Burgess, 1999 (51)	Nonpsychiatric patients at 137 VA hospitals (1988–1993)	Total variable cost from VA hospital accounting data. Type: accounting costs	Observed or expected outpatient follow-up within 30 d after inpatient discharge. Type: process	Instrumental variables analysis	A 1-unit increase in observed or expected outpatient follow-up rate was associated with 12%–21% higher cost in instrumental variable regressions for each of 4 y (P <0.100 for 3 y, P >0.100 for 1 y).	Positive

Chen et al, 2010 (32)	3146 hospitals, 518 473 discharges, and 400 068 unique Medicare patients with CHF; 3152 hospitals, 443 564 discharges, and 399 841 unique Medicare patients with pneumonia (2006)	Relative cost index based on cost per discharge calculated from cost to charge ratios and charges. Type: accounting costs	Process quality of care. Type: process	Multivariable regression model	Hospitals in the highest-cost quartile had higher quality scores than the lowest-cost quartile hospitals for CHF care (89.9% vs. 85.5%, P <0.001) and lower quality scores for pneumonia (85.7% vs. 86.6%, P <0.002).	Mixed

Chen et al, 2010 (32)	3146 hospitals, 518 473 discharges, and 400 068 unique Medicare patients with CHF; 3152 hospitals, 443 564 discharges, and 399 841 unique Medicare patients with pneumonia (2006)	Relative cost index based on cost per discharge calculated from cost to charge ratios and charges. Type: accounting costs	30-d mortality; readmission rates. Type: outcome	Multivariable regression model	Mortality: Hospitals in the highest-cost quartile had lower mortality for CHF compared with the lowest-cost quartile (9.8% vs. 10.8%, P <0.001) and higher mortality for pneumonia (11.7% vs. 10.9%, P <0.001). Readmissions: high-cost hospitals had lower readmission rates for CHF than low-cost hospitals (22.0% vs. 24.7%, P <0.0001) and similar readmission rates for pneumonia (17.3% vs. 17.9%, P = 0.20).	Mixed

Deily and McKay, 2006 (52)	416 urban, acute-care Florida hospitals (1999–2001)	Hospital inefficiency score (percentage difference between a hospital's actual cost and the most efficient frontier cost level). Type: accounting costs	Risk-adjusted in-hospital mortality rate. Type: outcome	Multivariable regression model	A reduction in inefficiency from the mean value of approximately 13% to 12% was associated with a significant reduction in the mortality rate of 0.01%.	Positive

Englesbe et al, 2009 (53)	43 393 high-cost Medicare kidney transplant patients (2003–2006)	Medicare payments for readmissions and outlier cases. Type: expenditure	Composite measure of 30-d mortality and kidney transplant volume. Type: composite measure	Multivariable regression model	Hospitals determined to be lower quality in 2003–2004 had an average payment for high-cost patients that was $1185 larger (P <0.001) than the average payments made to high-quality centers in 2005–2006.	Negative

Fisher et al, 2004 (54)	Medicare FFS beneficiaries aged 65–99 y with initial hospitalization for AMI, colorectal cancer, or hip fracture at 299 teaching hospitals (1993–1995)	HRR-level EOL-EI, assigned to patients by location of hospital of initial hospitalization. Type: care intensity index.	6 AMI process measures from the Cooperative Cardiovascular Project. Type: process	Multivariable regression model	Compared with hospitals in the lowest quintile of intensity, hospitals in the highest quintile did not have significantly different rates of reperfusion within 12 h (44.4% vs. 41.9%), in-hospital aspirin (92.1% vs. 93.8%), discharge ACE inhibitor (62.0% vs. 66.2%), and discharge β-blocker (60.3% vs. 65.5%); all P >0.050. High-intensity hospitals had lower rates of discharge aspirin (82.2% vs. 90.5%) and in-hospital β-blocker (60.0% vs. 62.0%); both P <0.050.	Mixed-negative

Fisher et al, 2004 (54)	Medicare FFS beneficiaries aged 65–99 y with initial hospitalization for AMI, colorectal cancer, or hip fracture at 299 teaching hospitals (1993–1995)	HRR-level EOL-EI, assigned to patients by location of hospital of initial hospitalization. Type: care intensity index.	5-y mortality rate. Type: outcome	Multivariable regression model	A 10% increase in practice intensity was associated with the following mortality relative risk: hip fracture, 1.003 (95% CI, 0.999–1.007); colorectal cancer, 1.007 (CI, 1.000–1.013); and AMI, 1.012 (CI, 1.005–1.020).	Mixed-negative

Fleming, 1991 (42)	Medicare beneficiaries hospitalized at 659 hospitals (1985)	Total variable cost as reported on AHA annual survey. Type: accounting costs	Ratio of actual to expected mortality index; ratio of actual to expected readmission index. Type: outcome	Multivariable regression model	Higher cost had a cubic association with the readmission index and surgical mortality index (P <0.010). Total and medical mortality were not significantly associated with cost.	Mixed

Glance et al, 2010 (31)	67 124 trauma patients admitted to 73 trauma centers drawn from HCUP NIS (2006)	Relative cost of care per admission using charges and cost-to-charge ratios. Type: accounting costs	Predicted probability of mortality at admission compared with admission at average hospital, controlling for patient risk factors. Type: outcome	Multivariable regression model	The relative cost of trauma patients treated in hospitals with low risk-adjusted mortality rates was 0.78 (CI, 0.64–0.95) compared with average-mortality hospitals. The cost of treating patients in high-mortality trauma centers was 1.08 times higher than average-mortality hospitals, but the difference was not significant (CI, 0.92–1.27).	Mixed-negative

Huerta et al, 2008 (3)	273 hospitals in 19 markets (2005)	X-inefficiency based on data envelopment analysis using expenses, case-mix-adjusted admissions, LOS, and number of beds. Type: accounting costs	Leapfrog Group safe practice score. Type: structure	Multivariable regression model	Higher safe practice scores were significantly associated with higher hospital efficiency (increase of 1 quintile in safe practice score associated with 0.105 increase in X-inefficiency scale, P = 0.050).	Negative

Jha et al, 2009 (13)	4048 acute care hospitals (2004)	Relative cost index based on ratio of actual average cost per case (from CMS Hospital Cost Reports) for Medicare patients divided by predicted average cost per case for Medicare patients. Type: accounting costs	15 HQA process measures for AMI, CHF, and pneumonia; condition-specific composites constructed as ratio of number of times a hospital performed appropriate action across total number of opportunities to provide appropriate care. Type: process	Multivariable regression model	Compared with hospitals in the highest cost quartile, hospitals in the lowest cost quartile had, on average, lower AMI performance (88.9 vs. 90.8%, P <0.001) and CHF performance (77.0 vs. 81.7%, P <0.001). There was no significant association between risk-adjusted hospital costs and performance on pneumonia quality metrics (76.9 vs. 77.4%, P = 0.68).	Article-level: mixed-positive. This comparison: Mixed-positive

Jha et al, 2009 (13)	4048 acute care hospitals (2004)	Relative cost index based on ratio of actual average cost per case (from CMS Hospital Cost Reports) for Medicare patients divided by predicted average cost per case for Medicare patients. Type: accounting costs	30-d mortality. Type: outcome	Multivariable regression model	No significant difference in mortality rates between low- and high-cost hospitals for AMI (19.4 vs. 19.5, P = 0.56), CHF (13.3 vs. 13.2, P = 0.80), and pneumonia (14.4 vs. 14.2, P = 0.18).	Imprecise or indeterminate

Kaestner and Silber, 2010 (18)	Medicare patients hospitalized for surgery (general, orthopedic, vascular) and medical conditions (AMI, CHF, stroke, and gastrointestinal bleeding) (2001–2005)	Total inpatient charges per Medicare admission. Type: charges	30-d mortality. Type: outcome	Instrumental variables analysis	For all conditions except AMI, a 10% ($2000–$5000) increase in charges was associated with a 3.1%–11.3% decrease in 30-d mortality (P <0.050), varying by condition.	Positive

Lagu et al, 2011 (30)	Patients aged ≥18 y with sepsis in 309 nationwide hospitals in the Premier Perspective database (2004–2006)	Observed − expected costs from hospital cost accounting systems. Type: accounting costs	Severity-adjusted in-hospital mortality rate. Type: outcome	Multivariable regression model	An additional $1000 in patient costs was associated with a 0.1% increase in adjusted hospital-level mortality (95% [0.0%, 0.2%]).	No difference

McKay and Deily, 2008 (55)	National sample of 3384 short-term, acute-care hospitals in operation for full year, with at least 16 beds and 100 discharges (1999–2001)	Cost inefficiency estimated using stochastic frontier analysis of costs from Medicare cost reports and AHA survey. Type: accounting costs	In-hospital mortality and complication rate. Type: outcome	Multivariable regression model	Cost inefficiency was not significantly associated with in-hospital mortality or complication rates (1-unit increase in cost inefficiency score associated with 0.00002–percentage point decrease in mortality rate and 0.0008–percentage point decrease in complication rate, P >0.050).	Imprecise or indeterminate

Morey et al, 1992 (56)	National sample of 300 hospitals (1981)	Cost inefficiency estimated using data envelopment analysis of hospital costs from AHA survey. Type: accounting costs	Ratio of actual to predicted in-hospital deaths. Type: outcome	Multivariable regression model	A reduction of 1 death was associated with an increase in efficient cost of $28 926 (P <0.001).	Positive

Mukamel et al, 2002 (57)	338 hospitals in California with available data (1982–1989)	Hospital costs (from AHA cost reports) per adjusted discharge. Type: accounting costs	Risk-standardized mortality rates from all causes and from AMI, CHF, pneumonia, and stroke. Type: outcome	Multivariable regression model	An additional $1000 in cost per adjusted discharge was associated with 0.47 fewer deaths per 100 discharges (P <0.001).	Positive

Mukamel et al, 2001 (58)	FFS Medicare beneficiaries	Wage-adjusted hospital costs per adjusted admission reported to AHA. Type: accounting costs	30-d mortality. Type: outcome	Multivariable regression model	Compared with hospitals at the 50th percentile of cost per admission, hospitals at the 75th percentile had lower mortality rates (9.11 vs. 9.36 deaths per 100 discharges; P <0.001), with the largest effect observed for hospitals with expenditures at or above the 90th percentile (8.84 vs. 9.36; P <0.001).	Positive

Ong et al, 2009 (59)	3999 patients hospitalized with CHF at 6 California hospitals from 1 January 2001 to 30 June 30 ("looking forward" cohort); 1650 patients in the "looking forward" cohort who died between 1 July 2001 and 31 December 2005 ("looking back" cohort).	Total hospital direct costs (from hospital cost accounting systems) per discharge. Type: accounting costs	180-d mortality. Type: outcome	Multivariable regression model	Spearman rank correlation between adjusted cost and adjusted mortality for the "looking forward" cohort was −0.93 (P <0.010). Patterns of resource utilization across hospitals were not the same between the "looking forward" and "looking back" cohorts.	Positive

Picone et al, 2003 (23)	5332 Medicare beneficiaries aged >65y with hip fracture, stroke, coronary heart disease, or CHF diagnosis and surviving initial admission	Total cost of inpatient admission, calculated as sum of adjusted hospital charges (using cost-to-charge ratios) and physician Part B payments. Type: accounting costs	2-y mortality. Type: outcome	Instrumental variables analysis and quasi-maximum-likelihood estimator with discrete factor approximations	Probability of dying within 2 y decreased 0.0043 for each $1000 increase in cost of a hospital stay (P <0.010).	Positive

Romley and Goldman, 2008 (60)	Medicare beneficiaries aged >65y with pneumonia diagnosis	Hospital total costs per discharge measured as adjusted charges using cost-to-charge ratios. Type: accounting costs	"Revealed quality" measured by patient choice of hospital. Type: patient experience	Instrumental variables analysis	Quality improvement from the 25th to 75th percentile would increase costs at the average hospital by approximately 50%.	Positive

Romley et al, 2011 (24)	Patients hospitalized with 1 of 6 major medical conditions	Average hospital spending in the last 2 y of life for patients with chronic conditions. Type: expenditure	Inpatient mortality. Type: outcome	Multivariable regression model	For each of 6 diagnoses at admission higher-spending hospitals were associated with lower risk-adjusted inpatient mortality (highest- vs. lowest-spending quintile in 2004–2008: AMI OR, 0.741 [95% CI, 0.590–0.891]; CHF OR, 0.755 [CI, 0.630–0.879]; stroke OR, 0.811 [CI, 0.680–0.942]; gastrointestinal hemorrhage OR, 0.821 [CI, 0.668–0.975]; hip fracture OR, 0.973 [CI, 0.758–1.188]; pneumonia OR, 0.729 [CI, 0.624–0.834]).	Positive

Saleh et al, 2012 (61)	48 574 pneumonia patients admitted to 189 New York hospitals (2005)	Standardized total average cost of care per discharge calculated from cost-to-charge ratios. Type: accounting costs	Composite measure of successfully delivered process measures to opportunities to provide appropriate care. Type: process	Multivariable regression models	Compared with hospitals in the top performance quartile, the ratios of average cost for hospitals in the 2nd, 3rd, and 4th quartiles were 1.05, 1.04, and 0.98, respectively.	Imprecise or indeterminate

Schreyögg and Stargardt, 2010 (20)	35 279 patients treated for AMI at 115 VA hospitals (2000–2006)	Costs incurred during index hospitalization, from cost accounting system. Type: accounting costs	1-y mortality and readmission. Type: outcome	Instrumental variables analysis	A $100 decrease in cost was associated with a 0.63% increase in the hazard of dying (P <0.001) and a 1.24% increase in the hazard to be readmitted conditional on not dying (P <0.001).	Positive

Silber et al, 2010 (62)	Medicare admissions to 3065 hospitals for general, orthopedic, and vascular surgery (n = 4 558 215 unique patients) (2000–2005)	EOL-EI. Type: care intensity index	30-d mortality; in-hospital complications; failure-to-rescue. Type: outcome	Multivariable regression model	The OR for complications in hospitals at the 75th percentile of aggressive treatment style compared with those at the 25th percentile (a U.S. $10 000 difference) was 1.01 (P <0.066), whereas the OR for mortality was 0.94 (P <0.001) and failure-to-rescue was 0.93 (P <0.001).	Mixed-positive

Yasaitis et al, 2009 (14)	2712 U.S. hospitals reporting to Hospital Compare (2004–2007)	EOL-EI. Type: care intensity index	Composite of 11 Hospital Compare process quality measures for AMI, pneumonia, and CHF. Type: process	Multivariable regression model	Increase of $10 000 in end-of-life spending associated with change of –5.3 percentage points for overall quality (P <0.001), –5.2 percentage points for AMI (P <0.001), –9.2 percentage points for pneumonia (P = 0.001), and –0.3 percentage points for CHF (P = 0.687).	Negative

Zhang et al, 2009 (63)	316 deceased cancer patients at 7 treatment sites (2002–2007)	Per-capita spending for hospital stays and hospice care received in last week of life. Type: expenditure	Caregiver rating of patient quality of death, mortality. Type: outcome	Multivariable regression model	Patients with higher costs had lower quality of death in their final week (Pearson partial correlation coefficient = −0.17; P = 0.006).	Negative
Nursing homes

Anderson et al, 1998 (64)	494 nursing homes in Texas (1990)	Total cost per resident day. Type: accounting costs	Composite of 11 resident outcomes. Type: outcome	Multivariable regression model	Nursing homes with the best outcomes had 7% higher cost per resident day than nursing homes with the lowest cost per day ($45.52 vs. $42.48; P <0.050).	Positive

Cohen and Spector, 1996 (35)	658 Medicaid-certified nursing homes and 2663 residents (1987)	Medicaid nursing home payment rate per day. Type: expenditure	Mortality; change in functional status; presence of bedsores. Type: outcome	Multivariable regression model	The reimbursement rate was not significantly associated with outcomes (magnitude not presented).	Article-level: mixed. This comparison: imprecise or indeterminate

Cohen and Spector, 1996 (35)	658 Medicaid-certified nursing homes and 2663 residents (1987)	Medicaid nursing home payment rate per day. Type: expenditure	Number of RNs, LPNs, and total nursing staff per 100 facility residents. Type: structure	Multivariable regression model	Additional dollar of Medicaid reimbursement per day associated with 0.16 more LPNs per 100 residents (P <0.050), 0.003 more RNs per 100 residents (P >0.050), and 0.061 more total staff per 100 residents (P >0.050).	Mixed-positive

Grabowski, 2001 (36)	15 067 federally certified Medicaid and Medicare nursing homes (1995–1996)	Medicaid nursing home payment rate. Type: expenditure	Medication error rate, use of urethral catheters, use of feeding tubes, use of physical restraints. Type: process	Multipart multivariable regression models	No significant association between Medicaid reimbursement and 4 process measures (Medicaid rate of $105 vs. $65 associated with 0.62–percentage point decrease in medication errors, 0.23–percentage point decrease in use of feeding tubes, 0.07–percentage point decrease in use of catheters, and 0.80–percentage point decrease in use of physical restraints; all P >0.050).	Imprecise or indeterminate

Grabowski, 2001 (36)	15 067 federally certified Medicaid and Medicare nursing homes (1995–1996)	Medicaid nursing home payment rate. Type: expenditure	Number of facility deficiencies assigned in Medicaid certification process, including 175 measures of structure, process, and outcome. Type: composite measure	Multipart multivariable regression models	No significant association between Medicaid reimbursement and number of deficiencies (Medicaid rate of $105 vs. $65 associated with 0.62 fewer deficiencies [5.66 vs. 6.28 {95% CI for difference, −4.07 to 20.42}]).	Imprecise or indeterminate

Grabowski, 2001 (36)	15 067 federally certified Medicaid and Medicare nursing homes (1995–1996)	Medicaid nursing home payment rate. Type: expenditure	Number of RNs, LPNs, and nurses' assistants per 100 facility residents. Type: structure	Multipart multivariable regression model	Medicaid rate of $105 vs. $65 associated with 1.44 (22%) more RNs per 100 residents (P <0.050). For LPN and nurses’ assistant measures, there was a positive but not significant effect (Medicaid rate of $105 vs. $65 associated with increase of 13% and 11%, respectively; both P <0.050).	Mixed-positive

Grabowski, 2001 (37)	15 643 federally certified Medicare and Medicaid nursing homes (1996)	Medicaid nursing home payment rate. Type: expenditure	Proportion of residents with pressure sores. Type: outcome	Multivariable regression model	An increase in Medicaid reimbursement of $1 was associated with a 0.9969 (1996 national sample, P <0.010) and a 0.9983 (1996 New York sample, P >0.050) lower likelihood of a resident acquiring a pressure sore.	Mixed-positive

Grabowski, 2001 (37)	15 643 federally certified Medicare and Medicaid nursing homes (1996)	Medicaid nursing home payment rate. Type: expenditure	Number of RNs. Type: structure	Multivariable regression model	An increase in the Medicaid rate of $1 was associated with an additional 0.14 RNs per nursing home (P <0.001) in a 1981 national sample; 0.13 in a 1996 New York sample (P <0.010); but no significant association in a 1996 national sample.	Mixed-positive

Hicks et al, 2004 (43)	446 non–hospital-based nursing homes in Missouri (1999)	Variable costs for patient care, ancillary services, and administration from cost reports. Type: accounting costs	ADL decrease; pressure ulcers; weight loss; initiation of psychotropic drugs. Type: outcome	Multivariable regression model	Negative, cubic association between variable costs and decrease in ADL (P <0.050), weight loss (P <0.050), pressure ulcer incidence (P = 0.106), and psychotropic drug use (P = 0.708).	Mixed-negative

Mukamel and Spector, 2000 (65)	525 public and private freestanding nursing homes in New York (1991)	Facility variable costs. Type: accounting costs	ADL decrease; pressure ulcers; 6-mo mortality. Type: outcome	Multivariable regression model	Regression result shows inverted U-shaped association between quality and costs (interpretation of magnitudes not presented; ADL decrease, P <0.050 for linear term and P <0.100 for quadratic term; pressure ulcers, P >0.100 for linear term and P <0.050 for quadratic term; mortality, P >0.100 for linear term and P <0.050 for quadratic term).	Mixed

Weech-Maldonado et al, 2006 (66)	749 nursing homes in New York, Kansas, Vermont, Maine, and South Dakota (1996)	Total patient care costs (direct, ancillary, and indirect costs) per resident day. Type: accounting costs	Pressure ulcers worsening; mood decline. Type: outcome	Instrumental variables analysis	Pressure ulcers had a significant inverted U-shaped association with quality, with increasing costs at the lower range of quality but decreasing costs associated with higher quality after a threshold. Mood decline exhibited the opposite pattern, with a relatively flat curve at the lower range of quality but increasing costs after a threshold.	Mixed

Weech-Maldonado et al, 2003 (67)	781 nursing homes in New York, Kansas, Vermont, Maine, and South Dakota (1996)	Total patient care costs (direct, ancillary, and indirect costs) per resident day. Type: accounting costs	Use of physical restraints; prevalence of urethral catheters. Type: process	Structural equation modeling	Process quality did not have a significant direct effect on costs (magnitude not reported).	Article-level: mixed. This comparison: imprecise or indeterminate

Weech-Maldonado et al, 2003 (67)	781 nursing homes in New York, Kansas, Vermont, Maine, and South Dakota (1996)	Total patient care costs (direct, ancillary, and indirect costs) per resident day. Type: accounting costs	Cognitive decline; mood decline; pressure ulcer prevalence and incidence. Type: outcome	Structural equation modeling	Better outcomes quality was associated with lower costs (magnitude not reported, P <0.010).	Negative

Weech-Maldonado et al, 2003 (67)	781 nursing homes in New York, Kansas, Vermont, Maine, and South Dakota (1996)	Total patient care costs (direct, ancillary, and indirect costs) per resident day. Type: accounting costs	Staffing mix. Type: outcome	Structural equation modeling	Greater RN staffing was associated with higher costs (magnitude not reported, P <0.100).	Positive
Physician

Bradbury et al, 2000 (68)	175 249 adult medical service admissions to 100 hospitals in 25 states for 26 DRGs (1993–1994)	Total charges, ancillary charges, and LOS. Type: charges	In-hospital mortality and morbidity, defined as continued clinical instability determined by presence of MedisGroups key clinical findings. Type: outcome	Multivariable regression model	Total charges showed a positive, significant (P <0.010) association with mortality and morbidity; insufficient information presented to abstract magnitude of associations.	Negative

Rosenthal et al, 2008 (38)	Commercially-insured beneficiaries of 6 Massachusetts health plans treated by 496 Bridges to Excellence–recognized physicians and 5120 nonrecognized physicians (2003–2006)	Price-standardized payments per episode of care. Type: expenditure	Bridges to Excellence Physician Office Link recognition based on a composite of structure measures. Type: structure	Multivariable regression model	Physician Office Link–recognized physicians had significantly fewer episodes per patient (2.09 vs. 2.22, P <0.050) and lower average resource use per episode ($570 vs. $700, P <0.050) than non-recognized physicians.	Article-level: mixed. This comparison: Negative

Rosenthal et al, 2008 (38)	Commercially-insured beneficiaries of 6 Massachusetts health plans treated by 496 Bridges to Excellence–recognized physicians and 5120 nonrecognized physicians (2003–2006)	Price-standardized payments per episode of care. Type: expenditure	Bridges to Excellence Diabetes Care Link recognition based on a composite of process measures. Type: process	Multivariable regression model	Diabetes Care Link–recognized PCPs had more episodes per patient (2.61 vs. 2.44, P <0.050) and lower average resource use per episode ($623 vs. $649, P <0.050) compared with nonrecognized PCPs. Diabetes Care Link–recognized endocrinologists had more episodes per patient (1.66 vs. 1.58; P <0.050) and higher average resource use per episode ($2671 vs. $2534; P <0.050) compared with nonrecognized endocrinologists.	Mixed-positive

Starfield et al, 1994 (69)	2024 Medicaid patients aged >65 y treated by 135 Maryland physicians for diabetes, hypertension, asthma, well-child care, or otitis media (1988)	Annual total Medicaid payments per capita. Type: expenditure	Emergency care visits and ambulatory care-sensitive hospitalizations. Type: access	Risk adjustment of payments variable	No significant association between access and cost (magnitude not reported).	Article-level: mixed. This comparison: imprecise or indeterminate

Starfield et al, 1994 (69)	2024 Medicaid patients aged >65 y treated by 135 Maryland physicians for diabetes, hypertension, asthma, well-child care, or otitis media (1988)	Annual total Medicaid payments per capita. Type: expenditure	Condition-specific composites of multiple process quality measures. Type: process	Risk adjustment of payments variable	No consistent association between process measures and cost, although patients of low-cost providers had the highest (worst) scores for diabetes, hypertension, and well-adult care (magnitude not reported).	Mixed-positive

Starfield et al, 1994 (69)	2024 Medicaid patients aged >65 y treated by 135 Maryland physicians for diabetes, hypertension, asthma, well-child care, or otitis media (1988)	Annual total Medicaid payments per capita. Type: expenditure	Diabetes outcome (specific measure not reported). Type: outcome	Risk adjustment of payments variable	No significant association between outcomes and cost (magnitude not reported).	Imprecise or indeterminate
Provider groups

Kralewski et al, 2011 (70)	36 medical groups in Minnesota that care for at least 300 patients (2007–2008)	Risk-adjusted sum of average allowed amount paid for each service, procedure, and prescription PMPY. Type: expenditure	6 process measures from Minnesota Community Measurement database. Type: process	None	Spearman correlation coefficients between cost and process quality measures were negative for 6 of 7 quality measures, ranging from −0.19 to 0.04; statistical significance not reported.	Imprecise or indeterminate

Solberg et al, 2002 (71)	110 000–150 000 employees and dependents of member companies of an employer coalition in Minnesota receiving care from 18 provider groups (1996–1998)	Price-standardized payments per patient-year as reported in employer coalition claims database. Type: expenditure	Multiple process quality measures for depression; adult and child asthma; diabetes; and preventive services. Type: process)	Multivariable regression model	No significant association between cost and 13 quality measures (low-cost tercile vs. middle tercile: OR, 0.85–1.1.38; high-cost tercile vs. middle tercile: OR, 0.82–1.62; all P >0.050). Low-cost tercile associated with higher quality compared with middle tercile for 4 quality measures (OR, 1.34–1.85; P <0.050) and lower quality for 1 quality measure (OR, 0.49; P <0.010). High-cost tercile associated higher quality compared with middle tercile for 3 quality measures (OR, 1.14–1.51; P <0.050).	Mix ed
Patient-level

Cunningham, 2009 (72)	32 210 adults sampled from 60 Community Tracking Study sites in 2003 reporting they have a physician usual source of care	High medical cost burden, defined as out-of-pocket medical spending: insurance premiums ratio. Type: expenditure	Patient trust in their physician, patient assessment of quality of care from physician. Type: patient experience	Multivariable regression model	Persons with high medical cost burdens had greater odds of lacking trust in their physician to put their needs first (OR, 1.40 [95% CI, 1.15–1.70]), and 2 other measures of mistrust of their physician. High medical cost burden was also associated with negative assessments of the thoroughness of care they receive (OR, 1.26 [CI, 1.02–1.56]) and 2 other measures of perceived quality.	Negative

Doyle et al, 2012 (73)	667 143 Medicare FFS beneficiaries hospitalized through ED; secondary analysis with 637 813 patients in New York within 5 miles of an ambulance referral boundary (2002–2008)	Hospital costs per discharge, estimated using charges and cost-to-charge ratios. Type: accounting costs	Mortality within 30 d or 1 y of discharge. Type: outcome	Instrumental variables analysis	10% higher cost associated with 1.44 percentage points lower 1-y mortality rate (P <0.010); second empirical strategy finds that 10% higher cost associated with 0.47–0.54 percentage points lower 1-y mortality rate (P <0.050), varying by sample.	Positive

Fenton et al, 2012 (74)	51 946 adult respondents to MEPS (2000–2007)	Total annual health spending per capita. Type: expenditure	Patient satisfaction with physician communication. Type: patient experience	Multivariable regression models	Compared with patients in the lowest quartile of patient satisfaction, patients in the highest quartile had 8.8% higher (95% CI, 2.3%–16.4%) total health spending.	Positive

Fu and Wang, 2008 (19)	A nationally representative sample of 13 980 adults (aged ≥18 y) in the MEPS (2003)	Annual per-capita total health spending, including private insurance, public payers, and other sources. Type: expenditure	Patient self-rating of health care for all physicians and providers encountered. Type: patient experience	Multivariable regression model	No significant association between patient satisfaction and annual per-capita total health expenditure (coefficient = 0.004, no other information on magnitude presented, P = 0.60).	Imprecise or indeterminate

Hadley et al, 2011 (25)	17 438 beneficiaries aged >64 y entering MCBS (1991–1999)	Total health spending per-capita, total Medicare spending per capita. Type: expenditure	Mortality after 3 y; HALex. Type: outcome	Instrumental variables analysis	10% greater medical spending over previous 3 y was associated with a 1.5% greater survival probability (P = 0.039; range, 1.2–1.7, depending on spending measure) and a 1.9% larger HALex value (P = 0.45; range, 1.2–2.2).	Positive

ACE = angiotensin-converting enzyme; AC-EI = Acute Care Expenditure Index; ADL = activity of daily living; AHA = American Hospital Association; AMI = acute myocardial infarction; CHF = congestive heart failure; CMS = Centers for Medicare & Medicaid Services; DRG = diagnosis-related group; ED = emergency department; EOL-EI = End-Of-Life Expenditure Index; FFS = fee-for-service; HALex = Health and Activity Limitations Index; HCAHPS = Hospital Consumer Assessment of Healthcare Providers and Systems; HCUP NIS = Healthcare Cost and Utilization Project National Inpatient Sample; HQA = Hospital Quality Alliance; HRR = hospital referral region; ICU = intensive care unit; LDL = low-density lipoprotein; LOS = length of stay; LPN = licensed practical nurse; MCBS = Medicare Current Beneficiary Survey; MEPS = Medical Expenditure Panel Survey; OR = odds ratio; PCP = primary care physician; PMPY = per member per year; PPD = predicted probability of dying; QIO = quality improvement organization; RN = registered nurse; RR = relative risk; SEER = Surveillance, Epidemiology and End Results; VA = Veterans Affairs; VHA = Veterans Health Administration.