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Importance Rigorous evidence describing the relationship between private equity acquisition and changes in hospital spending and quality is currently lacking. Objective To examine changes in hospital income, use, and quality measures that may be associated with private equity acquisition. Design, Setting, and Participants This cohort study identified 204 hospitals acquired by private equity firms from 2005 to 2017 and 532 matched hospitals not acquired by private equity. Using a difference-in-differences design, this study evaluated changes in net income, charges, charge to cost ratios, case mix index (a measure of reported illness burden), share of discharges for patients with Medicare or Medicaid coverage, discharges per year, and aggregate hospital quality measures associated with private equity acquisition through 3 years after acquisition, adjusted for case mix, hospital beds, calendar year, and adjustment …