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Analyses of adverse events (AEs) are an important aspect of the evaluation of experimental therapies. The SAVVY (Survival analysis for AdVerse events with Varying follow-up times) project aims to improve the analyses of AE data in clinical trials through the use of survival techniques appropriately dealing with varying follow-up times, censoring, and competing events (CE). In an empirical study including seventeen randomized clinical trials the effect of varying follow-up times, censoring, and competing events on comparisons of two treatment arms with respect to AE risks is investigated. The comparisons of relative risks (RR) of standard probability-based estimators to the gold-standard Aalen-Johansen estimator or hazard-based estimators to an estimated hazard ratio (HR) from Cox regression are done descriptively, with graphical displays, and using a random effects meta-analysis on AE level. The influence of different factors on the size of the bias is investigated in a meta-regression. We find that for both, avoiding bias and categorization of evidence with respect to treatment effect on AE risk into categories, the choice of the estimator is key and more important than features of the underlying data such as percentage of censoring, CEs, amount of follow-up, or value of the gold-standard RR. There is an urgent need to improve the guidelines of reporting AEs so that incidence proportions are finally replaced by the Aalen-Johansen estimator - rather than by Kaplan-Meier - with appropriate definition of CEs. For RRs based on hazards, the HR based on Cox regression has better properties than the ratio of incidence densities.

The Aalen-Johansen estimator generalizes the Kaplan-Meier estimator for independently left-truncated and right-censored survival data to estimating the transition probability matrix of a time-inhomogeneous Markov model with finite state space. Such multi-state models have a wide range of applications for modelling complex courses of a disease over the course of time, but the Markov assumption may often be in doubt. If censoring is entirely unrelated to the multi-state data, it has been noted that the Aalen-Johansen estimator, standardized by the initial empirical distribution of the multi-state model, still consistently estimates the state occupation probabilities. Recently, this result has been extended to transition probabilities using landmarking, which is, inter alia, useful for dynamic prediction. We complement these results in three ways. Firstly, delayed study entry is a common phenomenon in observational studies, and we extend the earlier results to multi-state data also subject to left-truncation. Secondly, we present a rigorous proof of consistency of the Aalen-Johansen estimator for state occupation probabilities, on which also correctness of the landmarking approach hinges, correcting, simplifying and extending the earlier result. Thirdly, our rigorous proof motivates wild bootstrap resampling. Our developments for left-truncation are motivated by a prospective observational study on the occurrence and the impact of a multi-resistant infectious organism in patients undergoing surgery. Both the real data example and simulation studies are presented. Studying wild bootstrap is motivated by the fact that, unlike drawing with replacement from the data, it is desirable to have a technique that works both with non-Markov models subject to random left-truncation and right-censoring and with Markov models where left-truncation and right-censoring need not be entirely random., Comment: 21 pages with 3 figures

Competing risks model time to first event and type of first event. An example from hospital epidemiology is the incidence of hospital-acquired infection, which has to account for hospital discharge of non-infected patients as a competing risk. An illness-death model would allow to further study hospital outcomes of infected patients. Such a model typically relies on a Markov assumption. However, it is conceivable that the future course of an infected patient does not only depend on the time since hospital admission and current infection status but also on the time since infection. We demonstrate how a modified competing risks model can be used for nonparametric estimation of transition probabilities when the Markov assumption is violated.