Economic Evaluation of Australian Stroke Services
A Prospective, Multicenter Study Comparing Dedicated Stroke Units With
Other Care Modalities
Marjory Moodie, DrPH; Dominique Cadilhac, MpubHlth; Dora Pearce, MIT;
Cathrine Mihalopoulos, PGDHthEc; Robert Carter, PhD; Stephen Davis, MD; Geoffrey Donnan, MD;
for the SCOPES Study Group
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Background and Purpose—Level I evidence from randomized controlled trials demonstrates that the model of hospital
care influences stroke outcomes; however, the economic evaluation of such is limited. An economic appraisal of 3 acute
stroke care models was facilitated through the Stroke Care Outcomes: Providing Effective Services (SCOPES) study in
Melbourne, Australia. The aim was to describe resource use up to 28 weeks poststroke for each model and examine the
cost-effectiveness of stroke care units (SCUs).
Methods—A prospective, multicenter, cohort study design was used. Costs and outcomes of stroke patients receiving 100%
treatment in 1 of 3 inpatient care models (SCUs, mobile service, conventional care) were compared. Health-sector
resource use up to 28 weeks was measured in 1999. Outcomes were thorough adherence to a suite of important clinical
processes and the number of severe inpatient complications.
Results—The sample comprised 395 participants (mean age 73 [SD 14], 77% first-ever strokes, males 53%). When
compared with conventional care (n⫽84), costs for mobile service (n⫽209) were significantly higher (P⫽0.024), but
borderline for SCU (n⫽102, P⫽0.08; $AUD12 251; $AUD15 903; $AUD15 383 respectively). This was primarily
explained by the greater use of specialist medical services. The incremental cost-effectiveness of SCUs over
conventional care was $AUD9867 per patient achieving thorough adherence to clinical processes and $AUD16 372 per
patient with severe complications avoided, based on costs to 28 weeks.
Conclusions—Although acute SCU costs are generally higher, they are more cost-effective than either mobile service or
conventional care. (Stroke. 2006;37:2790-2795.)
Key Words: cost-effectiveness 䡲 stroke management 䡲 stroke units
S
troke is a high-cost, chronic condition. The lifetime costs
of first-ever strokes, estimated as $AUD1.3 billion in
Australia for 1997,1 are expected to increase given an ageing
population. With most acute stroke patients (89%) in Australia admitted to hospital,1 effective management is important.
It has been shown that stroke care units (SCU) provide
improved patient outcomes reducing mortality and morbidity
by about 20% compared with conventional care (CC).2,3 The
reasons for the improved outcomes achieved by SCUs remain
unclear. However, there is consensus that a focused multidisciplinary approach in a localized ward with ongoing education and specialization are essential.3 Adherence to important
processes of care may also be a factor.4 –7 Nevertheless, only
20% of Australian acute public hospitals offer SCUs.8
Although there is worldwide interest in identifying costeffective clinical management strategies, economic evalua-
tions of alternative models of stroke management are few,9 –11
with none in Australia. Most studies use length of hospital
stay to describe stroke management costs12,13; however, it is
a crude surrogate measure which is insensitive and not
generalizable.
An economic appraisal of stroke care was facilitated
through the SCOPES (Stroke Care Outcomes: Providing
Effective Services) study, which examined the structure,
process, resource utilization and outcomes of care for stroke
patients in Victoria, Australia.5 Previously, we provided
evidence for the increased uptake of SCUs through the
delineation of factors that contribute to their greater effectiveness. This included the development of process indicators, which were demonstrated to be adhered to more often in
SCUs. In addition, there was improved survival if all or all
except one applicable indicator was completed.5
Received April 11, 2006; final revision received July 18, 2006; accepted August 9, 2006.
From the Program Evaluation Unit (M.M., D.C., C.M., R.C.), School of Population Health, The University of Melbourne; the National Stroke Research
Institute (D.C., D.P., G.D.), Austin Health, Heidelberg Heights; the National Stroke Foundation (D.C., S.D., G.D.), Melbourne; the Neurology Department
(S.D.), Royal Melbourne Hospital, Parkville; the Neurology Department (G.D.), Austin Health, Heidelberg Heights; and the Department of Medicine
(D.C., S.D., G.D.), The University of Melbourne.
Correspondence to Marjory L Moodie, Program Evaluation Unit, School of Public Health, 4/207 Bouverie Street, The University of Melbourne,
Victoria 3010, Australia. E-mail [email protected]
© 2006 American Heart Association, Inc.
Stroke is available at http://www.strokeaha.org
DOI: 10.1161/01.STR.0000245083.97460.e1
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Moodie et al
Economic Evaluation of Australian Stroke Services
This is the first Australian study to economically evaluate
acute stroke care models using patient-level data. We aimed
to: i) describe the costs associated with each model up to 28
weeks post stroke onset, and (ii) examine the costeffectiveness (efficiency) of SCU and mobile inpatient service (MS) compared with CC. The primary hypothesis was
that SCUs would be more cost-effective up to six months in
terms of adherence to clinically important process of care
indicators and avoidance of severe complications. As
SCOPES was not powered to detect statistically significant
differences in death or dependency,5 these surrogate end
points were used.
Methods
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The methods for SCOPES, a prospective, multicenter cohort
design, have been previously published.5 In brief, 468 participants
were recruited from 8 different public hospitals in Victoria
(Australia). All eligible hospitals participated and included facilities admitting more than 100 stroke patients annually that had a
stroke care model operating ⬎12 months. While some heterogeneity existed between the SCUs, all had the key characteristics
described in the literature.4 Patient eligibility included all consecutive admissions of first-ever or recurrent strokes (ischemic or
intracerebral hemorrhage only) presenting to hospital within 3
days of onset and aged ⱖ18 years. Participating hospitals provided Human Research Ethics Committee approval and subjects
provided informed consent.
Definitions
Stroke: vascular lesion of the brain resulting in a neurological deficit
persisting for at least 24 hours or resulting in the death of the
individual.14
Stroke Care Unit: a designated (geographically localized) ward
area where a dedicated multidisciplinary stroke team focuses its
expertise.
Mobile Service: a dedicated, hospital-based multidisciplinary
team, which reviews stroke patients located in different wards
throughout a hospital.
Conventional Care: general medical ward care with no dedicated
stroke service or health professional team.
Economic Perspective: broad health sector including costs and
outcomes for the government (as third party payer) and patients.
Stroke Subtypes Included: partial anterior circulation infarcts,
posterior circulation infarcts, lacunar infarcts15 and intracerebral
hemorrhage.
Direct Hospital Costs: costs traceable back to individual patients.
Indirect Hospital Costs: costs apportioned to patients to cover
overheads and infrastructure expenses (eg, administration).
Process Indicators: fifteen clinically important indicators including: (1) activities within 24 hours (CT scan, swallowing
assessment, allied health assessment, neurological observations);
(2) documentation of premorbid function and discharge needs;
and (3) management practices (enteric feeding if nil orally for
⬎48 hours, measures to avoid aspiration, deep vein thrombosis
prophylaxis, fever management and use of antiplatelet agents at
discharge (protocol developed before published guidelines for
acute therapy).
Completeness of Care (indicator adherence): “Thorough adherence” was adherence to all, or all except one, applicable process
indicators. Applicability was determined for each indicator based on
its relevance to individual patients (eg, antiplatelet agents were only
applicable for ischemic events).
Severe Complications or Comorbidities: Any new vascular medical condition (stroke progression, recurrent stroke or acute myocardial infarction) or adverse event (eg, aspiration pneumonia) occurring during acute hospitalization and considered incapacitating, life
2791
threatening or resulting in a prolonged stay or increased patient
acuity.
Data Collection
Cost Data
A microcosting approach using individual patient resource-use data
were used. Resource use attributable only to the index stroke was
measured for a median 28-week period and included prehospital
referral and transport costs obtained via self-report or from hospital
medical records.
Costs of the acute admission were sourced directly from
hospital finance departments. Five of the 8 hospitals provided
clinical costing data for each patient, in accordance with the
Clinical Costing Standards Association of Australia.16 In 4 of
these 5 hospitals, a “bottom-up” costing approach entailed the
tracking of resources used by individual patients. All operating
costs of individual cost centers were included, thereby enabling
differentiation between the models. Hospitals typically apportioned indirect costs on a monthly basis, which allowed variations
in patient caseload and staff fluctuations to be captured. An
itemized breakdown was available for the direct costs, but
indirect costs by subcategories were not available for MS.
For 1 MS hospital, average costs per category of care were
extrapolated from the other 2 MS hospitals. The absence of patientlevel clinical costing data for the 2 CC hospitals was overcome by
obtaining average cost data for a patient group matched by ICD-10
codes17 from a comparable CC hospital in Melbourne.
All participants recorded posthospital resource-use in a diary.
Stroke-specific resource-use was then obtained by self-report using a
standardized telephone interview schedule. Where information was
unclear or incomplete, follow-up calls were made, wherever possible, to service providers.
Posthospital costs were based on the unit costs used in the
Australian stroke cost-of-illness study,1 obtained from professional associations and national references, such as the Medicare
Benefits Schedule (refer to supplemental Table I of “unit costs,”
available online at http://stroke.ahajournals.org). Costs were adjusted to the 1998 reference year using the Total Health Price
Inflation factor,18 and are reported in $AUD.
Acute Care Outcomes
Health outcomes were: (1) adherence to a suite of applicable, high
priority process indicators7 to reflect best-practice and as a surrogate
measure for better survival5; and (2) rates of severe medical complications. The data for these end points was obtained directly from audit of
patient medical records by trained clinical data abstractors using
standardized proformas with prespecified definitions. Whereas hospitaldata abstractors were not blinded to the models of care, inter-rater
SCOPES cohort used in economic evaluation.
2792
Stroke
November 2006
reliability was assessed and longer-term outcomes including resourceuse were obtained by a blinded researcher.5
Statistical Analysis
Costs and benefits for participants receiving 100% treatment in 1
of the 3 acute care models were compared. Discounting was
unnecessary as both costs and benefits occurred in the same year.
Mean costs were reported to estimate incremental costeffectiveness ratios, and paired comparisons made assuming
unequal variances. Standard tests for categorical data (Fisher
exact test and Pearson ␹2 test) and nonparametric tests (MannWhitney) were used for paired comparisons. Incremental costeffectiveness ratio were determined (ie, net cost of the extra unit
of benefit) of SCU and MS relative to the comparator (CC).
Sensitivity analysis was undertaken for thorough adherence to
process indicators using @RISK software (Palisade Corp, 1997).
TABLE 1.
The 97% uncertainty range (median, 2.5 and 97.5 percentile) was
calculated with 5000 iterations (Monte Carlo simulation) and
based on a triangular distribution of ⫾10% around costs and
effects. Level of significance was P⬍0.05. Statistical analysis
was undertaken using Excel (97) and Intercooled Stata 8.0.
Results
Participating Hospitals
All 3 SCU and the 3 MS sites were in tertiary teaching
hospitals although MS hospitals were smaller in terms of bed
numbers. Although the 2 CC facilities were in smaller
suburban hospitals, the average cost data used for CC
participants was extrapolated from a larger (nonteaching)
hospital.
Characteristics of Cohort by Treatment Model
Care Model*
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100% Treatment in Care Type
No. of patients
Age stroke onset median (Q1, Q3)†
SCU*
MS*
P Values
CC*
102
209
84
75 (64, 81)
76 (65, 84)
77 (68, 87)
Stroke Subtype n (%)†
Total anterior circulation infarct
11 (11)
47 (23)
17 (20)
Partial anterior circulation infarct
30 (29)
45 (22)
24 (29)
Posterior circulation infarct
15 (15)
29 (14)
6 (7)
Lacunar infarct
31 (30)
65 (31)
31 (37)
Intracerebral hemorrhage
15 (15)
23 (11)
Length of stay median (Q1, Q3)†
MS vs CC
0.099
0.019
0.180
0.107
0.092
0.268
6 (7)
0.646
0.400
0.490
61 (60)
104 (50)
45 (54)
0.116
0.457
0.606
First-ever stroke, n (%)§
81 (79)
165 (79)
59 (70)
1.000
0.173
0.128
Admission Glascow Coma Score⫽15
(normal)
69 (68)
123 (59)
52 (62)
0.139
0.442
0.693
Urinary incontinence ⬍72 hours of stroke
38 (37)
97 (46)
35 (42)
0.144
0.550
0.517
6 (6)
33 (16)
21 (25)
0.017
⬍0.001
0.069
3 (50)
7 (21)
5 (24)
6 (18)
5 (24)
Aspiration pneumonia**
Stroke progression**
2 (33)
7 (5, 14)
SCU vs CC
Male, n (%)§
Severe complication or co-morbidity n(%)§储
8 (4, 16)
SCU vs MS
9 (5, 15)
Total adherence to priority indicators
(n-i⫽0) n (%)§
12 (12)
11 (5)
0 (0)
0.062
0.001
0.037
Thorough adherence to priority indicators
(n-iⱕ1) n (%)§
36 (35)
27 (13)
3 (4)
⬍0.001
⬍0.001
0.018
0.137
0.104
0.873
Home
38 (37)
71 (34)
27 (32)
Inpatient rehabilitation
47 (46)
82 (39)
32 (38)
Aged care (nursing home or hostel)
8 (8)
24 (12)
12 (14)
Other hospital
2 (2)
4 (2)
2 (2)
Discharge destination†
Cost to discharge (average) - all strokes¶
- first stroke
$6187
$7078
$4676
0.103
⬍0.001
⬍0.001
$6274
$6103
$4680
0.756
0.003
0.003
$5851
$10 737
$4665
0.001
0.223
⬍0.001
$15 383
$15 903
$12 251
0.748
0.082
0.024
- first strokes
$16 072
$14 599
$12 826
0.431
0.154
0.380
- recurrent strokes
$12 726
$20 791
$10 893
0.009
0.471
⬍0.001
- recurrent stroke
Total costs (average) - all strokes¶
*SCU: stroke care unit (excludes 73 patients who received only some SCU care), MS: mobile inpatient service, CC: conventional care.
For paired comparisons, the following are used: †Mann-Whitney test; ‡Pearson ␹2 test; §Fisher exact test; ¶t tests with unequal variances assumed.
储Medical complications included falls, urinary tract infections, aspiration pneumonia, other chest infections, decubitis ulcers, deep vein thrombosis. Comorbidities
were defined as progression of index stroke, a recurrent stroke or acute myocardial infarction.
**Main types of severe complications or comorbidities recorded, individual numbers too small for meaningful interpretation.
Moodie et al
TABLE 2.
Economic Evaluation of Australian Stroke Services
2793
Average Patient Costs, All Strokes, by Care Phase and Model
Average Cost ($AUD)
Model
SCU
MS
P Value†
CC
SCU vs MS
SCU vs CC
MS vs CC
Pre-acute costs
Referral costs‡
$49
$79
$42
0.266
0.805
0.183
$376
$421
$424
0.152
0.197
0.915
$426
$500
$466
0.067
0.378
0.401
Nursing
$1615
$1311
$833
0.086
⬍0.001
⬍0.001
ICU/CCU
$0
$66
$31
0.163
0.006
0.479
Surgery
$1
$22
$11
0.015
0.177
0.324
Medical
$941
$582
$418
⬍0.001
⬍0.001
⬍0.001
Emergency
$302
$316
$195
0.540
⬍0.001
⬍0.001
Imaging
$417
$275
$515
0.009
0.376
0.024
Pathology
$188
$737
$506
⬍0.001
⬍0.001
0.008
Pharmacy
$210
$204
$165
0.891
0.025
0.269
$20
$49
$66
0.145
0.005
0.400
Allied health
$463
$495
$373
0.620
0.102
0.003
Catering
$300
$272
$290
0.344
0.689
0.346
Ambulance costs
Total
Acute costs
Direct costs
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Theatre
Direct costs total
$4457
$4329
$3402
0.733
0.003
0.002
Indirect costs total
$1305
$2249
$808
⬍0.001
⬍0.001
⬍0.001
$5761
$6579
$4210
0.129
⬍0.001
⬍0.001
$6187
$7078
$4676
0.103
⬍0.001
⬍0.001
Home to hostel or NH§; or hostel to NH
$844
$1832
$1196
0.042
0.366
0.225
General practitioner
$190
$165
$157
0.324
0.207
0.642
Specialist medical
$107
$72
$56
0.149
0.079
0.425
Acute costs total
Costs to discharge
Postacute costs
Rehabilitation㛳
$6337
$5370
$4237
0.406
0.084
0.272
Community support
$156
$154
$249
0.976
0.359
0.318
Allied health
$453
$392
$412
0.604
0.771
0.857
$1108
$839
$1267
0.694
0.862
0.540
Other#
Postacute costs total
Total costs to 28 weeks (SD)
$9196
$8824
$7575
0.795
0.328
0.401
$15 383 ($12 866)
$15 903 ($14 388)
$12 251 ($11 558)
0.748
0.082
0.024
†For paired comparisons, t tests are used with unequal variances assumed. ‡General practitioner; §NH indicates nursing home; 储Includes inpatient
rehabilitation in a dedicated subacute hospital or ward, day rehabilitation and outpatient rehabilitation; #Includes other stroke-related costs.
Patient Sample
Of the 468 SCOPES participants, 395 (84%) were patients
receiving 100% care in 1 of the 3 care models (SCU 102, MS
209, CC 84; Figure). The economic analysis included 305
first-ever and 90 recurrent stroke patients, of which the mean age
was 73 (SD 14) and 53% were male. The participants were
comparable in terms of age, gender, stroke subtype, stroke
severity and length of acute hospital stay (Table 1). The 73
excluded cases not receiving 100% treatment in a SCU did not
differ from included patients in terms of age, gender and stroke
subtype; however, more had upper-limb weakness on admission
and were incontinent within 72 hours of stroke.
Cost Analysis
Table 2 outlines the resource categories and associated
average costs per patient for each category by care model.
When compared with CC ($AUD12 251), average costs to 28
weeks for both MS ($AUD15 903, P⫽0.024) and SCU
($AUD15 383, P⫽0.08) were higher.
Prehospital costs, accounting for about 3% of total average
costs, exhibited minimal variation between the 3 models. The
major component was ambulance transport to hospital.
Acute hospital costs accounted for between 34% (CC) and
41% (SCU) of average total costs. Direct hospital costs
accounted for a higher proportion of acute costs in CC (81%)
than the other 2 models (SCU 77%, MS 66%). The categories
of acute direct costs varied according to care model with
higher costs for nursing, medical and emergency in SCU than
CC. Nursing costs were consistently the largest acute cost
component for each model (between 20% to 28%), with
SCUs spending more. Average medical costs in SCUs were
significantly greater than for MS and CC, whereas MS had
lower imaging, but higher pathology costs.
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Stroke
November 2006
TABLE 3.
Outcomes by Care Models: All Strokes
Model
SCU
MS
CC
SCU vs MS
SCU vs CC
MS vs CC
Outcomes
No. per 1000
P Values†
Thorough adherence to process of care measures
353
129
36
⬍0.001
⬍0.001
0.018
158
250
0.017
⬍0.001
0.069
Dominant储
$9867
$39 039
Dominant储
$16 372
$39 629
At least one severe complication
59
Incremental cost-effectiveness ratios‡ ($AUD)
Thorough adherence to process of care measures
Mean§
One or more severe complication avoided
Mean§
†Obtained from 2-sided Fisher exact test; ‡differences in costs between 2 models of care divided
by the difference in health benefit gained; §based on total costs to 28 weeks; 储more health benefits
coupled with cost savings (win-win).
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The major postacute cost driver across all models was
rehabilitation, with the average cost of $AUD6637 for SCU
patients accounting for as much as 69% of these costs (MS
61%, CC 56%).
Acute Outcome Analysis
SCUs were superior to CC in terms of quality of care with
almost 10 times the rate of patients with thorough adherence
to process indicators (353 per 1000 compared with 36,
P⫽⬍0.001). The difference between MS and CC was also
significant (Table 3). The rate of severe complications was
significantly lower for SCU patients (59 per 1000) compared
with CC (250), P⫽⬍0.001).
Incremental Cost-Effectiveness
The incremental cost of SCUs achieving another patient with
thorough adherence was $AUD9867 (median $9977 [$4810 –
$14 885]) over the CC cost (compared with MS $AUD39 039).
In terms of avoiding additional patients with severe complications, the incremental cost-effectiveness of SCU over CC was
$AUD16 372, less than half that of MS over CC ($AUD39 629).
SCUs were “dominant” compared with MS in that for lower
costs, they produced better results for both outcome measures
(Table 3).
Discussion
This study provides further evidence of the superiority of care
delivered in a geographically localized unit. SCUs were
cost-effective and the additional cost in providing SCUs
compared with CC was found to be justified given the greater
health benefits in terms of delivering best practice processes
and avoiding severe complications. Our analysis was
strengthened by the use of individual patient resource-use
data from a prospective, multicenter study.
Although this study lacked power to detect differences in
“hard” outcomes, we have previously established that our
definition of “thorough adherence” was directly linked to a
3-fold improvement in odds of survival at discharge when
differences in age, gender and stroke severity were taken into
account.5 Therefore, this end point was an appropriate surrogate measure of effectiveness. Our adjusted odds of being
independent at 6 months (modified Rankin score 0 to 2) for
cases receiving 100% treatment in a SCU compared with CC
was 1.23 (95% CI, 0.52 to 2.9) which is consistent with the
Cochrane meta-analysis.3
The generalizability of these results may be limited given
differences in stroke care treatment patterns between countries, study perspective, timeframe and cost methodology.
Nevertheless, although different end points were used, the
findings generally accorded with the economic evaluation by
Patel et al.11 This is the first Australian study to detail the
costs and cost-effectiveness of different acute care models,
and it provides important information to underpin increased
investment in SCUs.
Every effort was made to ensure that costs for the different
models were derived on the same basis. However, the higher
acute costs of SCUs and MS may possibly stem from a better
accounting system in the larger hospitals, such as a more
finely grained method for apportioning costs between cost
centers. Nevertheless, each site reported that they conformed
to agreed standards for clinical costing.16 In addition, these
sites may have had more senior nonclinical staff and utility
costs (electricity, gas, water). Furthermore, SCUs were located within mixed ward settings (usually either neurology or
another specialty), which were likely to be associated with a
higher order of costs than general medical wards. For example, one SCU cost-center included renal dialysis resulting in
higher average costs being apportioned to all patients in that
ward. Also, tertiary hospitals are characterized by higher
teaching and research loads, and the increased staff costs may
not have been offset by economies of scale.
Another explanation for higher costs in SCUs was the
provision of more and/or more costly care to patients.
Nursing and medical care were consistent drivers of acute
costs. More specialized or experienced nursing and medical
staff probably accounted for the higher direct costs of SCU
patients, given the likelihood of their higher salaries. The
higher postacute costs of SCU patients may reflect different
management practices between the models of care as more
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Economic Evaluation of Australian Stroke Services
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SCU patients used rehabilitation and had specialist medical
follow-up. This additional resource use of SCUs is justified
by their better outcomes.9,11
This study only applied to a subset of typically moderate
strokes5 and may not be representative of the entire stroke
population.1 However, because process indicators are often
universally applicable irrespective of stroke type or severity,
they permit a more generalizable estimate of outcome than
rates of severe complications. Several potential sources of
bias arose because of reliance on self-reported information
from telephone follow-up surveys and the abstraction of end
point data from medical records. Although research officers
were not blinded to the model of care when auditing medical
records, a 10% random reaudit indicated acceptable interrater reliability.5 Furthermore, all follow-up telephone interviews, including the resource-use schedule, were conducted
by a research officer blinded to the model of care received by
participants.
This study confirms the cost-effectiveness of dedicated
SCUs over the first 28 weeks, and provides information
important to policymakers concerned with stroke care management and associated resource allocation decisions.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Acknowledgments
The involvement of the study participants, project officers and the
assistance and cooperation of the Finance Departments of the
participating hospitals in providing clinical costing data is acknowledged. It should be noted that coauthors Donnan and Davis are the
heads of dedicated stroke units in their respective hospitals. They
were not directly involved in the collection of data or analysis of
the results.
11.
12.
13.
Sources of Funding
The SCOPES study was supported by the Department of Human
Services Victoria, the Ian Potter Foundation and the National Stroke
Foundation of Australia.
Disclosures
None.
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Stroke. 2006;37:2790-2795; originally published online September 28, 2006;
doi: 10.1161/01.STR.0000245083.97460.e1
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