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01.12.2012 | Research article | Ausgabe 1/2012 Open Access

BMC Health Services Research 1/2012

Evaluating the effects of variation in clinical practice: a risk adjusted cost-effectiveness (RAC-E) analysis of acute stroke services

BMC Health Services Research > Ausgabe 1/2012
Clarabelle Pham, Orla Caffrey, David Ben-Tovim, Paul Hakendorf, Maria Crotty, Jonathan Karnon
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​1472-6963-12-266) contains supplementary material, which is available to authorized users.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

All authors have contributed significantly to the design and coordination of the study. CP, OC and JK performed the statistical analyses and interpretation of data and drafted the manuscript. All authors made substantial contributions to the critical revisions of the manuscript and gave final approval of the version to be published.



Methods for the cost-effectiveness analysis of health technologies are now well established, but such methods may also have a useful role in the context of evaluating the effects of variation in applied clinical practice. This study illustrates a general methodology for the comparative analysis of applied clinical practice at alternative institutions – risk adjusted cost-effectiveness (RAC-E) analysis – with an application that compares acute hospital services for stroke patients admitted to the main public hospitals in South Australia.


Using linked, routinely collected data on all South Australian hospital separations from July 2001 to June 2008, an analysis of the RAC-E of services provided at four metropolitan hospitals was undertaken using a decision analytic framework. Observed (plus extrapolated) and expected lifetime costs and survival were compared across patient populations, from which the relative cost-effectiveness of services provided at the different hospitals was estimated.


Unadjusted results showed that at one hospital patients incurred fewer costs and gained more life years than at the other hospitals (i.e. it was the dominant hospital). After risk adjustment, the cost minimizing hospital incurred the lowest costs, but with fewer life-years gained than one other hospital. The mean incremental cost per life-year gained of services provided at the most effective hospital was under $20,000, with an associated 65% probability of being cost-effective at a $50,000 per life year monetary threshold.


RAC-E analyses can be used to identify important variation in the costs and outcomes associated with clinical practice at alternative institutions. Such data provides an impetus for further investigation to identify specific areas of variation, which may then inform the dissemination of best practice service delivery and organisation.
Additional file 1: Table S1. Relevant covariates for the stroke cost extrapolation models. PDF - Table S2. Relevant covariates for the stroke survival extrapolation models. PDF - Table S3. Relevant covariates for the expected lifetime survival and cost models. (PDF 109 KB)
Additional file 2: Figure S1. Mean survival curves versus Kaplan-Meier survival curves for intermediate endpoints. (PDF 66 KB)
Authors’ original file for figure 1
Authors’ original file for figure 2
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