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Medicare spending on pharmaceuticals varies substantially among US localities and hospital-referral regions, even after adjustment for variation in demographic characteristics, individual health status, and insurance coverage. 1 If the drugs that are prescribed in highspending regions are necessary and appropriate, the high spending may be justified by the health improvement they generate. But if such prescribing is not appropriate, the higher use could have serious adverse consequences. The elderly are twice as likely as people under the age of 65 years to have adverse events associated with drugs and almost seven times as likely to be hospitalized as a result. 2 Although we have established that regions with higher drug spending do not seem to have offsetting reductions in medical spending (after adjustment for variation in medical risk), 1 little is known about how, if at all, the quality of prescribing varies …