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Hernández-Herrera G, Moriña D, Navarro A. Left-censored recurrent event analysis in epidemiological studies: a proposal for when the number of previous episodes is unknown. BMC Med Res Methodol 2022; 22:20. [PMID: 35034622 PMCID: PMC8761288 DOI: 10.1186/s12874-022-01503-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 01/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND When dealing with recurrent events in observational studies it is common to include subjects who became at risk before follow-up. This phenomenon is known as left censoring, and simply ignoring these prior episodes can lead to biased and inefficient estimates. We aimed to propose a statistical method that performs well in this setting. METHODS Our proposal was based on the use of models with specific baseline hazards. In this, the number of prior episodes were imputed when unknown and stratified according to whether the subject had been at risk of presenting the event before t = 0. A frailty term was also used. Two formulations were used for this "Specific Hazard Frailty Model Imputed" based on the "counting process" and "gap time." Performance was then examined in different scenarios through a comprehensive simulation study. RESULTS The proposed method performed well even when the percentage of subjects at risk before follow-up was very high. Biases were often below 10% and coverages were around 95%, being somewhat conservative. The gap time approach performed better with constant baseline hazards, whereas the counting process performed better with non-constant baseline hazards. CONCLUSIONS The use of common baseline methods is not advised when knowledge of prior episodes experienced by a participant is lacking. The approach in this study performed acceptably in most scenarios in which it was evaluated and should be considered an alternative in this context. It has been made freely available to interested researchers as R package miRecSurv.
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Affiliation(s)
- Gilma Hernández-Herrera
- Instituto de Investigaciones Médicas, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia.,Methodology of Biomedical Research and Public Health, Autonomous University of Barcelona, Cerdanyola del Vallès, Spain
| | - David Moriña
- Department of Econometrics, Statistics and Applied Economics, Riskcenter-IREA, University of Barcelona (UB), Barcelona, Spain. .,Centre de Recerca Matemàtica (CRM), Cerdanyola del Vallès, Spain. .,Facultat d'Economia i Empresa, Universitat de Barcelona (UB), Avinguda Diagonal, 690-694, 08034, Barcelona, Spain.
| | - Albert Navarro
- Psychosocial Risks, Organization of Work and Health (POWAH), Autonomous University of Barcelona (UAB), Cerdanyola del Vallès, Spain.,Biostatistics Unit, Faculty of Medicine, Autonomous University of Barcelona (UAB), Cerdanyola del Vallès, Spain
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Kyr M, Polaskova K, Kuttnerova Z, Merta T, Neradil J, Berkovcova J, Horky O, Jezova M, Veselska R, Klement GL, Valik D, Sterba J. Individualization of Treatment Improves the Survival of Children With High-Risk Solid Tumors: Comparative Patient Series Analysis in a Real-Life Scenario. Front Oncol 2019; 9:644. [PMID: 31380281 PMCID: PMC6650566 DOI: 10.3389/fonc.2019.00644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 07/01/2019] [Indexed: 11/13/2022] Open
Abstract
Introduction: The individualization of treatment is attractive, especially in children with high-risk cancer. In such a rare and very heterogeneous group of diseases, large population-based clinical randomized trials are not feasible without international collaboration. We therefore propose comparative patient series analysis in a real-life scenario. Methods: Open cohort observational study, comparative analysis. Seventy patients with high-risk solid tumors diagnosed between 2003 and 2015 and in whom the treatment was individualized either empirically or based on biomarkers were analyzed. The heterogeneity of the cohort and repeated measurements were advantageously utilized to increase effective sample size using appropriate statistical tools. Results: We demonstrated a beneficial effect of empirically given low-dose metronomic chemotherapy (HR 0.46 for relapses, p = 0.017) as well as various repurposed or targeted agents (HR 0.15 for deaths, p = 0.004) in a real-life scenario. However, targeted agents given on the basis of limited biological information were not beneficial. Conclusions: Comparative patient series analysis provides institutional-level evidence for treatment individualization in high-risk pediatric malignancies. Our findings emphasize the need for a comprehensive, multi omics assessment of the tumor and the host as well whenever molecularly driven targeted therapies are being considered. Low-dose metronomic chemotherapy or local control of the disease may be a more rational option in situations where targeted treatment cannot be justified by robust evidence and comprehensive biological information. “Targeted drugs” may be given empirically with a realistic benefit expectation when based on robust rationale.
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Affiliation(s)
- Michal Kyr
- Department of Pediatric Oncology, University Hospital Brno and School of Medicine, Masaryk University, Brno, Czechia.,International Clinical Research Centre, St. Anne's University Hospital Brno, Brno, Czechia
| | - Kristyna Polaskova
- Department of Pediatric Oncology, University Hospital Brno and School of Medicine, Masaryk University, Brno, Czechia.,International Clinical Research Centre, St. Anne's University Hospital Brno, Brno, Czechia
| | - Zuzana Kuttnerova
- Department of Pediatric Oncology, University Hospital Brno and School of Medicine, Masaryk University, Brno, Czechia.,International Clinical Research Centre, St. Anne's University Hospital Brno, Brno, Czechia
| | - Tomas Merta
- Department of Pediatric Oncology, University Hospital Brno and School of Medicine, Masaryk University, Brno, Czechia.,International Clinical Research Centre, St. Anne's University Hospital Brno, Brno, Czechia
| | - Jakub Neradil
- Department of Pediatric Oncology, University Hospital Brno and School of Medicine, Masaryk University, Brno, Czechia.,International Clinical Research Centre, St. Anne's University Hospital Brno, Brno, Czechia.,Laboratory of Tumor Biology, Department of Experimental Biology, School of Science, Masaryk University, Brno, Czechia
| | - Jitka Berkovcova
- Laboratory of Molecular Pathology, Department of Oncological Pathology, Masaryk Memorial Cancer Institute, Brno, Czechia
| | - Ondrej Horky
- Laboratory of Molecular Pathology, Department of Oncological Pathology, Masaryk Memorial Cancer Institute, Brno, Czechia
| | - Marta Jezova
- Department of Pathology, University Hospital Brno and School of Medicine, Masaryk University, Brno, Czechia
| | - Renata Veselska
- Department of Pediatric Oncology, University Hospital Brno and School of Medicine, Masaryk University, Brno, Czechia.,International Clinical Research Centre, St. Anne's University Hospital Brno, Brno, Czechia.,Laboratory of Tumor Biology, Department of Experimental Biology, School of Science, Masaryk University, Brno, Czechia
| | - Giannoula Lakka Klement
- Department of Pediatric Oncology, University Hospital Brno and School of Medicine, Masaryk University, Brno, Czechia.,CSTS Health Care Inc., Toronto, ON, Canada
| | - Dalibor Valik
- Department of Laboratory Medicine, Masaryk Memorial Cancer Institute, Brno, Czechia
| | - Jaroslav Sterba
- Department of Pediatric Oncology, University Hospital Brno and School of Medicine, Masaryk University, Brno, Czechia.,International Clinical Research Centre, St. Anne's University Hospital Brno, Brno, Czechia
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Vasudevan A, Choi JW, Feghali GA, Lander SR, Jialiang L, Schussler JM, Stoler RC, Vallabhan RC, Velasco CE, McCullough PA. Event dependence in the analysis of cardiovascular readmissions postpercutaneous coronary intervention. J Investig Med 2019; 67:943-949. [PMID: 30659091 DOI: 10.1136/jim-2018-000873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2018] [Indexed: 11/04/2022]
Abstract
Recurrent hospitalizations are common in longitudinal studies; however, many forms of cumulative event analyses assume recurrent events are independent. We explore the presence of event dependence when readmissions are spaced apart by at least 30 and 60 days. We set up a comparative framework with the assumption that patients with emergency percutaneous coronary intervention (PCI) will be at higher risk for recurrent cardiovascular readmissions than those with elective procedures. A retrospective study of patients who underwent PCI (January 2008-December 2012) with their follow-up information obtained from a regional database for hospitalization was conducted. Conditional gap time (CG), frailty gamma (FG) and conditional frailty models (CFM) were constructed to evaluate the dependence of events. Relative bias (%RB) in point estimates using CFM as the reference was calculated for comparison of the models. Among 4380 patients, emergent cases were at higher risk as compared with elective cases for recurrent events in different statistical models and time-spaced data sets, but the magnitude of HRs varied across the models (adjusted HR [95% CI]: all readmissions [unstructured data]-CG 1.16 [1.09 to 1.22], FG 1.45 [1.33 to 1.57], CFM 1.24 [1.16 to 1.32]; 30-day spaced-CG1.14 [1.08 to 1.21], FG 1.28 [1.17 to 1.39], CFM 1.17 [1.10 to 1.26]; and 60-day spaced-CG 1.14 [1.07 to 1.22], FG 1.23 [1.13 to 1.34] CFM 1.18 [1.09 to 1.26]). For all of the time-spaced readmissions, we found that the values of %RB were closer to the conditional models, suggesting that event dependence dominated the data despite attempts to create independence by increasing the space in time between admissions. Our analysis showed that independent of the intercurrent event duration, prior events have an influence on future events. Hence, event dependence should be accounted for when analyzing recurrent events and challenges contemporary methods for such analysis.
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Affiliation(s)
- Anupama Vasudevan
- Department of Cardiology, Baylor Scott & White Research Institute, Plano, Texas, USA
| | - James W Choi
- Baylor Heart and Vascular Institute, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Georges A Feghali
- Baylor Heart and Vascular Institute, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Stuart R Lander
- Baylor Heart and Vascular Institute, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Li Jialiang
- National University of Singapore Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Jeffrey M Schussler
- Baylor Heart and Vascular Institute, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Robert C Stoler
- Baylor Heart and Vascular Institute, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Ravi C Vallabhan
- Baylor Heart and Vascular Institute, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Carlos E Velasco
- Baylor Heart and Vascular Institute, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Peter A McCullough
- Baylor Heart and Vascular Institute, Baylor University Medical Center at Dallas, Dallas, Texas, USA
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