Abstract
Care of stroke patients costs considerably more in specialized stroke units (SU) compared to care in general medical wards (GMW) but the technology may be cost effective if it leads to significantly improved outcomes. While randomized control trials show better outcomes for stroke patients admitted to SU, observational studies report mixed findings. In this paper we use individual level data from first-ever stroke patients in four European cities and find evidence of selection by the initial severity of stroke into SU in some cities. In these cases, the impact of admission to SU on outcomes is overestimated by multivariate logit models even after controlling for case-mix. However, when the imbalance in patient characteristics and severity of stroke by admission to SU and GMW is adjusted using propensity score methods, the differences in outcomes are no longer statistically significant in most cases. Our analysis explains why earlier studies using observational data have found mixed results on the benefits of admission to SU.
Highlights
European health care systems have significant differences among them but a common feature is to typically rely on a coordinated or centrally planned decision about the adoption of new technologies and services
534 patients were admitted to stroke units (SU) wards of which 15% died within one month, while 958 patients were admitted to general medical wards (GMW) wards, of which 12% died within one month
Randomized control trials, as well as meta analysis of randomized trials have typically shown benefits to patients admitted to stroke units over general wards and have formed the foundation of evidence based stroke care since the mid 1990’s [16,20,21]
Summary
European health care systems have significant differences among them but a common feature is to typically rely on a coordinated or centrally planned decision about the adoption of new technologies and services. Cost-effectiveness analysis plays an important role in this decision. Analysis based on observational data, as opposed to randomized control trials, may reach different conclusions about the relative effectiveness (or cost effectiveness) of a new service. In part this may be due to selective assignment of patients to new technologies or services relative to the standard care in different centers. In this paper we use observational data on patient outcomes from four European cities on stroke patients who are exposed to an expensive technology – admission to a specialized stroke unit ward (SU) or general medical wards (GMW), and demonstrate the importance
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