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This paper provides guidance for researchers with some mathematical background on the conduct of time-to-event analysis in observational studies based on intensity (hazard) models. Discussions of basic concepts like time axis, event definition and censoring are given. Hazard models are introduced, with special emphasis on the Cox proportional hazards regression model. We provide check lists that may be useful both when fitting the model and assessing its goodness of fit and when interpreting the results. Special attention is paid to how to avoid problems with immortal time bias by introducing time-dependent covariates. We discuss prediction based on hazard models and difficulties when attempting to draw proper causal conclusions from such models. Finally, we present a series of examples where the methods and check lists are exemplified. Computational details and implementation using the freely available R software are documented in Supplementary Material. The paper was prepared as part of the STRATOS initiative. [ABSTRACT FROM AUTHOR]

Stepped-wedge cluster randomized trials, which randomize clusters of subjects to treatment sequences in which clusters switch from control to intervention conditions, are being conducted with increasing frequency. Due to the real-world nature of this design, methodological and implementation challenges are ubiquitous. To account for such challenges, more complex statistical models to plan studies and analyze data are required. In this paper, we consider stepped-wedge trials that accommodate treatment effect heterogeneity across clusters, implementation periods during which no data are collected, or both treatment effect heterogeneity and implementation periods. Previous work has shown that the sequence-period cells of a stepped-wedge design contribute unequal amounts of information to the estimation of the treatment effect. In this paper, we extend that work by considering the amount of information available for the estimation of the treatment effect in each sequence-period cell, sequence, and period of stepped-wedge trials with more complex designs and outcome models. When either treatment effect heterogeneity and/or implementation periods are present, the pattern of information content of sequence-period cells tends to be clustered around the times of the switch from control to intervention condition, similarly to when these complexities are absent. However, the presence and degree of treatment effect heterogeneity and the number of implementation periods can influence the information content of periods and sequences markedly. [ABSTRACT FROM AUTHOR]

Clinical studies on periodontal disease (PD) often lead to data collected which are clustered in nature (viz. clinical attachment level, or CAL, measured at tooth-sites and clustered within subjects) that are routinely analyzed under a linear mixed model framework, with underlying normality assumptions of the random effects and random errors. However, a careful look reveals that these data might exhibit skewness and tail behavior, and hence the usual normality assumptions might be questionable. Besides, PD progression is often hypothesized to be spatially associated, that is, a diseased tooth-site may influence the disease status of a set of neighboring sites. Also, the presence/absence of a tooth is informative, as the number and location of missing teeth informs about the periodontal health in that region. In this paper, we develop a (shared) random effects model for site-level CAL and binary presence/absence status of a tooth under a Bayesian paradigm. The random effects are modeled using a spatial skew-normal/independent (S-SNI) distribution, whose dependence structure is conditionally autoregressive (CAR). Our S-SNI density presents an attractive parametric tool to model spatially referenced asymmetric thick-tailed structures. Both simulation studies and application to a clinical dataset recording PD status reveal the advantages of our proposition in providing a significantly improved fit, over models that do not consider these features in a unified way. [ABSTRACT FROM AUTHOR]

Clinical prediction models (CPMs) can predict clinically relevant outcomes or events. Typically, prognostic CPMs are derived to predict the risk of a single future outcome. However, there are many medical applications where two or more outcomes are of interest, meaning this should be more widely reflected in CPMs so they can accurately estimate the joint risk of multiple outcomes simultaneously. A potentially naïve approach to multi-outcome risk prediction is to derive a CPM for each outcome separately, then multiply the predicted risks. This approach is only valid if the outcomes are conditionally independent given the covariates, and it fails to exploit the potential relationships between the outcomes. This paper outlines several approaches that could be used to develop CPMs for multiple binary outcomes. We consider four methods, ranging in complexity and conditional independence assumptions: namely, probabilistic classifier chain, multinomial logistic regression, multivariate logistic regression, and a Bayesian probit model. These are compared with methods that rely on conditional independence: separate univariate CPMs and stacked regression. Employing a simulation study and real-world example, we illustrate that CPMs for joint risk prediction of multiple outcomes should only be derived using methods that model the residual correlation between outcomes. In such a situation, our results suggest that probabilistic classification chains, multinomial logistic regression or the Bayesian probit model are all appropriate choices. We call into question the development of CPMs for each outcome in isolation when multiple correlated or structurally related outcomes are of interest and recommend more multivariate approaches to risk prediction. [ABSTRACT FROM AUTHOR]

Large-scale association analyses based on observational health care databases such as electronic health records have been a topic of increasing interest in the scientific community. However, challenges due to nonprobability sampling and phenotype misclassification associated with the use of these data sources are often ignored in standard analyses. The extent of the bias introduced by ignoring these factors is not well-characterized. In this paper, we develop an analytic framework for characterizing the bias expected in disease-gene association studies based on electronic health records when disease status misclassification and the sampling mechanism are ignored. Through a sensitivity analysis approach, this framework can be used to obtain plausible values for parameters of interest given summary results from standard analysis. We develop an online tool for performing this sensitivity analysis. Simulations demonstrate promising properties of the proposed method. We apply our approach to study bias in disease-gene association studies using electronic health record data from the Michigan Genomics Initiative, a longitudinal biorepository effort within The University Michigan health system. [ABSTRACT FROM AUTHOR]

Multiple imputation by chained equations (MICE) has emerged as a leading strategy for imputing missing epidemiological data due to its ease of implementation and ability to maintain unbiased effect estimates and valid inference. Within the MICE algorithm, imputation can be performed using a variety of parametric or nonparametric methods. Literature has suggested that nonparametric tree-based imputation methods outperform parametric methods in terms of bias and coverage when there are interactions or other nonlinear effects among the variables. However, these studies fail to provide a fair comparison as they do not follow the well-established recommendation that any effects in the final analysis model (including interactions) should be included in the parametric imputation model. We show via simulation that properly incorporating interactions in the parametric imputation model leads to much better performance. In fact, correctly specified parametric imputation and tree-based random forest imputation perform similarly when estimating the interaction effect. Parametric imputation leads to slightly higher coverage for the interaction effect, but it has wider confidence intervals than random forest imputation and requires correct specification of the imputation model. Epidemiologists should take care in specifying MICE imputation models, and this paper assists in that task by providing a fair comparison of parametric and tree-based imputation in MICE. [ABSTRACT FROM AUTHOR]

Surrogate endpoints play an important role in drug development when they can be used to measure treatment effect early compared to the final clinical outcome and to predict clinical benefit or harm. Such endpoints are assessed for their predictive value of clinical benefit by investigating the surrogate relationship between treatment effects on the surrogate and final outcomes using meta-analytic methods. When surrogate relationships vary across treatment classes, such validation may fail due to limited data within each treatment class. In this paper, two alternative Bayesian meta-analytic methods are introduced which allow for borrowing of information from other treatment classes when exploring the surrogacy in a particular class. The first approach extends a standard model for the evaluation of surrogate endpoints to a hierarchical meta-analysis model assuming full exchangeability of surrogate relationships across all the treatment classes, thus facilitating borrowing of information across the classes. The second method is able to relax this assumption by allowing for partial exchangeability of surrogate relationships across treatment classes to avoid excessive borrowing of information from distinctly different classes. We carried out a simulation study to assess the proposed methods in nine data scenarios and compared them with subgroup analysis using the standard model within each treatment class. We also applied the methods to an illustrative example in colorectal cancer which led to obtaining the parameters describing the surrogate relationships with higher precision. [ABSTRACT FROM AUTHOR]

Data collected for a genome-wide association study of a primary phenotype are often used for additional genome-wide association analyses of secondary phenotypes. However, when the primary and secondary traits are dependent, naïve analyses of secondary phenotypes may induce spurious associations in non-randomly ascertained samples. Previously, retrospective likelihood-based methods have been proposed to correct for sampling biases arising in secondary trait association analyses. However, most methods have been introduced to handle studies featuring a case-control design based on a binary primary phenotype. As such, these methods are not directly applicable to more complicated study designs such as multiple-trait studies, where the sampling mechanism also depends on the secondary phenotype, or extreme-trait studies, where individuals with extreme primary phenotype values are selected. To accommodate these more complicated sampling mechanisms, only a few prospective likelihood approaches have been proposed. These approaches assume a normal distribution for the secondary phenotype (or the latent secondary phenotype) and a bivariate normal distribution for the primary-secondary phenotype dependence. In this paper, we propose a unified copula-based approach to appropriately detect genetic variant/secondary phenotype association in the presence of selected samples. Primary phenotype is either binary or continuous and the secondary phenotype is continuous although not necessary normal. We use both prospective and retrospective likelihoods to account for the sampling mechanism and use a copula model to allow for potentially different dependence structures between the primary and secondary phenotypes. We demonstrate the effectiveness of our approach through simulation studies and by analyzing data from the Avon Longitudinal Study of Parents and Children cohort. [ABSTRACT FROM AUTHOR]

In developing products for rare diseases, statistical challenges arise due to the limited number of patients available for participation in drug trials and other clinical research. Bayesian adaptive clinical trial designs offer the possibility of increased statistical efficiency, reduced development cost and ethical hazard prevention via their incorporation of evidence from external sources (historical data, expert opinions, and real-world evidence), and flexibility in the specification of interim looks. In this paper, we propose a novel Bayesian adaptive commensurate design that borrows adaptively from historical information and also uses a particular payoff function to optimize the timing of the study's interim analysis. The trial payoff is a function of how many samples can be saved via early stopping and the probability of making correct early decisions for either futility or efficacy. We calibrate our Bayesian algorithm to have acceptable long-run frequentist properties (Type I error and power) via simulation at the design stage. We illustrate our approach using a pediatric trial design setting testing the effect of a new drug for a rare genetic disease. The optimIA R package available at https://github.com/wxwx1993/Bayesian_IA_Timing provides an easy-to-use implementation of our approach. [ABSTRACT FROM AUTHOR]

The literature about Prediction Interval (PI) and Tolerance Interval (TI) in linear mixed models is usually developed for specific designs, which is a main limitation to their use. This paper proposes to reformulate the two-sided PI to be generalizable under a wide variety of designs (one random factor, nested and crossed designs for multiple random factors, and balanced or unbalanced designs). This new methodology is based on the Hessian matrix, namely, the inverse of (observed) Fisher Information matrix, and is built with a cell mean model. The degrees of freedom for the total variance are calculated with the generalized Satterthwaite method and compared to the Kenward-Roger's degrees of freedom for fixed effects. Construction of two-sided TIs are also detailed with one random factor, and two nested and two crossed random variables. An extensive simulation study is carried out to compare the widths and coverage probabilities of Confidence Intervals (CI), PIs, and TIs to their nominal levels. It shows excellent coverage whatever the design and the sample size are. Finally, these CIs, PIs, and TIs are applied to two real data sets: one from orthopedic surgery study (intralesional resection risk) and the other from assay validation study during vaccine development. [ABSTRACT FROM AUTHOR]

Cox proportional hazard regression model is a popular tool to analyze the relationship between a censored lifetime variable with other relevant factors. The semiparametric Cox model is widely used to study different types of data arising from applied disciplines such as medical science, biology, and reliability studies. A fully parametric version of the Cox regression model, if properly specified, can yield more efficient parameter estimates, leading to better insight generation. However, the existing maximum likelihood approach of generating inference under the fully parametric proportional hazards model is highly nonrobust against data contamination (often manifested through outliers), which restricts its practical usage. In this paper, we develop a robust estimation procedure for the parametric proportional hazards model based on the minimum density power divergence approach. The proposed minimum density power divergence estimator is seen to produce highly robust estimates under data contamination with only a slight loss in efficiency under pure data. Further, it is always seen to generate more precise inference than the likelihood based estimates under the semiparametric Cox models or their existing robust versions. We also justify their robustness theoretically through the influence function analysis. The practical applicability and usefulness of the proposal are illustrated through simulations and real data examples. [ABSTRACT FROM AUTHOR]

In many applications of linear mixed-effects models to longitudinal and multilevel data especially from medical studies, it is of interest to test for the need of random effects in the model. It is known that classical tests such as the likelihood ratio, Wald, and score tests are not suitable for testing random effects because they suffer from testing on the boundary of the parameter space. Instead, permutation and bootstrap tests as well as Bayesian tests, which do not rely on the asymptotic distributions, avoid issues with the boundary of the parameter space. In this paper, we first develop a permutation test based on the likelihood ratio test statistic, which can be easily used for testing multiple random effects and any subset of them in linear mixed-effects models. The proposed permutation test would be an extension to two existing permutation tests. We then aim to compare permutation tests and Bayesian tests for random effects to find out which test is more powerful under which situation. Nothing is known about this in the literature, although this is an important practical problem due to the usefulness of both methods in tackling the challenges with testing random effects. For this, we consider a Bayesian test developed using Bayes factors, where we also propose a new alternative computation for this Bayesian test to avoid some computational issue it encounters in testing multiple random effects. Extensive simulations and a real data analysis are used for evaluation of the proposed permutation test and its comparison with the Bayesian test. We find that both tests perform well, albeit the permutation test with the likelihood ratio statistic tends to provide a relatively higher power when testing multiple random effects. [ABSTRACT FROM AUTHOR]

Standard methods for two-sample tests such as the t-test and Wilcoxon rank sum test may lead to incorrect type I errors when applied to longitudinal or clustered data. Recent alternatives of two-sample tests for clustered data often require certain assumptions on the correlation structure and/or noninformative cluster size. In this paper, based on a novel pseudolikelihood for correlated data, we propose a score test without knowledge of the correlation structure or assuming data missingness at random. The proposed score test can capture differences in the mean and variance between two groups simultaneously. We use projection theory to derive the limiting distribution of the test statistic, in which the covariance matrix can be empirically estimated. We conduct simulation studies to evaluate the proposed test and compare it with existing methods. To illustrate the usefulness proposed test, we use it to compare self-reported weight loss data in a friends' referral group, with the data from the Internet self-joining group. [ABSTRACT FROM AUTHOR]

The proportional subdistribution hazard regression model has been widely used by clinical researchers for analyzing competing risks data. It is well known that quantile regression provides a more comprehensive alternative to model how covariates influence not only the location but also the entire conditional distribution. In this paper, we develop variable selection procedures based on penalized estimating equations for competing risks quantile regression. Asymptotic properties of the proposed estimators including consistency and oracle properties are established. Monte Carlo simulation studies are conducted, confirming that the proposed methods are efficient. A bone marrow transplant data set is analyzed to demonstrate our methodologies. [ABSTRACT FROM AUTHOR]

Epidemiologic research often aims to estimate the association between a binary exposure and a binary outcome, while adjusting for a set of covariates (eg, confounders). When data are clustered, as in, for instance, matched case-control studies and co-twin-control studies, it is common to use conditional logistic regression. In this model, all cluster-constant covariates are absorbed into a cluster-specific intercept, whereas cluster-varying covariates are adjusted for by explicitly adding these as explanatory variables to the model. In this paper, we propose a doubly robust estimator of the exposure-outcome odds ratio in conditional logistic regression models. This estimator protects against bias in the odds ratio estimator due to misspecification of the part of the model that contains the cluster-varying covariates. The doubly robust estimator uses two conditional logistic regression models for the odds ratio, one prospective and one retrospective, and is consistent for the exposure-outcome odds ratio if at least one of these models is correctly specified, not necessarily both. We demonstrate the properties of the proposed method by simulations and by re-analyzing a publicly available dataset from a matched case-control study on induced abortion and infertility. [ABSTRACT FROM AUTHOR]

The relative risk, risk difference, and odds ratio are three major indices of differences in risks of diseases between different groups. Although widely used in research and practice in biomedical and epidemiologic research, misconceptions are not uncommon about their relationships. Many publications offer contradicting advices in how to use them in studies. Some biomedical researchers believe that these indices are related in a monotone fashion, and, thus, changes in one direction in one of the indices can be interpreted as same directional changes in the other two. Misconceptions about these three indices such as the monotone relationship are so prevalent in the biomedical and epidemiologic research that clarifications of such popular beliefs are warranted. In this paper, we take a systematic approach to characterize the relationships among the indices. We develop key results to elucidate the intricate relationships between the indices. Our findings speak to the need for investigators to carefully consider the different indices before using them in their studies, since they are not interchangeable and results based on one index are generally not translatable into any of the others. [ABSTRACT FROM AUTHOR]

Among several semiparametric models, the Cox proportional hazard model is widely used to assess the association between covariates and the time-to-event when the observed time-to-event is interval-censored. Often, covariates are measured with error. To handle this covariate uncertainty in the Cox proportional hazard model with the interval-censored data, flexible approaches have been proposed. To fill a gap and broaden the scope of statistical applications to analyze time-to-event data with different models, in this paper, a general approach is proposed for fitting the semiparametric linear transformation model to interval-censored data when a covariate is measured with error. The semiparametric linear transformation model is a broad class of models that includes the proportional hazard model and the proportional odds model as special cases. The proposed method relies on a set of estimating equations to estimate the regression parameters and the infinite-dimensional parameter. For handling interval censoring and covariate measurement error, a flexible imputation technique is used. Finite sample performance of the proposed method is judged via simulation studies. Finally, the suggested method is applied to analyze a real data set from an AIDS clinical trial. [ABSTRACT FROM AUTHOR]

Analyzing safety data from clinical trials to detect safety signals worth further examination involves testing multiple hypotheses, one for each observed adverse event (AE) type. There exists certain hierarchical structure for these hypotheses due to the classification of the AEs into system organ classes, and these AEs are also likely correlated. Many approaches have been proposed to identify safety signals under the multiple testing framework and tried to achieve control of false discovery rate (FDR). The FDR control concerns the expectation of the false discovery proportion (FDP). In practice, the control of the actual random variable FDP could be more relevant and has recently drawn much attention. In this paper, we proposed a two-stage procedure for safety signal detection with direct control of FDP, through a permutation-based approach for screening groups of AEs and a permutation-based approach of constructing simultaneous upper bounds for false discovery proportion. Our simulation studies showed that this new approach has controlled FDP. We demonstrate our approach using data sets derived from a drug clinical trial. [ABSTRACT FROM AUTHOR]

In this paper, we derive the joint distribution of progression-free and overall survival as a function of transition probabilities in a multistate model. No assumptions on copulae or latent event times are needed and the model is allowed to be non-Markov. From the joint distribution, statistics of interest can then be computed. As an example, we provide closed formulas and statistical inference for Pearson's correlation coefficient between progression-free and overall survival in a parametric framework. The example is inspired by recent approaches to quantify the dependence between progression-free survival, a common primary outcome in Phase 3 trials in oncology and overall survival. We complement these approaches by providing methods of statistical inference while at the same time working within a much more parsimonious modeling framework. Our approach is completely general and can be applied to other measures of dependence. We also discuss extensions to nonparametric inference. Our analytical results are illustrated using a large randomized clinical trial in breast cancer. [ABSTRACT FROM AUTHOR]

When several types of recurrent events may arise, interest often lies in marginal modeling and studying the nature of the dependence structure. In this paper, we propose a multivariate mixed-Poisson model with the dependence between events accommodated by type-specific random effects which are associated through use of a Gaussian copula. Such models retain marginal features with a simple interpretation, reflect the heterogeneity in risk for each type of event, and provide insight into the dependence between the different types of events. Semiparametric inference is proposed based on composite likelihood to avoid high dimensional integration. An application to a study of nutritional supplements in malnourished children is given in which the goal is to evaluate the reduction in the rate of several different kinds of infection. [ABSTRACT FROM AUTHOR]

Bayesian adaptive designs have become popular because of the possibility of increasing the number of patients treated with more beneficial treatments, while still providing sufficient evidence for treatment efficacy comparisons. It can be essential, for regulatory and other purposes, to conduct frequentist analyses both before and after a Bayesian adaptive trial, and these remain challenging. In this paper, we propose a general simulation-based approach to compare frequentist designs with Bayesian adaptive designs based on frequentist criteria such as power and to compute valid frequentist p-values. We illustrate our approach by comparing the power of an equal randomization (ER) design with that of an optimal Bayesian adaptive (OBA) design. The Bayesian design considered here is the dynamic programming solution of the optimization of a specific utility function defined by the number of successes in a patient horizon, including patients whose treatment will be affected by the trial's results after the end of the trial. While the power of an ER design depends on treatment efficacy and the sample size, the power of the OBA design also depends on the patient horizon size. Our results quantify the trade-off between power and the optimal assignment of patients to treatments within the trial. We show that, for large patient horizons, the two criteria are in agreement, while for small horizons, differences can be substantial. This has implications for precision medicine, where patient horizons are decreasing as a result of increasing stratification of patients into subpopulations defined by molecular markers. [ABSTRACT FROM AUTHOR]

Wearable device technology allows continuous monitoring of biological markers and thereby enables study of time-dependent relationships. For example, in this paper, we are interested in the impact of daily energy expenditure over a period of time on subsequent progression toward obesity among children. Data from these devices appear as either sparsely or densely observed functional data and methods of functional regression are often used for their statistical analyses. We study the scalar-on-function regression model with imprecisely measured values of the predictor function. In this setting, we have a scalar-valued response and a function-valued covariate that are both collected at a single time period. We propose a generalized method of moments-based approach for estimation, while an instrumental variable belonging in the same time space as the imprecisely measured covariate is used for model identification. Additionally, no distributional assumptions regarding the measurement errors are assumed, while complex covariance structures are allowed for the measurement errors in the implementation of our proposed methods. We demonstrate that our proposed estimator is L2 consistent and enjoys the optimal rate of convergence for univariate nonparametric functions. In a simulation study, we illustrate that ignoring measurement error leads to biased estimations of the functional coefficient. The simulation studies also confirm our ability to consistently estimate the function-valued coefficient when compared to approaches that ignore potential measurement errors. Our proposed methods are applied to our motivating example to assess the impact of baseline levels of energy expenditure on body mass index among elementary school-aged children. [ABSTRACT FROM AUTHOR]

The literature on causal effect estimation tends to focus on the population mean estimand, which is less informative as medical treatments are becoming more personalized and there is increasing awareness that subpopulations of individuals may experience a group-specific effect that differs from the population average. In fact, it is possible that there is underlying systematic effect heterogeneity that is obscured by focusing on the population mean estimand. In this context, understanding which covariates contribute to this treatment effect heterogeneity (TEH) and how these covariates determine the differential treatment effect (TE) is an important consideration. Towards such an understanding, this paper briefly reviews three approaches used in making causal inferences and conducts a simulation study to compare these approaches according to their performance in an exploratory evaluation of TEH when the heterogeneous subgroups are not known a priori. Performance metrics include the detection of any heterogeneity, the identification and characterization of heterogeneous subgroups, and unconfounded estimation of the TE within subgroups. The methods are then deployed in a comparative effectiveness evaluation of drug-eluting versus bare-metal stents among 54 099 Medicare beneficiaries in the continental United States admitted to a hospital with acute myocardial infarction in 2008. [ABSTRACT FROM AUTHOR]

Economic evaluations from individual-level data are an important component of the process of technology appraisal, with a view to informing resource allocation decisions. A critical problem in these analyses is that both effectiveness and cost data typically present some complexity (eg, nonnormality, spikes, and missingness) that should be addressed using appropriate methods. However, in routine analyses, standardised approaches are typically used, possibly leading to biassed inferences. We present a general Bayesian framework that can handle the complexity. We show the benefits of using our approach with a motivating example, the MenSS trial, for which there are spikes at one in the effectiveness and missingness in both outcomes. We contrast a set of increasingly complex models and perform sensitivity analysis to assess the robustness of the conclusions to a range of plausible missingness assumptions. We demonstrate the flexibility of our approach with a second example, the PBS trial, and extend the framework to accommodate the characteristics of the data in this study. This paper highlights the importance of adopting a comprehensive modelling approach to economic evaluations and the strategic advantages of building these complex models within a Bayesian framework. [ABSTRACT FROM AUTHOR]

In this paper, we propose a large-scale multiple testing procedure to find the significant sub-areas between two samples of curves automatically. The procedure is optimal in that it controls the directional false discovery rate at any specified level on a continuum asymptotically. By introducing a nonparametric Gaussian process regression model for the two-sided multiple test, the procedure is computationally inexpensive. It can cope with problems with multidimensional covariates and accommodate different sampling designs across the samples. We further propose the significant curve/surface, giving an insight on dynamic significant differences between two curves. Simulation studies demonstrate that the proposed procedure enjoys superior performance with strong power and good directional error control. The procedure is also illustrated with the application to two executive function studies in hemiplegia. [ABSTRACT FROM AUTHOR]

Mediation analysis allows the examination of effects of a third variable in the pathway between an exposure and an outcome. The general multiple mediation analysis method, proposed by Yu et al, improves traditional methods (eg, estimation of natural and controlled direct effects) to enable consideration of multiple mediators/confounders simultaneously and the use of linear and nonlinear predictive models for estimating mediation/confounding effects. In this paper, we extend the method for time-to-event outcomes and apply the method to explore the racial disparity in breast cancer survivals. Breast cancer is the most common cancer and the second leading cause of cancer death among women of all races. Despite improvement of survival rates of breast cancer in the US, a significant difference between white and black women remains. Previous studies have found that more advanced and aggressive tumors and less than optimal treatment may explain the lower survival rates for black women as compared to white women. Due to limitations of current analytic methods and the lack of comprehensive data sets, researchers have not been able to differentiate the relative effect each factor contributes to the overall racial disparity. We use the CDC-funded Patterns of Care study to examine the determinants of racial disparities in breast cancer survival using a novel multiple mediation analysis. Using the proposed method, we applied the Cox hazard model and multiple additive regression trees as predictive models and found that all racial disparity in survival among Louisiana breast cancer patients were explained by factors included in the study. [ABSTRACT FROM AUTHOR]

Phenotyping, ie, identification of patients possessing a characteristic of interest, is a fundamental task for research conducted using electronic health records. However, challenges to this task include imperfect sensitivity and specificity of clinical codes and inconsistent availability of more detailed data such as laboratory test results. Despite these challenges, most existing electronic health records-derived phenotypes are rule-based, consisting of a series of Boolean arguments informed by expert knowledge of the disease of interest and its coding. The objective of this paper is to introduce a Bayesian latent phenotyping approach that accounts for imperfect data elements and missing not at random missingness patterns that can be used when no gold-standard data are available. We conducted simulation studies to compare alternative phenotyping methods under different patterns of missingness and applied these approaches to a cohort of 68 265 children at elevated risk for type 2 diabetes mellitus (T2DM). In simulation studies, the latent class approach had similar sensitivity to a rule-based approach (95.9% vs 91.9%) while substantially improving specificity (99.7% vs 90.8%). In the PEDSnet cohort, we found that biomarkers and clinical codes were strongly associated with latent T2DM status. The latent T2DM class was also strongly predictive of missingness in biomarkers. Glucose was missing in 83.4% of patients (odds ratio for latent T2DM status = 0.52) while hemoglobin A1c was missing in 91.2% (odds ratio for latent T2DM status = 0.03 ), suggesting missing not at random missingness. The latent phenotype approach may substantially improve on rule-based phenotyping. [ABSTRACT FROM AUTHOR]

Clinical trials are often designed to compare treatments on the basis of multiple outcomes. For the analysis of the treatment comparison from such a trial, in 1999, the Finkelstein-Schoenfeld test was proposed, which was a generalization of the Gehan-Wilcoxon test based on pairwise comparison of patients on a primary outcome when possible but otherwise on a secondary outcome. In 2012, Pocock and colleagues suggested an estimate based on this concept, the Win Ratio, which summarized the ratio of the number of patients who fared better versus worse on the experimental arm. However, in 2016, Oakes noted that the Win Ratio could be a function of the distribution of follow-up times of the trial. The aim of this paper is to propose an approach to representing the Win Ratio graphically in such a way that the effect of time on the estimate would be apparent. In addition, the methods are used to display the contribution of each endpoint to the composite. We apply the methods to clinical trials in cancer, cardiology, and neurology. Software is available named winRatioAnalysis in CRAN. [ABSTRACT FROM AUTHOR]

Drug-drug interactions (DDIs) are a common cause of adverse drug events (ADEs). The electronic medical record (EMR) database and the FDA's adverse event reporting system (FAERS) database are the major data sources for mining and testing the ADE associated DDI signals. Most DDI data mining methods focus on pair-wise drug interactions, and methods to detect high-dimensional DDIs in medical databases are lacking. In this paper, we propose 2 novel mixture drug-count response models for detecting high-dimensional drug combinations that induce myopathy. The "count" indicates the number of drugs in a combination. One model is called fixed probability mixture drug-count response model with a maximum risk threshold (FMDRM-MRT). The other model is called count-dependent probability mixture drug-count response model with a maximum risk threshold (CMDRM-MRT), in which the mixture probability is count dependent. Compared with the previous mixture drug-count response model (MDRM) developed by our group, these 2 new models show a better likelihood in detecting high-dimensional drug combinatory effects on myopathy. CMDRM-MRT identified and validated (54; 374; 637; 442; 131) 2-way to 6-way drug interactions, respectively, which induce myopathy in both EMR and FAERS databases. We further demonstrate FAERS data capture much higher maximum myopathy risk than EMR data do. The consistency of 2 mixture models' parameters and local false discovery rate estimates are evaluated through statistical simulation studies. [ABSTRACT FROM AUTHOR]

Pharmacokinetic studies aim to study how a compound is absorbed, distributed, metabolised, and excreted. The concentration of the compound in the blood or plasma is measured at different time points after administration and pharmacokinetic parameters such as the area under the curve (AUC) or maximum concentration (Cmax ) are derived from the resulting concentration time profile. In this paper, we want to compare different methods for collecting concentration measurements (traditional sampling versus microsampling) on the basis of these derived parameters. We adjust and evaluate an existing method for testing superiority of multiple derived parameters that accounts for model uncertainty. We subsequently extend the approach to allow testing for equivalence. We motivate the methods through an illustrative example and evaluate the performance using simulations. The extensions show promising results for application to the desired setting. [ABSTRACT FROM AUTHOR]

National health surveys, such as the National Health and Nutrition Examination Survey, are used to monitor trends of nutritional biomarkers. These surveys try to maintain the same biomarker assay over time, but there are a variety of reasons why the assay may change. In these cases, it is important to evaluate the potential impact of a change so that any observed fluctuations in concentrations over time are not confounded by changes in the assay. To this end, a subset of stored specimens previously analyzed with the old assay is retested using the new assay. These paired data are used to estimate an adjustment equation, which is then used to 'adjust' all the old assay results and convert them into 'equivalent' units of the new assay. In this paper, we present a new way of approaching this problem using modern statistical methods designed for missing data. Using simulations, we compare the proposed multiple imputation approach with the adjustment equation approach currently in use. We also compare these approaches using real National Health and Nutrition Examination Survey data for 25-hydroxyvitamin D. Published 2017. This article is a U.S. Government work and is in the public domain in the USA. [ABSTRACT FROM AUTHOR]

An increasingly important data source for the development of clinical risk prediction models is electronic health records (EHRs). One of their key advantages is that they contain data on many individuals collected over time. This allows one to incorporate more clinical information into a risk model. However, traditional methods for developing risk models are not well suited to these irregularly collected clinical covariates. In this paper, we compare a range of approaches for using longitudinal predictors in a clinical risk model. Using data from an EHR for patients undergoing hemodialysis, we incorporate five different clinical predictors into a risk model for patient mortality. We consider different approaches for treating the repeated measurements including use of summary statistics, machine learning methods, functional data analysis, and joint models. We follow up our empirical findings with a simulation study. Overall, our results suggest that simple approaches perform just as well, if not better, than more complex analytic approaches. These results have important implication for development of risk prediction models with EHRs. Copyright © 2017 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Nonparametric comparison of survival functions is one of the most commonly required task in failure time studies such as clinical trials, and for this, many procedures have been developed under various situations. This paper considers a situation that often occurs in practice but has not been discussed much: the comparison based on interval-censored data in the presence of unequal censoring. That is, one observes only interval-censored data, and the distributions of or the mechanisms behind censoring variables may depend on treatments and thus be different for the subjects in different treatment groups. For the problem, a test procedure is developed that takes into account the difference between the distributions of the censoring variables, and the asymptotic normality of the test statistics is given. For the assessment of the performance of the procedure, a simulation study is conducted and suggests that it works well for practical situations. An illustrative example is provided. Copyright © 2017 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

This paper considers the analysis of a repeat event outcome in clinical trials of chronic diseases in the context of dependent censoring (e.g. mortality). It has particular application in the context of recurrent heart failure hospitalisations in trials of heart failure. Semi-parametric joint frailty models (JFMs) simultaneously analyse recurrent heart failure hospitalisations and time to cardiovascular death, estimating distinct hazard ratios whilst individual-specific latent variables induce associations between the two processes. A simulation study was carried out to assess the suitability of the JFM versus marginal analyses of recurrent events and cardiovascular death using standard methods. Hazard ratios were consistently overestimated when marginal models were used, whilst the JFM produced good, well-estimated results. An application to the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity programme was considered. The JFM gave unbiased estimates of treatment effects in the presence of dependent censoring. We advocate the use of the JFM for future trials that consider recurrent events as the primary outcome. © 2016 The Authors. Statistics in Medicine Published by John Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]

In clinical trials with survival endpoint, it is common to observe an overlap between two Kaplan-Meier curves of treatment and control groups during the early stage of the trials, indicating a potential delayed treatment effect. Formulas have been derived for the asymptotic power of the log-rank test in the presence of delayed treatment effect and its accompanying sample size calculation. In this paper, we first reformulate the alternative hypothesis with the delayed treatment effect in a rescaled time domain, which can yield a simplified sample size formula for the log-rank test in this context. We further propose an intersection-union test to examine the efficacy of treatment with delayed effect and show it to be more powerful than the log-rank test. Simulation studies are conducted to demonstrate the proposed methods. [ABSTRACT FROM AUTHOR]

In this paper, we present a unified modeling framework to combine aggregated data from randomized controlled trials (RCTs) with individual participant data (IPD) from observational studies. Rather than simply pooling the available evidence into an overall treatment effect, adjusted for potential confounding, the intention of this work is to explore treatment effects in specific patient populations reflected by the IPD. In this way, by collecting IPD, we can potentially gain new insights from RCTs' results, which cannot be seen using only a meta-analysis of RCTs. We present a new Bayesian hierarchical meta-regression model, which combines submodels, representing different types of data into a coherent analysis. Predictors of baseline risk are estimated from the individual data. Simultaneously, a bivariate random effects distribution of baseline risk and treatment effects is estimated from the combined individual and aggregate data. Therefore, given a subgroup of interest, the estimated treatment effect can be calculated through its correlation with baseline risk. We highlight different types of model parameters: those that are the focus of inference (e.g., treatment effect in a subgroup of patients) and those that are used to adjust for biases introduced by data collection processes (e.g., internal or external validity). The model is applied to a case study where RCTs' results, investigating efficacy in the treatment of diabetic foot problems, are extrapolated to groups of patients treated in medical routine and who were enrolled in a prospective cohort study. [ABSTRACT FROM AUTHOR]

In many biomedical studies, covariates of interest may be measured with errors. However, frequently in a regression analysis, the quantiles of the exposure variable are often used as the covariates in the regression analysis. Because of measurement errors in the continuous exposure variable, there could be misclassification in the quantiles for the exposure variable. Misclassification in the quantiles could lead to bias estimation in the association between the exposure variable and the outcome variable. Adjustment for misclassification will be challenging when the gold standard variables are not available. In this paper, we develop two regression calibration estimators to reduce bias in effect estimation. The first estimator is normal likelihood-based. The second estimator is linearization-based, and it provides a simple and practical correction. Finite sample performance is examined via a simulation study. We apply the methods to a four-arm randomized clinical trial that tested exercise and weight loss interventions in women aged 50-75 years. [ABSTRACT FROM AUTHOR]

Generalized estimating equations (GEE) is a general statistical method to fit marginal models for longitudinal data in biomedical studies. The variance-covariance matrix of the regression parameter coefficients is usually estimated by a robust "sandwich" variance estimator, which does not perform satisfactorily when the sample size is small. To reduce the downward bias and improve the efficiency, several modified variance estimators have been proposed for bias-correction or efficiency improvement. In this paper, we provide a comprehensive review on recent developments of modified variance estimators and compare their small-sample performance theoretically and numerically through simulation and real data examples. In particular, Wald tests and t-tests based on different variance estimators are used for hypothesis testing, and the guideline on appropriate sample sizes for each estimator is provided for preserving type I error in general cases based on numerical results. Moreover, we develop a user-friendly R package "geesmv" incorporating all of these variance estimators for public usage in practice. [ABSTRACT FROM AUTHOR]

Left-truncated data arise when lifetimes are observed only if they are larger than independent truncation times. For example, in a cross-sectional sampling, only individuals who live long enough to be present on the sampling day are observed. There are several ways to perform statistical inference under this setting. One can do the following: (i) use an unconditional approach, (ii) condition on the value of the truncation variable, or (iii) condition on all the history up to the time of truncation. The latter two approaches are equivalent when analyzing univariate survival outcomes but differ under the multi-state framework. In this paper, we consider the illness-death model and compare between the three estimation approaches in a parametric regression framework. We show that approach (ii) is more efficient than the standard approach (iii), although it requires more computational effort. Approach (i) is the most efficient approach, but it requires knowledge on the distribution of the truncation variable and hence is less robust. The methods are compared using a theoretical example and simulations and are applied to intensive care units data collected in a cross-sectional design, where the illness state corresponds to a bloodstream infection. [ABSTRACT FROM AUTHOR]

Simon's optimal two-stage design has been widely used in early phase clinical trials for Oncology and AIDS studies with binary endpoints. With this approach, the second-stage sample size is fixed when the trial passes the first stage with sufficient activity. Adaptive designs, such as those due to Banerjee and Tsiatis (2006) and Englert and Kieser (2013), are flexible in the sense that the second-stage sample size depends on the response from the first stage, and these designs are often seen to reduce the expected sample size under the null hypothesis as compared with Simon's approach. An unappealing trait of the existing designs is that they are not associated with a second-stage sample size, which is a non-increasing function of the first-stage response rate. In this paper, an efficient intelligent process, the branch-and-bound algorithm, is used in extensively searching for the optimal adaptive design with the smallest expected sample size under the null, while the type I and II error rates are maintained and the aforementioned monotonicity characteristic is respected. The proposed optimal design is observed to have smaller expected sample sizes compared to Simon's optimal design, and the maximum total sample size of the proposed adaptive design is very close to that from Simon's method. The proposed optimal adaptive two-stage design is recommended for use in practice to improve the flexibility and efficiency of early phase therapeutic development. [ABSTRACT FROM AUTHOR]

Interventions with multivalued treatments are common in medical and health research, such as when comparing the efficacy of competing drugs or interventions, or comparing between various doses of a particular drug. In recent years, there has been a growing interest in the development of multivalued treatment effect estimators using observational data. In this paper, we compare the performance of commonly used regression-based methods that estimate multivalued treatment effects based on the unconfoundedness assumption. These estimation methods fall into three general categories: (i) estimators based on a model for the outcome variable using conventional regression adjustment; (ii) weighted estimators based on a model for the treatment assignment; and (iii) 'doubly-robust' estimators that model both the treatment assignment and outcome variable within the same framework. We assess the performance of these models using Monte Carlo simulation and demonstrate their application with empirical data. Our results show that (i) when models estimating both the treatment and outcome are correctly specified, all adjustment methods provide similar unbiased estimates; (ii) when the outcome model is misspecified, regression adjustment performs poorly, while all the weighting methods provide unbiased estimates; (iii) when the treatment model is misspecified, methods based solely on modeling the treatment perform poorly, while regression adjustment and the doubly robust models provide unbiased estimates; and (iv) when both the treatment and outcome models are misspecified, all methods perform poorly. Given that researchers will rarely know which of the two models is misspecified, our results support the use of doubly robust estimation. [ABSTRACT FROM AUTHOR]

Adrenocorticotropic hormone (ACTH) diurnal patterns contain both smooth circadian rhythms and pulsatile activities. How to evaluate and compare them between different groups is a challenging statistical task. In particular, we are interested in testing (1) whether the smooth ACTH circadian rhythms in chronic fatigue syndrome and fibromyalgia patients differ from those in healthy controls and (2) whether the patterns of pulsatile activities are different. In this paper, a hierarchical state space model is proposed to extract these signals from noisy observations. The smooth circadian rhythms shared by a group of subjects are modeled by periodic smoothing splines. The subject level pulsatile activities are modeled by autoregressive processes. A functional random effect is adopted at the pair level to account for the matched pair design. Parameters are estimated by maximizing the marginal likelihood. Signals are extracted as posterior means. Computationally efficient Kalman filter algorithms are adopted for implementation. Application of the proposed model reveals that the smooth circadian rhythms are similar in the two groups but the pulsatile activities in patients are weaker than those in the healthy controls. [ABSTRACT FROM AUTHOR]

Meta-analyses of clinical trials are increasingly seeking to go beyond estimating the effect of a treatment and may also aim to investigate the effect of other covariates and how they alter treatment effectiveness. This requires the estimation of treatment-covariate interactions. Meta-regression can be used to estimate such interactions using published data, but it is known to lack statistical power, and is prone to bias.The use of individual patient data can improve estimation of such interactions, among other benefits, but it can be difficult and time-consuming to collect and analyse. This paper derives, under certain conditions, the power of meta-regression and IPD methods to detect treatment-covariate interactions. These power formulae are shown to depend on heterogeneity in the covariate distributions across studies. This allows the derivation of simple tests, based on heterogeneity statistics, for comparing the statistical power of the analysis methods. [ABSTRACT FROM AUTHOR]

It is common for longitudinal clinical trials to face problems of item non-response, unit non-response, and drop-out. In this paper, we compare two alternative methods of handling multivariate incomplete data across a baseline assessment and three follow-up time points in a multi-centre randomized controlled trial of a disease management programme for late-life depression. One approach combines hot-deck (HD) multiple imputation using a predictive mean matching method for item non-response and the approximate Bayesian bootstrap for unit non-response. A second method is based on a multivariate normal (MVN) model using PROC MI in SAS software V8.2. These two methods are contrasted with a last observation carried forward (LOCF) technique and available-case (AC) analysis in a simulation study where replicate analyses are performed on subsets of the originally complete cases. Missing-data patterns were simulated to be consistent with missing-data patterns found in the originally incomplete cases, and observed complete data means were taken to be the targets of estimation. Not surprisingly, the LOCF and AC methods had poor coverage properties for many of the variables evaluated. Multiple imputation under the MVN model performed well for most variables but produced less than nominal coverage for variables with highly skewed distributions. The HD method consistently produced close to nominal coverage, with interval widths that were roughly 7 per cent larger on average than those produced from the MVN model. [ABSTRACT FROM AUTHOR]

The average nutritional status of children in Nigeria is, just as in most developing countries, still in an alarmingly bad condition. Prior studies have shown that this status relies on a series of different influences and can be measured by three anthropometric variables for stunting, wasting, and underweight. Different regression modeling techniques have been adopted over the years to explain the determinants and spatial clustering. Those indicators, however, show patterns that are not necessarily full filling requirements for ordinary regression models for the mean and are correlated among each other, a fact that has until now been ignored by most studies. Methods to model outcomes in the light of both, the whole distribution of and the correlation between two or more outcomes based on a set of covariates, have lately been developed. The aim of this paper is to make use of those methods to explain the underlying spatial structure in malnutrition in Nigeria. The study brings to limelight the pattern of spread as well as the interwoven relationships among childhood malnutrition indicators that would have otherwise remained unknown in Nigeria. [ABSTRACT FROM AUTHOR]