1
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Hebdon R, Stamey J, Kahle D, Zhang X. unmconf : an R package for Bayesian regression with unmeasured confounders. BMC Med Res Methodol 2024; 24:195. [PMID: 39244581 PMCID: PMC11380322 DOI: 10.1186/s12874-024-02322-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 08/27/2024] [Indexed: 09/09/2024] Open
Abstract
The inability to correctly account for unmeasured confounding can lead to bias in parameter estimates, invalid uncertainty assessments, and erroneous conclusions. Sensitivity analysis is an approach to investigate the impact of unmeasured confounding in observational studies. However, the adoption of this approach has been slow given the lack of accessible software. An extensive review of available R packages to account for unmeasured confounding list deterministic sensitivity analysis methods, but no R packages were listed for probabilistic sensitivity analysis. The R package unmconf implements the first available package for probabilistic sensitivity analysis through a Bayesian unmeasured confounding model. The package allows for normal, binary, Poisson, or gamma responses, accounting for one or two unmeasured confounders from the normal or binomial distribution. The goal of unmconf is to implement a user friendly package that performs Bayesian modeling in the presence of unmeasured confounders, with simple commands on the front end while performing more intensive computation on the back end. We investigate the applicability of this package through novel simulation studies. The results indicate that credible intervals will have near nominal coverage probability and smaller bias when modeling the unmeasured confounder(s) for varying levels of internal/external validation data across various combinations of response-unmeasured confounder distributional families.
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Affiliation(s)
- Ryan Hebdon
- Department of Statistical Science, Baylor University, Waco, TX, USA.
| | - James Stamey
- Department of Statistical Science, Baylor University, Waco, TX, USA
| | - David Kahle
- Department of Statistical Science, Baylor University, Waco, TX, USA
| | - Xiang Zhang
- CSL Behring, CSL Limited, King of Prussia, PA, USA
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2
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Lambert-Obry V, Lafrance JP, Savoie M, Lachaine J. Real-world evidence: a practical toolbox for collecting health state utilities. J Comp Eff Res 2021; 11:57-64. [PMID: 34668758 DOI: 10.2217/cer-2021-0121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Health state utilities (HSU) data collected in real-world evidence studies are at risk of bias. Although numerous guidance documents are available, practical advice to avoid bias in HSU studies is limited. Thus, the objective of this article was to develop a concise toolbox intended for investigators seeking to collect HSU in a real-world setting. The proposed toolbox builds on existing guidance and provides practical steps to help investigators perform good quality research. The toolbox aims at increasing the credibility of HSU data for future reimbursement decision making.
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Affiliation(s)
- Veronique Lambert-Obry
- The Faculty of Pharmacy, Université de Montréal, 2940, Chemin de Polytechnique, Montréal, Québec H3T 1J4, Canada
| | - Jean-Philippe Lafrance
- The Faculty of Medicine, Université de Montréal, 2900, Boulevard Édouard-Montpetit, Montréal, Québec H3T 1J4, Canada
| | - Michelle Savoie
- The Faculty of Pharmacy, Université de Montréal, 2940, Chemin de Polytechnique, Montréal, Québec H3T 1J4, Canada
| | - Jean Lachaine
- The Faculty of Pharmacy, Université de Montréal, 2940, Chemin de Polytechnique, Montréal, Québec H3T 1J4, Canada
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3
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Levenson M, He W, Chen J, Fang Y, Faries D, Goldstein BA, Ho M, Lee K, Mishra-Kalyani P, Rockhold F, Wang H, Zink RC. Biostatistical Considerations When Using RWD and RWE in Clinical Studies for Regulatory Purposes: A Landscape Assessment. Stat Biopharm Res 2021. [DOI: 10.1080/19466315.2021.1883473] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
| | - Weili He
- Global Medical Affairs Statistics, Data and Statistical Sciences, AbbVie, North Chicago, IL
| | - Jie Chen
- Overland Pharmaceuticals, Dover, DE
| | - Yixin Fang
- Global Medical Affairs Statistics, Data and Statistical Sciences, AbbVie, North Chicago, IL
| | - Douglas Faries
- Global Statistical Sciences, Eli Lilly & Company, Indianapolis, IN
| | - Benjamin A. Goldstein
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC
- Duke Clinical Research Institute, Duke University, Durham, NC
| | | | - Kwan Lee
- Statistics and Decision Sciences, Janssen Research and Development (retired), Spring House, PA
| | | | - Frank Rockhold
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - Hongwei Wang
- Global Medical Affairs Statistics, Data and Statistical Sciences, AbbVie, North Chicago, IL
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4
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Onyeakusi NE, Mukhtar F, Gbadamosi SO, Oshunbade A, Adejumo AC, Olufajo O, Owoh J. Cancer-Related Pain Is an Independent Predictor of In-Hospital Opioid Overdose: A Propensity-Matched Analysis. PAIN MEDICINE 2019; 20:2552-2561. [PMID: 31197321 DOI: 10.1093/pm/pnz130] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND About 50% of patients with cancer who have undergone surgery suffer from cancer-related pain (CP). The use of opioids for postoperative pain management presents the potential for overdose, especially among these patients. OBJECTIVE The primary objective of this study was to determine the association between CP and postoperative opioid overdose among inpatients who had undergone major elective procedures. The secondary objective was to assess the relationship between CP and inpatient mortality, total hospital charge, and length of stay in this population. METHODS Data of adults 18 years and older from the National Inpatient Sample (NIS) were analyzed. Variables were identified using ICD-9 codes. Propensity-matched regression models were employed in evaluating the association between CP and outcomes of interest. RESULTS Among 4,085,355 selected patients, 0.8% (N = 2,665) had CP, whereas 99.92% (N = 4,082,690) had no diagnosis of CP. We matched patients with CP (N = 2,665) and no CP (N = 13,325) in a 1:5 ratio. We found higher odds of opioid overdose (adjusted odds ratio [aOR] = 4.82, 95% confidence interval [CI] = 2.68-8.67, P < 0.0001) and inpatient mortality (aOR = 1.39, 95% CI = 1.11-1.74, P = 0.0043) in patients with CP vs no CP. Also, patients with CP were more likely to stay longer in the hospital (12.76 days vs 7.88 days) with higher total hospital charges ($140,220 vs $88,316). CONCLUSIONS CP is an independent risk factor for opioid overdose, increased length of stay, and increased total hospital charges.
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Affiliation(s)
- Nnaemeka E Onyeakusi
- Department of Anesthesiology, Case Western Reserve University/MetroHealth Med Ctr, Cleveland, Ohio.,Department of Pediatrics, BronxCare Health System, Bronx, New York
| | - Fahad Mukhtar
- Department of Psychiatry, St. Elizabeth's Hospital, Washington, DC.,Department of Epidemiology and Biostatistics, University of South Florida, Tampa, Florida
| | - Semiu O Gbadamosi
- Department of Epidemiology, Robert Stempel College of Public Health & Social Work, Florida International University, Miami, Florida
| | | | | | - Olubode Olufajo
- Department of Surgery, Howard University College of Medicine, Washington, DC
| | - Jude Owoh
- Quinnipiac University, Hamden, Salem, Connecticut, USA
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5
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Van Domelen DR, Lyles RH. A LOOK AT THE UNIQUE IDENTIFIABILITY OF PROPENSITY SCORE CALIBRATION. Am J Epidemiol 2019; 188:1397-1399. [PMID: 30896016 DOI: 10.1093/aje/kwz072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 03/11/2019] [Accepted: 03/12/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Dane R Van Domelen
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Robert H Lyles
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
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6
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Dasgupta N, Schwarz J, Hennessy S, Ertefaie A, Dart RC. Causal inference for evaluating prescription opioid abuse using trend-in-trend design. Pharmacoepidemiol Drug Saf 2019; 28:716-725. [PMID: 30714239 DOI: 10.1002/pds.4736] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 12/20/2018] [Accepted: 12/26/2018] [Indexed: 11/06/2022]
Abstract
PURPOSE One response to the opioid crisis in the United States has been the development of opioid analgesics with properties intended to reduce non-oral use. Previous evaluations of abuse in the community have relied on population averaged interrupted time series Poisson models with utilization offsets. However, competing interventions and secular trends complicate interpretation of time-series analyses. An alternative research design, trend-in-trend, accounts for heterogeneity in per capita opioid dispensing and unmeasured time-varying confounding, which provides a causal evaluation, provided that underlying assumptions are met. METHODS Trend-in-trend can be modeled using a logistic regression framework. In logistic regression, exposure was any product-specific outpatient dispensing by three-digit ZIP code and calendar quarter, for 22 opioids. The outcome was any product-specific abuse case ascertained from poison centers and drug treatment programs, covering 94% of the US population, between July 2009 and December 2016. Product-specific odds ratios compared places without dispensing with places with any dispensing; the causal contrast represents the odds of product-specific abuse in the community given exposure. RESULTS Dispensing of new and low-volume opioids varied considerably across the country, with no region showing high of all products. Of 22 opioids analyzed, the three with approved labeling as intended to deter abuse ranked near the lowest in both absolute (population-adjusted rates: 1.7, 0.9, and 8.2 per million people per quarter, respectively) and relative measures (trend-in-trend ORs: 1.96, 1.79, 1.69, respectively). CONCLUSIONS Postmarketing studies of prescription opioid abuse may benefit by evolving from unadjusted surveillance rates to a causal inference approach.
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Affiliation(s)
- Nabarun Dasgupta
- Rocky Mountain Poison and Drug Center, Denver Health, Denver, CO, USA.,Injury Prevention Research Center and Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - John Schwarz
- Rocky Mountain Poison and Drug Center, Denver Health, Denver, CO, USA
| | - Sean Hennessy
- Center for Pharmacoepidemiology Research and Training and Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Askhan Ertefaie
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, USA
| | - Richard C Dart
- Rocky Mountain Poison and Drug Center, Denver Health, Denver, CO, USA.,Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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7
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Zhang X, Faries DE, Li H, Stamey JD, Imbens GW. Addressing unmeasured confounding in comparative observational research. Pharmacoepidemiol Drug Saf 2018; 27:373-382. [DOI: 10.1002/pds.4394] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 10/19/2017] [Accepted: 12/29/2017] [Indexed: 11/08/2022]
Affiliation(s)
- Xiang Zhang
- Eli Lilly and Company; Lilly Corporate Center; Indianapolis IN USA
| | | | - Hu Li
- Eli Lilly and Company; Lilly Corporate Center; Indianapolis IN USA
| | | | - Guido W. Imbens
- Graduate School of Business; Stanford University; Stanford CA USA
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8
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Markevych I, Schoierer J, Hartig T, Chudnovsky A, Hystad P, Dzhambov AM, de Vries S, Triguero-Mas M, Brauer M, Nieuwenhuijsen MJ, Lupp G, Richardson EA, Astell-Burt T, Dimitrova D, Feng X, Sadeh M, Standl M, Heinrich J, Fuertes E. Exploring pathways linking greenspace to health: Theoretical and methodological guidance. ENVIRONMENTAL RESEARCH 2017; 158:301-317. [PMID: 28672128 DOI: 10.1016/j.envres.2017.06.028] [Citation(s) in RCA: 1003] [Impact Index Per Article: 143.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 06/22/2017] [Accepted: 06/23/2017] [Indexed: 05/18/2023]
Abstract
BACKGROUND In a rapidly urbanizing world, many people have little contact with natural environments, which may affect health and well-being. Existing reviews generally conclude that residential greenspace is beneficial to health. However, the processes generating these benefits and how they can be best promoted remain unclear. OBJECTIVES During an Expert Workshop held in September 2016, the evidence linking greenspace and health was reviewed from a transdisciplinary standpoint, with a particular focus on potential underlying biopsychosocial pathways and how these can be explored and organized to support policy-relevant population health research. DISCUSSIONS Potential pathways linking greenspace to health are here presented in three domains, which emphasize three general functions of greenspace: reducing harm (e.g. reducing exposure to air pollution, noise and heat), restoring capacities (e.g. attention restoration and physiological stress recovery) and building capacities (e.g. encouraging physical activity and facilitating social cohesion). Interrelations between among the three domains are also noted. Among several recommendations, future studies should: use greenspace and behavioural measures that are relevant to hypothesized pathways; include assessment of presence, access and use of greenspace; use longitudinal, interventional and (quasi)experimental study designs to assess causation; and include low and middle income countries given their absence in the existing literature. Cultural, climatic, geographic and other contextual factors also need further consideration. CONCLUSIONS While the existing evidence affirms beneficial impacts of greenspace on health, much remains to be learned about the specific pathways and functional form of such relationships, and how these may vary by context, population groups and health outcomes. This Report provides guidance for further epidemiological research with the goal of creating new evidence upon which to develop policy recommendations.
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Affiliation(s)
- Iana Markevych
- Institute for Occupational, Social, and Environmental Medicine, Ludwig-Maximilians-University of Munich, Munich, Germany; Institute of Epidemiology I, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany.
| | - Julia Schoierer
- Institute for Occupational, Social, and Environmental Medicine, Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Terry Hartig
- Institute for Housing and Urban Research, Uppsala University, Uppsala, Sweden
| | - Alexandra Chudnovsky
- AIRO Lab, Department of Geography and Human Environment, School of Geosciences, Tel-Aviv University, Tel-Aviv, Israel
| | - Perry Hystad
- College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA
| | - Angel M Dzhambov
- Department of Hygiene and Ecomedicine, Faculty of Public Health, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Sjerp de Vries
- Wageningen University & Research, Environmental Research, Wageningen, The Netherlands
| | - Margarita Triguero-Mas
- ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Michael Brauer
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mark J Nieuwenhuijsen
- ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Gerd Lupp
- Strategic Landscape Planning and Management, Technical University of Munich, Munich, Germany
| | - Elizabeth A Richardson
- Centre for Research on Environment, Society and Health (CRESH), University of Edinburgh, Edinburgh, Scotland, UK
| | - Thomas Astell-Burt
- Population Wellbeing and Environment Research Lab (PowerLab), Faculty of Social Sciences, University of Wollongong, Wollongong, Australia; Early Start, University of Wollongong, Faculty of Social Sciences, University of Wollongong, Wollongong, Australia
| | - Donka Dimitrova
- Department of Health Management and Healthcare Economics, Faculty of Public Health, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Xiaoqi Feng
- Population Wellbeing and Environment Research Lab (PowerLab), Faculty of Social Sciences, University of Wollongong, Wollongong, Australia; Early Start, University of Wollongong, Faculty of Social Sciences, University of Wollongong, Wollongong, Australia
| | - Maya Sadeh
- School of Public Health, Tel-Aviv University, Tel-Aviv, Israel
| | - Marie Standl
- Institute of Epidemiology I, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany
| | - Joachim Heinrich
- Institute for Occupational, Social, and Environmental Medicine, Ludwig-Maximilians-University of Munich, Munich, Germany; Institute of Epidemiology I, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany
| | - Elaine Fuertes
- ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
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9
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Guertin JR, Bowen JM, De Rose G, O'Reilly DJ, Tarride JE. Illustration of the Impact of Unmeasured Confounding Within an Economic Evaluation Based on Nonrandomized Data. MDM Policy Pract 2017; 2:2381468317697711. [PMID: 30288418 PMCID: PMC6124939 DOI: 10.1177/2381468317697711] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 02/02/2017] [Indexed: 11/17/2022] Open
Abstract
Background: Propensity score (PS) methods are frequently used
within economic evaluations based on nonrandomized data to adjust for measured
confounders, but many researchers omit the fact that they cannot adjust for
unmeasured confounders. Objective: To illustrate how confounding
due to unmeasured confounders can bias an economic evaluation despite PS
matching. Methods: We used data from a previously published
nonrandomized study to select a prematched population consisting of 121 patients
(46.5%) who received endovascular aneurysm repair (EVAR) and 139 patients
(53.5%) who received open surgical repair (OSR), in which sufficient data
regarding eight measured confounders were available. One-to-one PS matching was
used within this population to select two PS-matched subpopulations. The Matched
PS-Smoking Excluded Subpopulation was selected by matching patients using a PS
model that omitted patients’ smoking status (one of the measured confounders),
whereas the Matched PS-Smoking Included Subpopulation was selected by matching
patients using a PS model that included all eight measured confounders.
Incremental cost-effectiveness ratios (ICERs) were assessed within both
subpopulations. Results: Both subpopulations were composed of two
different sets of 164 patients. Balance within the Matched PS-Smoking Excluded
Subpopulation was achieved on all confounders except for patients’ smoking
status, whereas balance within the Matched PS-Smoking Included Subpopulation was
achieved on all confounders. Results indicated that the ICER of EVAR over OSR
differed between both subpopulations; the ICER was estimated at $157,909 per
life-year gained (LYG) within the Matched PS-Smoking Excluded Subpopulation,
while it was estimated at $235,074 per LYG within the Matched PS-Smoking
Included Subpopulation. Discussion: Although effective in
controlling for measured confounding, PS matching may not adjust for unmeasured
confounders that may bias the results of an economic evaluation based on
nonrandomized data.
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Affiliation(s)
- Jason R Guertin
- Programs for Assessment of Technology in Health, The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada (JRG, JMB, DJO, JT).,Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada (JRG, JMB, DJO, JT).,Department of Social and Preventive Medicine, Université Laval, Quebec City, Quebec, Canada (JRG).,Centre de recherche du CHU de Québec-Université Laval, Axe Santé des Populations et Pratiques Optimales en Santé, Hôpital du St-Sacrement, Quebec City, Quebec, Canada (JRG).,Division of Vascular Surgery, Department of Surgery, London Health Sciences Centre, London, Ontario, Canada (GDR).,Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Western University, London, Ontario, Canada (GDR)
| | - James M Bowen
- Programs for Assessment of Technology in Health, The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada (JRG, JMB, DJO, JT).,Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada (JRG, JMB, DJO, JT).,Department of Social and Preventive Medicine, Université Laval, Quebec City, Quebec, Canada (JRG).,Centre de recherche du CHU de Québec-Université Laval, Axe Santé des Populations et Pratiques Optimales en Santé, Hôpital du St-Sacrement, Quebec City, Quebec, Canada (JRG).,Division of Vascular Surgery, Department of Surgery, London Health Sciences Centre, London, Ontario, Canada (GDR).,Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Western University, London, Ontario, Canada (GDR)
| | - Guy De Rose
- Programs for Assessment of Technology in Health, The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada (JRG, JMB, DJO, JT).,Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada (JRG, JMB, DJO, JT).,Department of Social and Preventive Medicine, Université Laval, Quebec City, Quebec, Canada (JRG).,Centre de recherche du CHU de Québec-Université Laval, Axe Santé des Populations et Pratiques Optimales en Santé, Hôpital du St-Sacrement, Quebec City, Quebec, Canada (JRG).,Division of Vascular Surgery, Department of Surgery, London Health Sciences Centre, London, Ontario, Canada (GDR).,Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Western University, London, Ontario, Canada (GDR)
| | - Daria J O'Reilly
- Programs for Assessment of Technology in Health, The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada (JRG, JMB, DJO, JT).,Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada (JRG, JMB, DJO, JT).,Department of Social and Preventive Medicine, Université Laval, Quebec City, Quebec, Canada (JRG).,Centre de recherche du CHU de Québec-Université Laval, Axe Santé des Populations et Pratiques Optimales en Santé, Hôpital du St-Sacrement, Quebec City, Quebec, Canada (JRG).,Division of Vascular Surgery, Department of Surgery, London Health Sciences Centre, London, Ontario, Canada (GDR).,Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Western University, London, Ontario, Canada (GDR)
| | - Jean-Eric Tarride
- Programs for Assessment of Technology in Health, The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada (JRG, JMB, DJO, JT).,Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada (JRG, JMB, DJO, JT).,Department of Social and Preventive Medicine, Université Laval, Quebec City, Quebec, Canada (JRG).,Centre de recherche du CHU de Québec-Université Laval, Axe Santé des Populations et Pratiques Optimales en Santé, Hôpital du St-Sacrement, Quebec City, Quebec, Canada (JRG).,Division of Vascular Surgery, Department of Surgery, London Health Sciences Centre, London, Ontario, Canada (GDR).,Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Western University, London, Ontario, Canada (GDR)
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10
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Abstract
Uncontrolled confounding due to unmeasured confounders biases causal inference in health science studies using observational and imperfect experimental designs. The adoption of methods for analysis of bias due to uncontrolled confounding has been slow, despite the increasing availability of such methods. Bias analysis for such uncontrolled confounding is most useful in big data studies and systematic reviews to gauge the extent to which extraneous preexposure variables that affect the exposure and the outcome can explain some or all of the reported exposure-outcome associations. We review methods that can be applied during or after data analysis to adjust for uncontrolled confounding for different outcomes, confounders, and study settings. We discuss relevant bias formulas and how to obtain the required information for applying them. Finally, we develop a new intuitive generalized bias analysis framework for simulating and adjusting for the amount of uncontrolled confounding due to not measuring and adjusting for one or more confounders.
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Affiliation(s)
- Onyebuchi A Arah
- Department of Epidemiology, Fielding School of Public Health; UCLA Center for Health Policy Research; and California Center for Population Research, University of California, Los Angeles, California 90095;
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11
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Akacha M, Bretz F, Ruberg S. Estimands in clinical trials - broadening the perspective. Stat Med 2016; 36:5-19. [DOI: 10.1002/sim.7033] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 06/01/2016] [Accepted: 06/10/2016] [Indexed: 11/07/2022]
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12
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Zhang X, Faries DE, Boytsov N, Stamey JD, Seaman JW. “A Bayesian sensitivity analysis to evaluate the impact of unmeasured confounding with external data: a real world comparative effectiveness study in osteoporosis”. Pharmacoepidemiol Drug Saf 2016; 25:982-92. [DOI: 10.1002/pds.4053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 05/27/2016] [Accepted: 05/31/2016] [Indexed: 12/25/2022]
Affiliation(s)
- Xiang Zhang
- Eli Lilly and Company; Lilly Corporate Center; Indianapolis IN United States
| | - Douglas E. Faries
- Eli Lilly and Company; Lilly Corporate Center; Indianapolis IN United States
| | - Natalie Boytsov
- Eli Lilly and Company; Lilly Corporate Center; Indianapolis IN United States
| | - James D. Stamey
- Department of Statistical Science; Baylor University; Waco TX United States
| | - John W. Seaman
- Department of Statistical Science; Baylor University; Waco TX United States
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13
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Uddin MJ, Groenwold RHH, Ali MS, de Boer A, Roes KCB, Chowdhury MAB, Klungel OH. Methods to control for unmeasured confounding in pharmacoepidemiology: an overview. Int J Clin Pharm 2016; 38:714-23. [PMID: 27091131 DOI: 10.1007/s11096-016-0299-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 04/04/2016] [Indexed: 12/21/2022]
Abstract
Background Unmeasured confounding is one of the principal problems in pharmacoepidemiologic studies. Several methods have been proposed to detect or control for unmeasured confounding either at the study design phase or the data analysis phase. Aim of the Review To provide an overview of commonly used methods to detect or control for unmeasured confounding and to provide recommendations for proper application in pharmacoepidemiology. Methods/Results Methods to control for unmeasured confounding in the design phase of a study are case only designs (e.g., case-crossover, case-time control, self-controlled case series) and the prior event rate ratio adjustment method. Methods that can be applied in the data analysis phase include, negative control method, perturbation variable method, instrumental variable methods, sensitivity analysis, and ecological analysis. A separate group of methods are those in which additional information on confounders is collected from a substudy. The latter group includes external adjustment, propensity score calibration, two-stage sampling, and multiple imputation. Conclusion As the performance and application of the methods to handle unmeasured confounding may differ across studies and across databases, we stress the importance of using both statistical evidence and substantial clinical knowledge for interpretation of the study results.
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Affiliation(s)
- Md Jamal Uddin
- Department of Statistics (Biostatistics and Epidemiology), Shahjalal University of Science and Technology, Sylhet, 3114, Bangladesh. .,Division of Pharmacoepidemiology and Clinical Pharmacology, University of Utrecht, Utrecht, The Netherlands.
| | - Rolf H H Groenwold
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mohammed Sanni Ali
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology, University of Utrecht, Utrecht, The Netherlands
| | - Kit C B Roes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Muhammad A B Chowdhury
- Department of Biostatistics, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
| | - Olaf H Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, University of Utrecht, Utrecht, The Netherlands
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14
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Groenwold RHH, de Groot MCH, Ramamoorthy D, Souverein PC, Klungel OH. Unmeasured confounding in pharmacoepidemiology. Ann Epidemiol 2015; 26:85-6. [PMID: 26559329 DOI: 10.1016/j.annepidem.2015.10.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 10/08/2015] [Accepted: 10/13/2015] [Indexed: 11/18/2022]
Affiliation(s)
- Rolf H H Groenwold
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, University of Utrecht, Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Mark C H de Groot
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, University of Utrecht, Utrecht, The Netherlands
| | - Dhivya Ramamoorthy
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Patrick C Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, University of Utrecht, Utrecht, The Netherlands
| | - Olaf H Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, University of Utrecht, Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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15
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Lin HW, Chen YH. Adjustment for missing confounders in studies based on observational databases: 2-stage calibration combining propensity scores from primary and validation data. Am J Epidemiol 2014; 180:308-17. [PMID: 24966224 DOI: 10.1093/aje/kwu130] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Bias caused by missing or incomplete information on confounding factors constitutes an important challenge in observational studies. The incorporation of external data on more detailed confounding information into the main study data may help remove confounding bias. This work was motivated by a study of the association between chronic obstructive pulmonary disease and herpes zoster. Analyses were based on administrative databases in which information on important confounders-cigarette smoking and alcohol consumption-was lacking. We consider adjusting for the confounding bias arising from missing confounders by incorporating a validation sample with data on smoking and alcohol consumption obtained from a small-scale National Health Interview Survey study. We propose a 2-stage calibration (TSC) method, which summarizes the confounding information through propensity scores and combines the analysis results from the main and the validation study samples, where the propensity score adjustment from the main sample is crude and that from the validation sample is more precise. Unlike the existing methods, the validity of the TSC approach does not rely on any specific measurement error model. When applying the TSC method to the motivating study above, the odds ratio of herpes zoster associated with chronic obstructive pulmonary disease is 1.91 (95% confidence interval: 1.62, 2.26) after adjustment for cumulative smoking and alcohol consumption.
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16
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Girman CJ, Faries D, Ryan P, Rotelli M, Belger M, Binkowitz B, O’Neill R. Pre-study feasibility and identifying sensitivity analyses for protocol pre-specification in comparative effectiveness research. J Comp Eff Res 2014; 3:259-70. [DOI: 10.2217/cer.14.16] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The use of healthcare databases for comparative effectiveness research (CER) is increasing exponentially despite its challenges. Researchers must understand their data source and whether outcomes, exposures and confounding factors are captured sufficiently to address the research question. They must also assess whether bias and confounding can be adequately minimized. Many study design characteristics may impact on the results; however, minimal if any sensitivity analyses are typically conducted, and those performed are post hoc. We propose pre-study steps for CER feasibility assessment and to identify sensitivity analyses that might be most important to pre-specify to help ensure that CER produces valid interpretable results.
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Affiliation(s)
- Cynthia J Girman
- Comparative & Outcomes Evidence, Center for Observational & Real-world Evidence, Merck Sharp & Dohme, North Wales, PA 19454, USA
| | - Douglas Faries
- Global Statistical Sciences, Eli Lilly & Company, Indianapolis, IN, USA & UK
| | - Patrick Ryan
- Epidemiology Analytics, Janssen Research & Development, Titusville, NJ, USA
| | - Matt Rotelli
- Global PK/PD & Pharmacometrics, Eli Lilly & Company, Indianapolis, IN, USA
| | - Mark Belger
- Global Statistical Sciences, Eli Lilly & Company, Indianapolis, IN, USA & UK
| | - Bruce Binkowitz
- Late Development Statistics, Merck Sharp & Dohme, Rahway, NJ, USA
| | - Robert O’Neill
- The Office of Translational Sciences, CDER, US Food & Drug Administration, Rockville, MD, USA
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17
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Stamey JD, Beavers DP, Faries D, Price KL, Seaman JW. Bayesian modeling of cost-effectiveness studies with unmeasured confounding: a simulation study. Pharm Stat 2013; 13:94-100. [DOI: 10.1002/pst.1604] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 10/08/2013] [Accepted: 10/10/2013] [Indexed: 11/09/2022]
Affiliation(s)
- James D. Stamey
- Department of Statistical Science; Baylor University; Waco TX USA
| | - Daniel P. Beavers
- Department of Biostatistical Sciences; Wake Forest School of Medicine; Winston-Salem NC USA
| | | | | | - John W. Seaman
- Department of Statistical Science; Baylor University; Waco TX USA
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