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Recently, it has become common for applied works to combine commonly used survival analysis modeling methods, such as the multivariable Cox model and propensity score weighting, with the intention of forming a doubly robust estimator of an exposure effect hazard ratio that is unbiased in large samples when either the Cox model or the propensity score model is correctly specified. This combination does not, in general, produce a doubly robust estimator, even after regression standardization, when there is truly a causal effect. We demonstrate via simulation this lack of double robustness for the semiparametric Cox model, the Weibull proportional hazards model, and a simple proportional hazards flexible parametric model, with both the latter models fit via maximum likelihood. We provide a novel proof that the combination of propensity score weighting and a proportional hazards survival model, fit either via full or partial likelihood, is consistent under the null of no causal effect of the exposure on the outcome under particular censoring mechanisms if either the propensity score or the outcome model is correctly specified and contains all confounders. Given our results suggesting that double robustness only exists under the null, we outline two simple alternative estimators that are doubly robust for the survival difference at a given time point (in the above sense), provided the censoring mechanism can be correctly modeled, and one doubly robust method of estimation for the full survival curve. We provide R code to use these estimators for estimation and inference in the supporting information.

There are now many options for doubly robust estimation; however, there is a concerning trend in the applied literature to believe that the combination of a propensity score and an adjusted outcome model automatically results in a doubly robust estimator and/or to misuse more complex established doubly robust estimators. A simple alternative, canonical link generalized linear models (GLM) fit via inverse probability of treatment (propensity score) weighted maximum likelihood estimation followed by standardization (the g-formula) for the average causal effect, is a doubly robust estimation method. Our aim is for the reader not just to be able to use this method, which we refer to as IPTW GLM, for doubly robust estimation, but to fully understand why it has the doubly robust property. For this reason, we define clearly, and in multiple ways, all concepts needed to understand the method and why it is doubly robust. In addition, we want to make very clear that the mere combination of propensity score weighting and an adjusted outcome model does not generally result in a doubly robust estimator. Finally, we hope to dispel the misconception that one can adjust for residual confounding remaining after propensity score weighting by adjusting in the outcome model for what remains `unbalanced' even when using doubly robust estimators. We provide R code for our simulations and real open-source data examples that can be followed step-by-step to use and hopefully understand the IPTW GLM method. We also compare to a much better-known but still simple doubly robust estimator.

Meta-analyses of survival studies aim to reveal the variation of an effect measure of interest over different studies and present a meaningful summary. They must address between study heterogeneity in several dimensions and eliminate spurious sources of variation. Forest plots of the usual (adjusted) hazard ratios are fraught with difficulties from this perspective since both the magnitude and interpretation of these hazard ratios depend on factors ancillary to the true study-specific exposure effect. These factors generally include the study duration, the censoring patterns within studies, the covariates adjusted for and their distribution over exposure groups. Ignoring these mentioned features and accepting implausible hidden assumptions may critically affect interpretation of the pooled effect measure. Risk differences or restricted mean effects over a common follow-up interval and balanced distribution of a covariate set are natural candidates for exposure evaluation and possible treatment choice. In this paper, we propose differently standardized survival curves over a fitting time horizon, targeting various estimands with their own transportability. With each type of standardization comes a given interpretation within studies and overall, under stated assumptions. These curves can in turn be summarized by standardized study-specific contrasts, including hazard ratios with more consistent meaning. We prefer forest plots of risk differences at well chosen time points. Our case study examines overall survival among anal squamous cell carcinoma patients, expressing the tumor marker $p16^{INK4a}$ or not, based on the individual patient data of six studies., Comment: 23 pages, 8 figures

Numerous tutorials and research papers focus on methods in either survival analysis or causal inference, leaving common complications in medical studies unaddressed. In practice one must handle problems jointly, without the luxury of ignoring essential features of the data structure. In this paper, we follow incident cases of end-stage renal disease and examine the effect on all-cause mortality of starting treatment with transplant, so-called pre-emptive kidney transplantation, versus dialysis. The question is relatively simple: which treatment start is expected to bring the best survival for a target population? To address the question, we emulate a target trial drawing on the Swedish Renal Registry to estimate a causal effect on survival curves. Aware of important challenges, we see how previous studies have selected patients into treatment groups based on events occurring post treatment initiation. Our study reveals the dramatic impact of resulting immortal time bias and other typical features of long term incident disease registries, including: missing or mismeasured covariates during (the early) phases of the register, varying risk profile of patients entering treatment groups over calendar time and changes in risk as care improves over the years. With characteristics of cases and versions of treatment evolving over time, informative censoring is introduced in unadjusted Kaplan-Meier curves and also their IPW version is no longer valid. Here we discuss feasible ways of handling these features and answer different research questions relying on the no unmeasured baseline confounders assumption.

Missing data are ubiquitous in medical research. Although there is increasing guidance on how to handle missing data, practice is changing slowly and misapprehensions abound, particularly in observational research. We present a practical framework for handling and reporting the analysis of incomplete data in observational studies, which we illustrate using a case study from the Avon Longitudinal Study of Parents and Children. The framework consists of three steps: 1) Develop an analysis plan specifying the analysis model and how missing data are going to be addressed. An important consideration is whether a complete records analysis is likely to be valid, whether multiple imputation or an alternative approach is likely to offer benefits, and whether a sensitivity analysis regarding the missingness mechanism is required. 2) Explore the data, checking the methods outlined in the analysis plan are appropriate, and conduct the pre-planned analysis. 3) Report the results, including a description of the missing data, details on how the missing data were addressed, and the results from all analyses, interpreted in light of the missing data and the clinical relevance. This framework seeks to support researchers in thinking systematically about missing data, and transparently reporting the potential effect on the study results., Comment: 37 pages, including 3 Figures, 1 table and supplementary material

Although review papers on causal inference methods are now available, there is a lack of introductory overviews on what they can render and on the guiding criteria for choosing one particular method. This tutorial gives an overview in situations where an exposure of interest is set at a chosen baseline (`point exposure') and the target outcome arises at a later time point. We first phrase relevant causal questions and make a case for being specific about the possible exposure levels involved and the populations for which the question is relevant. Using the potential outcomes framework, we describe principled definitions of causal effects and of estimation approaches classified according to whether they invoke the no unmeasured confounding assumption (including outcome regression and propensity score-based methods) or an instrumental variable with added assumptions. We discuss challenges and potential pitfalls and illustrate application using a `simulation learner', that mimics the effect of various breastfeeding interventions on a child's later development. This involves a typical simulation component with generated exposure, covariate, and outcome data that mimic those from an observational or randomised intervention study. The simulation learner further generates various (linked) exposure types with a set of possible values per observation unit, from which observed as well as potential outcome data are generated. It thus provides true values of several causal effects. R code for data generation and analysis is available on www.ofcaus.org, where SAS and Stata code for analysis is also provided.

Inference for causal effects can benefit from the availability of an instrumental variable (IV) which, by definition, is associated with the given exposure, but not with the outcome of interest other than through a causal exposure effect. Estimation methods for instrumental variables are now well established for continuous outcomes, but much less so for dichotomous outcomes. In this article we review IV estimation of so-called conditional causal odds ratios which express the effect of an arbitrary exposure on a dichotomous outcome conditional on the exposure level, instrumental variable and measured covariates. In addition, we propose IV estimators of so-called marginal causal odds ratios which express the effect of an arbitrary exposure on a dichotomous outcome at the population level, and are therefore of greater public health relevance. We explore interconnections between the different estimators and support the results with extensive simulation studies and three applications., Comment: Published in at http://dx.doi.org/10.1214/11-STS360 the Statistical Science (http://www.imstat.org/sts/) by the Institute of Mathematical Statistics (http://www.imstat.org)