**8. Next Steps**

The large variation in both costs and outcomes coupled with limited evidence in health care to demonstrate the link between spending more money (higher health care costs) and better outcomes (higher quality) presents a dilemma when it comes to investing additional resources in a system that is already constrained. In order to reduce unnecessary health care spending, we must couple cost analyses with outcome studies and evaluate the relationship between the two. While quality improvement initiatives are often used as a tool to improve outcomes, there is also the necessary investment of resources (Figure 3). Therefore, trying to study the delicate balance between what costs are important and necessary and the quality of care delivered inherently comes with many confounders. It is possible to imagine that with greater investment of resources and thus increased costs, the quality of care delivered may be improved. Conversely, higher quality of care could also lead to decreased health care costs due to lower rates of complications, morbidities, and length of stay. Furthermore, utilizing mortality as a marker for quality of care can be problematic in and of itself, as mortality could also arguably decrease cost by reducing the length of stay and reducing resource utilization (in particular in the NICU population).

There is already a model that exists in collaborative quality improvement for centers to learn from best and worst performers in order to learn opportunities for improvement. The same approach should routinely incorporate costs into the conversation in order to allow tools such as *Choosing Wisely* and EHR to drive down unnecessary spending without a ffecting outcomes. There are both micro and macro-economic opportunities for cost reduction while allowing additional financial investments as new technologies, drugs and programs are introduced.

**Figure 3.** The relationship between quality improvement, outcomes, and costs.
