Hospitals in the largest US cities deliver a lower value patient care than other parts of the country, according to a new report.

Data Advantage’s 2009-2010 hospital value index studied hospital quality, price, efficiency, and patient satisfaction in 4,500 hospitals across the US.

It found that hospitals in urban areas surrounding the US’s largest cities provide less affordable and less efficient care.

Other than Fort Myers and Las Vegas, the lowest-ranking large markets were all in California, the report said.

The top five states for delivering value were North Dakota, Iowa, Montana, South Dakota and Maine.