title: The association between health care quality and cost: a systematic review.
abstract: BACKGROUND
  Although there is broad policy consensus that both cost containment and quality improvement are critical, the association between costs and quality is poorly understood.
  
  
  OBJECTIVE
  To systematically review evidence of the association between health care quality and cost.
  
  
  METHODS
  Electronic literature search of PubMed, EconLit, and EMBASE databases for U.S.-based studies published between 1990 and 2012.
  
  
  METHODS
  Title, abstract, and full-text review to identify relevant studies.
  
  
  METHODS
  Two reviewers independently abstracted data with differences reconciled by consensus. Studies were categorized by level of analysis, type of quality measure, type of cost measure, and method of addressing confounders.
  
  
  RESULTS
  Of 61 included studies, 21 (34%) reported a positive or mixed-positive association (higher cost associated with higher quality); 18 (30%) reported a negative or mixed-negative association; and 22 (36%) reported no difference, an imprecise or indeterminate association, or a mixed association. The associations were of low to moderate clinical significance in many studies. Of 9 studies using instrumental variables analysis to address confounding by unobserved patient health status, 7 (78%) reported a positive association, but other characteristics of these studies may have affected their findings.
  
  
  CONCLUSIONS
  Studies used widely heterogeneous methods and measures. The review is limited by the quality of underlying studies.
  
  
  CONCLUSIONS
  Evidence of the direction of association between health care cost and quality is inconsistent. Most studies have found that the association between cost and quality is small to moderate, regardless of whether the direction is positive or negative. Future studies should focus on what types of spending are most effective in improving quality and what types of spending represent waste.
  
  
  BACKGROUND
  Robert Wood Johnson Foundation.
authors.affiliation: RAND Health, Arlington, VA 22202, USA. peter_hussey@rand.org
authors.forename: Peter S
authors.initials: PS
authors.lastname: Hussey
authors.forename: Samuel
authors.initials: S
authors.lastname: Wertheimer
authors.forename: Ateev
authors.initials: A
authors.lastname: Mehrotra
mesh_terms: D015986:Confounding Factors, Epidemiologic; D003363:Cost Control; D017048:Health Care Costs; D006291:Health Policy; D058996:Quality Improvement; D011787:Quality of Health Care / Q000191:economics* / Q000592:standards; D014481:United States