Stronger Instruments and Refined Covariate Balance in an Observational Study of the Effectiveness of Prompt Admission to Intensive Care Units

Summary Instrumental variable methods, subject to appropriate identification assumptions, enable consistent estimation of causal effects in the presence of unobserved confounding. Near–far matching has been proposed as one analytic method to improve inference by strengthening the effect of the instrument on the exposure and balancing observable characteristics between groups of subjects with low and high values of the instrument. However, in settings with hierarchical data (e.g. patients nested within hospitals), or where several covariate interactions must be balanced, conventional near–far matching algorithms may fail to achieve the requisite covariate balance. We develop a new matching algorithm, that combines near–far matching with refined covariate balance, to balance large numbers of nominal covariates while also strengthening the instrumental variable. This extension of near–far matching is motivated by a case-study that aims to identify the causal effect of prompt admission to an intensive care unit on 7-day and 28-day mortality.