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(Stroke. 1999;30:2759.)
© 1999 American Heart Association, Inc.

Letters to the Editor

Systematic Review of Cost-Effectiveness Research of Stroke Evaluation and Treatment

Shah Ebrahim, DM, FRCP, FFPHM

Department of Social Medicine, Codinating Editor, Cochrane Heart Group, University of Bristol, Bristol, UK

	Introduction

 
To the Editor:

Holloway and colleagues’ review of cost-effectiveness studies in stroke evaluation and treatment¹ may have inadvertently introduced major biases by the selection criteria used for inclusion of studies. They decided to include only studies that used quality-adjusted life-years (QALYs) as the indicator of health effect. The justification for this criterion is not given. By doing this, cost-effectiveness studies that used indicators such as lives saved or strokes avoided are excluded, and the authors do not provide information on study exclusions to allow the reader to assess the potential bias created.

The review is biased in two ways. First, the use of QALYs is inappropriate in many areas of stroke evaluation and management where measures of diagnostic accuracy, patient satisfaction, or reduction in symptoms are of relevance. It is noteworthy that the review excluded consideration of the most effective intervention for stroke management—organized stroke care and rehabilitation—for which reviews of cost-effectiveness studies have been performed.^{2 3} Thus, the review is biased in describing the range of cost-effectiveness studies in stroke.

Second, the review provides biased estimates of cost-effectiveness. To illustrate this bias, consider the use of anticoagulation for patients with nonvalvular atrial fibrillation. The cost-effectiveness studies they present show that warfarin dominates among high- and medium-risk patients but in low-risk patients has a very high cost per QALY. The authors concluded that anticoagulation was the preferred option for all but the low-risk patients.

A cost-effectiveness study comparing anticoagulation only, anticoagulation or aspirin, or aspirin only that reported cost per stroke . . . [Full Text of this Article]

Robert G. Holloway, MD, MPH Curtis G. Benesch, MD

Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, New York

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