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Lotspeich SC, Ashner MC, Vazquez JE, Richardson BD, Grosser KF, Bodek BE, Garcia TP. Making Sense of Censored Covariates: Statistical Methods for Studies of Huntington's Disease. ANNUAL REVIEW OF STATISTICS AND ITS APPLICATION 2024; 11:255-277. [PMID: 38962579 PMCID: PMC11220439 DOI: 10.1146/annurev-statistics-040522-095944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
The landscape of survival analysis is constantly being revolutionized to answer biomedical challenges, most recently the statistical challenge of censored covariates rather than outcomes. There are many promising strategies to tackle censored covariates, including weighting, imputation, maximum likelihood, and Bayesian methods. Still, this is a relatively fresh area of research, different from the areas of censored outcomes (i.e., survival analysis) or missing covariates. In this review, we discuss the unique statistical challenges encountered when handling censored covariates and provide an in-depth review of existing methods designed to address those challenges. We emphasize each method's relative strengths and weaknesses, providing recommendations to help investigators pinpoint the best approach to handling censored covariates in their data.
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Affiliation(s)
- Sarah C Lotspeich
- Department of Statistical Sciences, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Marissa C Ashner
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jesus E Vazquez
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Brian D Richardson
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kyle F Grosser
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Benjamin E Bodek
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Tanya P Garcia
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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2
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Mikhail ME, Ackerman LS, Culbert KM, Burt SA, Neale MC, Keel PK, Katzman DK, Klump KL. A cotwin control study of associations between financial hardship and binge eating phenotypes during COVID-19. Int J Eat Disord 2023; 56:132-142. [PMID: 36300949 PMCID: PMC9851975 DOI: 10.1002/eat.23841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/20/2022] [Accepted: 10/14/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND COVID-19 was associated with significant financial hardship and increased binge eating (BE). However, it is largely unknown whether financial stressors contributed to BE during the pandemic. We used a longitudinal, cotwin control design that controls for genetic/environmental confounds by comparing twins in the same family to examine whether financial hardship during COVID-19 was associated with BE. METHODS Female twins (N = 158; Mage = 22.13) from the Michigan State University Twin Registry rated financial stressors (e.g., inability to afford necessities) daily for 49 consecutive days during COVID-19. We first examined whether financial hardship was associated with BE phenotypes across the full sample. We then examined whether cotwins who differed on financial hardship also differed in BE. RESULTS Participants who experienced greater mean financial hardship across the study had significantly greater dimensional BE symptoms, and participants who experienced greater financial hardship on a given day reported significantly more emotional eating that day. These results were replicated in cotwin control analyses. Twins who experienced more financial hardship than their cotwin across the study reported greater dimensional BE symptoms than their cotwin, and participants who experienced more financial hardship than their cotwin on a given day reported greater emotional eating that day. Results were identical when restricting analyses to monozygotic twins, suggesting associations were not due to genetic confounds. CONCLUSIONS Results suggest that BE-related symptoms may be elevated in women who experienced financial hardship during COVID-19 independent of potential genetic/environmental confounds. However, additional research in larger samples is needed. PUBLIC SIGNIFICANCE Little is known regarding how financial difficulties during the COVID-19 pandemic may have contributed to increased binge eating (BE). We found preliminary evidence that financial hardship during COVID-19 may be associated with greater rates of BE-related symptoms even when comparing twins from the same family. While additional research is needed, results suggest that people who experienced financial hardship during COVID-19 may be at increased risk for BE.
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Affiliation(s)
- Megan E. Mikhail
- Department of PsychologyMichigan State UniversityEast LansingMichiganUSA
| | | | - Kristen M. Culbert
- Department of PsychologyMichigan State UniversityEast LansingMichiganUSA
| | - S. Alexandra Burt
- Department of PsychologyMichigan State UniversityEast LansingMichiganUSA
| | - Michael C. Neale
- Departments of Psychiatry, Human Genetics, and PsychologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Pamela K. Keel
- Department of PsychologyFlorida State UniversityTallahasseeFloridaUSA
| | - Debra K. Katzman
- Department of PediatricsUniversity of TorontoTorontoOntarioCanada
| | - Kelly L. Klump
- Department of PsychologyMichigan State UniversityEast LansingMichiganUSA
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3
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Morimoto J. The effect of sample size and missingness on inference with missing data. COMMUN STAT-THEOR M 2022. [DOI: 10.1080/03610926.2022.2152287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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4
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Nevarez-Brewster M, Aran Ö, Narayan AJ, Harrall KK, Brown SM, Hankin BL, Davis EP. Adverse and Benevolent Childhood Experiences Predict Prenatal Sleep Quality. ADVERSITY AND RESILIENCE SCIENCE 2022; 3:391-402. [PMID: 36968335 PMCID: PMC10035559 DOI: 10.1007/s42844-022-00070-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/13/2022] [Indexed: 11/28/2022]
Abstract
The objective of the study was to investigate whether adverse and benevolent childhood experiences were associated with trajectories of sleep quality throughout pregnancy. The study was conducted at obstetrics and gynecology clinics in the Rocky Mountain region of the USA. The participants of the study were pregnant individuals (N = 164). Sleep quality was measured with the Pittsburgh Sleep Quality Index at three gestational time points, and adverse childhood experiences (ACEs) and benevolent childhood experiences (BCEs) were assessed once. Multilevel models were conducted to examine the trajectory of sleep quality across gestation in relation to ACEs and BCEs. Sleep quality was similar in early to mid-pregnancy, with a worsening of sleep quality late in pregnancy, following a quadratic trajectory. Higher levels of ACEs predicted poorer prenatal sleep quality (b = 0.36, SE = 0.13, p = .004) throughout pregnancy, while higher levels of BCEs predicted better sleep quality (b = -0.60, SE = 0.17, p < .001) throughout pregnancy. Examination of ACEs subtypes revealed that childhood maltreatment predicted poor sleep quality (b = 0.66, SE = 0.18, p < .001), while childhood household dysfunction was not significantly associated (b = 0.33, SE = 0.21, p = .11). Associations remained after covarying for socioeconomic status and current stressful life events. Both adverse and benevolent childhood experiences predict sleep health during pregnancy. Prevention and intervention strategies targeting resilience and sleep quality during pregnancy should be implemented to promote prenatal health and well-being.
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Affiliation(s)
| | - Özlü Aran
- Department of Psychology, University of Denver, 2155 S Race St, Denver, CO 80208, USA
| | - Angela J. Narayan
- Department of Psychology, University of Denver, 2155 S Race St, Denver, CO 80208, USA
| | - Kylie K. Harrall
- Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, Colorado School of Public Health, Aurora, USA
- Department of Epidemiology, Colorado School of Public Health, Aurora, USA
| | | | - Benjamin L. Hankin
- Department of Psychology, University of Illinois at Urbana-Champaign, Champaign, USA
| | - Elysia Poggi Davis
- Department of Psychology, University of Denver, 2155 S Race St, Denver, CO 80208, USA
- Department of Pediatrics, University of California, Irvine, Irvine, USA
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5
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Nevarez-Brewster M, Demers CH, Mejia A, Haase MH, Bagonis MM, Kim SH, Gilmore JH, Hoffman MC, Styner MA, Hankin BL, Davis EP. Longitudinal and prospective assessment of prenatal maternal sleep quality and associations with newborn hippocampal and amygdala volume. Dev Cogn Neurosci 2022; 58:101174. [PMID: 36375383 PMCID: PMC9661438 DOI: 10.1016/j.dcn.2022.101174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 10/12/2022] [Accepted: 11/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The rapid maturation of the fetal brain renders the fetus susceptible to prenatal environmental signals. Prenatal maternal sleep quality is known to have important health implications for newborns including risk for preterm birth, however, the effect on the fetal brain is poorly understood. METHOD Participants included 94 pregnant participants and their newborns (53% female). Pregnant participants (Mage = 30; SDage= 5.29) reported on sleep quality three times throughout pregnancy. Newborn hippocampal and amygdala volumes were assessed using structural magnetic resonance imaging. Multilevel modeling was used to test the associations between trajectories of prenatal maternal sleep quality and newborn hippocampal and amygdala volume. RESULTS The overall trajectory of prenatal maternal sleep quality was associated with hippocampal volume (left: b = 0.00003, p = 0.013; right: b = 0.00003, p = .008). Follow up analyses assessing timing of exposure indicate that poor sleep quality early in pregnancy was associated with larger hippocampal volume bilaterally (e.g., late gestation left: b = 0.002, p = 0.24; right: b = 0.004, p = .11). Prenatal sleep quality was not associated with amygdala volume. CONCLUSION These findings highlight the implications of poor prenatal maternal sleep quality and its role in contributing to newborn hippocampal development.
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Affiliation(s)
| | - Catherine H Demers
- University of Denver, Department of Psychology, United States; University of Colorado Anschutz Medical Campus, Department of Psychiatry, United States
| | - Alexandra Mejia
- University of Denver, Department of Psychology, United States
| | | | - Maria M Bagonis
- University of North Carolina - Chapel Hill, Department of Psychiatry, United States
| | - Sun Hyung Kim
- University of North Carolina - Chapel Hill, Department of Psychiatry, United States
| | - John H Gilmore
- University of North Carolina - Chapel Hill, Department of Psychiatry, United States
| | - M Camille Hoffman
- University of Colorado Anschutz Medical Campus, Department of Psychiatry, United States; University of Colorado Denver School of Medicine, Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, United States
| | - Martin A Styner
- University of North Carolina - Chapel Hill, Department of Psychiatry, United States; University of North Carolina - Chapel Hill, Department of Computer Science, United States
| | - Benjamin L Hankin
- University of Illinois at Urbana-Champaign, Department of Psychology, United States
| | - Elysia Poggi Davis
- University of Denver, Department of Psychology, United States; University of California, Irvine, Department of Pediatrics, United States
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6
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Wijesuriya R, Moreno-Betancur M, Carlin JB, De Silva AP, Lee KJ. Evaluation of approaches for accommodating interactions and non-linear terms in multiple imputation of incomplete three-level data. Biom J 2022; 64:1404-1425. [PMID: 34914127 PMCID: PMC10174217 DOI: 10.1002/bimj.202000343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 04/19/2021] [Accepted: 06/05/2021] [Indexed: 12/14/2022]
Abstract
Three-level data structures arising from repeated measures on individuals clustered within larger units are common in health research studies. Missing data are prominent in such studies and are often handled via multiple imputation (MI). Although several MI approaches can be used to account for the three-level structure, including adaptations to single- and two-level approaches, when the substantive analysis model includes interactions or quadratic effects, these too need to be accommodated in the imputation model. In such analyses, substantive model compatible (SMC) MI has shown great promise in the context of single-level data. Although there have been recent developments in multilevel SMC MI, to date only one approach that explicitly handles incomplete three-level data is available. Alternatively, researchers can use pragmatic adaptations to single- and two-level MI approaches, or two-level SMC-MI approaches. We describe the available approaches and evaluate them via simulations in the context of three three-level random effects analysis models involving an interaction between the incomplete time-varying exposure and time, an interaction between the time-varying exposure and an incomplete time-fixed confounder, or a quadratic effect of the exposure. Results showed that all approaches considered performed well in terms of bias and precision when the target analysis involved an interaction with time, but the three-level SMC MI approach performed best when the target analysis involved an interaction between the time-varying exposure and an incomplete time-fixed confounder, or a quadratic effect of the exposure. We illustrate the methods using data from the Childhood to Adolescence Transition Study.
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Affiliation(s)
- Rushani Wijesuriya
- Department of Paediatrics, Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia.,Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Margarita Moreno-Betancur
- Department of Paediatrics, Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia.,Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - John B Carlin
- Department of Paediatrics, Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia.,Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Anurika P De Silva
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Katherine J Lee
- Department of Paediatrics, Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia.,Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, Victoria, Australia
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7
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Zeng G, Maylott SE, Leung TS, Messinger DS, Wang J, Simpson EA. Infant temperamental fear, pupil dilation, and gaze aversion from smiling strangers. Dev Psychobiol 2022; 64:e22324. [PMID: 36282740 DOI: 10.1002/dev.22324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 07/06/2022] [Accepted: 08/17/2022] [Indexed: 01/27/2023]
Abstract
In childhood, higher levels of temperamental fear-an early-emerging proclivity to distress in the face of novelty-are associated with lower social responsivity and greater social anxiety. While the early emergence of temperamental fear in infancy is poorly understood, it is theorized to be driven by individual differences in reactivity and self-regulation to novel stimuli. The current study used eye tracking to capture infants' (N = 124) reactions to a video of a smiling stranger-a common social encounter-including infant gaze aversions from the stranger's face (indexing arousal regulation) and pupil dilation (indexing physiological reactivity), longitudinally at 2, 4, 6, and 8 months of age. Multilevel mixed-effects models indicated that more fearful infants took more time to look away from a smiling stranger's face than less fearful infants, suggesting that high-fear infants may have slower arousal regulation. At 2 and 4 months, more fearful infants also exhibited greater and faster pupil dilation before gaze aversions, consistent with greater physiological reactivity. Together, these findings suggest that individual differences in infants' gaze aversions and pupil dilation can index the development of fearful temperament in early infancy, facilitating the identification of, and interventions for, risk factors to social disruptions.
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Affiliation(s)
- Guangyu Zeng
- Department of Psychology, University of Miami, Coral Gables, Florida, USA
| | - Sarah E Maylott
- Department of Psychology, University of Miami, Coral Gables, Florida, USA.,Department of Psychology, University of Utah, Salt Lake City, Utah, USA.,Department of Psychiatry & Behavioral Sciences, Duke University, Durham, North Carolina, USA
| | - Tiffany S Leung
- Department of Psychology, University of Miami, Coral Gables, Florida, USA
| | - Daniel S Messinger
- Department of Psychology, University of Miami, Coral Gables, Florida, USA.,Departments of Pediatrics, Music Engineering, Electrical and Computer Engineering, University of Miami, Coral Gables, Florida, USA
| | - Jue Wang
- Department of Psychology, University of Science and Technology of China, Hefei, China
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8
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Mikhail ME, Fowler N, Burt SA, Neale MC, Keel PK, Katzman DK, Klump KL. A daily diary study of emotion regulation as a moderator of negative affect-binge eating associations. Int J Eat Disord 2022; 55:1305-1315. [PMID: 35779074 PMCID: PMC9529946 DOI: 10.1002/eat.23768] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 06/19/2022] [Accepted: 06/20/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND While negative affect (NA) typically increases risk for binge eating, the ultimate impact of NA may depend on a person's ability to regulate their emotions. In this daily, longitudinal study, we examined whether emotion regulation (ER) modified the strength of NA-dysregulated eating associations. METHODS Women (N = 311) from the Michigan State University Twin Registry first reported dimensional binge eating symptoms and broad ER difficulties (e.g., limited emotional awareness, difficulty controlling emotional impulses). Participants then rated use of adaptive (cognitive reappraisal, social sharing, situation modification, and acceptance) and maladaptive (rumination, expressive suppression, and self-criticism) ER strategies, emotional eating (EE), objective binge eating (OBE), and NA once daily for 49 consecutive days. RESULTS There were several main effects of ER on binge-eating pathology in both between-person (i.e., comparing women who differed on average) and within-person (i.e., examining fluctuations in variables day-to-day) analyses. Between-person, greater broad ER difficulties, greater maladaptive strategy use, and lower adaptive strategy use were all associated with greater binge-eating pathology. Within-person, greater maladaptive strategy use was associated with greater odds of OBE on that day and on the following day. However, neither broad ER difficulties nor use of specific strategies moderated associations between NA and dysregulated eating in between- or within-person analyses. CONCLUSIONS While ER is independently associated with risk for dysregulated eating, it may not fully mitigate the impact of NA. Additional strategies (e.g., decreasing environmental stressors and increasing social support) may be needed to minimize NA and its impact on dysregulated eating. PUBLIC SIGNIFICANCE Negative affect (NA; e.g., sadness, guilt) increases dysregulated eating risk. Because NA is sometimes unavoidable, we examined whether emotion regulation (ER; i.e., how a person responds to their emotions) might impact whether NA leads to dysregulated eating. Although more effective ER was associated with less dysregulated eating overall, ER did not impact the association between NA and dysregulated eating. Other approaches may therefore be needed to mitigate NA-dysregulated eating associations.
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Affiliation(s)
| | - Natasha Fowler
- Department of Behavioral Neuroscience, Oregon Health and Science University, USA
| | | | - Michael C. Neale
- Departments of Psychiatry, Human Genetics, and Psychology, Virginia Commonwealth University, USA
| | | | | | - Kelly L. Klump
- Department of Psychology, Michigan State University, USA
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9
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An evaluation of methods to handle missing data in the context of latent variable interaction analysis: multiple imputation, maximum likelihood, and random forest algorithm. JAPANESE JOURNAL OF STATISTICS AND DATA SCIENCE 2022. [DOI: 10.1007/s42081-022-00176-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Prud'homme J, Hofer MK, Ames ME, Turner BJ. Disparities in the prevalence, frequency and trajectories of substance use and disordered eating across first-year university in sexual minority undergraduates. JOURNAL OF AMERICAN COLLEGE HEALTH : J OF ACH 2022:1-13. [PMID: 35930358 DOI: 10.1080/07448481.2022.2103373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 05/13/2022] [Accepted: 07/12/2022] [Indexed: 06/15/2023]
Abstract
Objective. To compare the prevalence and trajectories of risky health behaviors in sexual minority (SM; lesbian/gay/bisexual/questioning/asexual) versus heterosexual undergraduates across their first year of post-secondary. Participants. First-year undergraduates (N = 704, Mage=17.97 years, 24% SM) from a midsized Canadian university. Methods. Students completed monthly (September-April) online questionnaires assessing substance use (binge drinking, tobacco, cannabis, illicit drug use) and disordered eating (binge eating, fasting, purging). Results. At the outset of the academic year, SM students endorsed more frequent cannabis use, illicit drug use, fasting, and binge eating, but less frequent tobacco use, versus heterosexual students. Over the year, SM students' binge drinking frequency declined less than that of heterosexual students, but their illicit drug use decreased while that of their heterosexual peers increased, and all students reported declining disordered eating frequency. Conclusions. Campus wellness initiatives for SM students should offer prevention and harm-reduction strategies prior to or shortly after their arrival on campus.
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Affiliation(s)
- Julie Prud'homme
- Department of Psychology, University of Victoria, Victoria, Canada
| | - Marlise K Hofer
- Department of Psychology, University of Victoria, Victoria, Canada
| | - Megan E Ames
- Department of Psychology, University of Victoria, Victoria, Canada
| | - Brianna J Turner
- Department of Psychology, University of Victoria, Victoria, Canada
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11
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Wijesuriya R, Moreno-Betancur M, Carlin J, De Silva AP, Lee KJ. Multiple imputation approaches for handling incomplete three-level data with time-varying cluster-memberships. Stat Med 2022; 41:4385-4402. [PMID: 35893317 PMCID: PMC9540355 DOI: 10.1002/sim.9515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 06/17/2022] [Accepted: 06/20/2022] [Indexed: 11/06/2022]
Abstract
Three-level data arising from repeated measures on individuals clustered within higher-level units are common in medical research. A complexity arises when individuals change clusters over time, resulting in a cross-classified data structure. Missing values in these studies are commonly handled via multiple imputation (MI). If the three-level, cross-classified structure is modeled in the analysis, it also needs to be accommodated in the imputation model to ensure valid results. While incomplete three-level data can be handled using various approaches within MI, the performance of these in the cross-classified data setting remains unclear. We conducted simulations under a range of scenarios to compare these approaches in the context of an acute-effects cross-classified random effects substantive model, which models the time-varying cluster membership via simple additive random effects. The simulation study was based on a case study in a longitudinal cohort of students clustered within schools. We evaluated methods that ignore the time-varying cluster memberships by taking the first or most common cluster for each individual; pragmatic extensions of single- and two-level MI approaches within the joint modeling (JM) and the fully conditional specification (FCS) frameworks, using dummy indicators (DI) and/or imputing repeated measures in wide format to account for the cross-classified structure; and a three-level FCS MI approach developed specifically for cross-classified data. Results indicated that the FCS implementations performed well in terms of bias and precision while JM approaches performed poorly. Under both frameworks approaches using the DI extension should be used with caution in the presence of sparse data.
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Affiliation(s)
- Rushani Wijesuriya
- Department of Pediatrics, Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Margarita Moreno-Betancur
- Department of Pediatrics, Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - John Carlin
- Department of Pediatrics, Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Center for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Anurika Priyanjali De Silva
- Center for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Katherine Jane Lee
- Department of Pediatrics, Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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12
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McMahon JM, Simmons J, Haberer JE, Mannheimer S, Leblanc NM, Torres L, Quiles R, Aedo G, Javier A, Braksmajer A, Harriman G, Trabold N, Pouget ER, Kurth A, Smith MDR, Brasch J, Podsiadly EJ, Anderson PL. The Magnetic Couples Study: protocol for a mixed methods prospective cohort study of HIV-serodifferent heterosexual couples' perspectives and use of pre-exposure prophylaxis (PrEP). BMJ Open 2021; 11:e048993. [PMID: 34210734 PMCID: PMC8252879 DOI: 10.1136/bmjopen-2021-048993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION HIV transmission within serodifferent heterosexual couples plays a key role in sustaining the global HIV pandemic. In the USA, transmission within established mixed-status couples accounts for up to half of all new HIV infections among heterosexuals. Oral HIV pre-exposure prophylaxis (PrEP) is a highly effective prevention method, although underutilised among serodifferent couples. Moreover, there is a dearth of research on US HIV-serodifferent couples' perspectives and use of PrEP, alone or in combination with other prevention methods. In this paper, we describe the study protocol for the Magnetic Couples Study, designed to fill critical knowledge gaps regarding HIV-serodifferent heterosexual couples' perspectives, experiences and utilisation of PrEP. METHODS AND ANALYSIS The Magnetic Couples Study is a mixed methods prospective cohort study designed to describe temporal patterns and identify determinants at multiple levels (individual, couple, HCF) of PrEP outcomes along the care continuum (PrEP awareness, linkage, uptake, retention and medication adherence) among HIV-serodifferent heterosexual couples residing in New York City. The study will also examine clinical management of PrEP, side effects and changes in sexual-related and substance use-related behaviour. A prospective cohort of 230 mixed-status couples already on oral PrEP was recruited, with quarterly assessments over 18 months; in addition, a cross-sectional sample of 150 mixed-status couples not currently on PrEP was recruited. In-depth semistructured qualitative interviews were conducted with a subsample of 25 couples. Actor-partner interdependence modelling using multilevel analysis will be employed for the analysis of longitudinal dyadic data. Framework analysis will be used to analyse qualitative data. A parallel convergent design will be used for mixed methods integration. ETHICS AND DISSEMINATION The study was approved by the University of Rochester Institutional Review Board (RSRB00052766). Study findings will be disseminated to community members and providers and to researchers and policy makers.
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Affiliation(s)
- James M McMahon
- School of Nursing, University of Rochester Medical Center, Rochester, New York, USA
| | - Janie Simmons
- School of Global Public Health, New York University, New York, New York, USA
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Sharon Mannheimer
- Department of Medicine, New York City Health + Hospitals Harlem, New York, New York, USA
- Department of Medicine, Columbia University Medical Center, New York, New York, USA
| | - Natalie M Leblanc
- School of Nursing, University of Rochester Medical Center, Rochester, New York, USA
| | - Leilani Torres
- School of Nursing, University of Rochester Medical Center, Rochester, New York, USA
| | - Robert Quiles
- School of Nursing, University of Rochester Medical Center, Rochester, New York, USA
| | - Guillermo Aedo
- School of Global Public Health, New York University, New York, New York, USA
| | - Anabel Javier
- School of Global Public Health, New York University, New York, New York, USA
| | - Amy Braksmajer
- Department of Sociology, State University of New York at Geneseo, Geneseo, New York, USA
| | - Graham Harriman
- HIV Health and Human Services Planning Council, New York City Department of Health and Mental Hygiene, Queens, New York, USA
| | - Nicole Trabold
- College of Health Science and Technology, Rochester Institute of Technology, Rochester, New York, USA
| | - Enrique R Pouget
- Department of Health and Nutrition Sciences, Brooklyn College, The City University of New York, Brooklyn, New York, USA
| | - Ann Kurth
- School of Nursing, Yale University, Orange, Connecticut, USA
| | - Martez D R Smith
- School of Nursing, University of Rochester Medical Center, Rochester, New York, USA
| | - Judith Brasch
- School of Nursing, University of Rochester Medical Center, Rochester, New York, USA
| | - Eric J Podsiadly
- School of Nursing, University of Rochester Medical Center, Rochester, New York, USA
| | - Peter L Anderson
- School of Pharmacy and Pharmaceutical Sciences, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
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13
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Toyama M, Fuller HR, Hektner JM. Longitudinal Associations of Conscientiousness and Neuroticism With Perceived Mastery and Constraints for Aging Adults. Res Aging 2021; 44:83-95. [PMID: 33563107 DOI: 10.1177/0164027521992892] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
It has not been well understood how conscientiousness and neuroticism are associated with two related but distinct dimensions of perceived control (i.e., perceived mastery and constraints) among aging adults. The present study examined these associations and their change over time, while addressing whether they differ by age or gender. For respondents aged 50+ at baseline (N = 2,768) in the Midlife in the United States (MIDUS) study, multilevel modeling analyses were conducted to assess how conscientiousness and neuroticism predicted perceived mastery and constraints over 2 decades. As expected, higher conscientiousness and lower neuroticism (for both between- and within-person variability) predicted higher perceived mastery and lower perceived constraints overall. Nuanced findings emerged related to age, gender and change over time for different associations of conscientiousness and neuroticism with the outcomes. These findings can inform future research suggesting directions of further investigations for these complex associations.
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Affiliation(s)
- Masahiro Toyama
- Division of Natural Sciences & Mathematics, University of the Ozarks, Clarksville, AR, USA.,Department of Human Development and Family Science, North Dakota State University, Fargo, ND, USA
| | - Heather R Fuller
- Department of Human Development and Family Science, North Dakota State University, Fargo, ND, USA
| | - Joel M Hektner
- Department of Human Development and Family Science, North Dakota State University, Fargo, ND, USA
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14
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Cheval B, Mongin D, Cullati S, Uribe A, Pihl-Thingvad J, Chopard P, Courvoisier DS. Associations of emotional burden and coping strategies with sick leave among healthcare professionals: A longitudinal observational study. Int J Nurs Stud 2021; 115:103869. [PMID: 33517081 DOI: 10.1016/j.ijnurstu.2021.103869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 12/21/2020] [Accepted: 01/02/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To investigate 1) whether care-related regrets (regret intensity, number of recent regrets) are associated with sick leave, independently of personality traits, perceived safety climate, and physical activity; and 2) whether these associations were mediated or moderated by coping strategies. METHODS Using a longitudinal international observational study (ICARUS), data were collected by the means of a weekly web survey. Descriptive and generalized estimation equations were performed. RESULTS A total of 276 newly practicing healthcare professionals (nurses, physicians, others) from 11 countries were included in this study. The average proportion of weeks with at least one day of sick leave was 3.2%. Nurses' sick leave increased with number of care-related regrets (Relative Risk [RR]=1.52; 95% Confidence Interval [CI]=[1.18; 1.95], p=.001), while physicians' sick leave increased with intensity of care-related regret (RR=1.21; 95%CI=[1.00; 1.21], p=.049). Coping was associated with lower risk of sick leave for nurses (RR problem-focused strategies = 0.53; 95%CI=[0.37; 0.74], p=.001, and RRphysical activity=0.68; 95%CI:[0.54; 0.85], p<.001), but not for physicians. Nevertheless, the association of regret with sick leave remained significant even when adjusting for coping. Finally, this study did not find evidence of moderation by the coping strategies. CONCLUSION Regrets are associated with increased risks of sick leave, even in young healthcare professionals. Use of coping strategies partially mediated these associations in nurses. The results of this study should be used to inform interventions to reduce emotional burdens and enhance protective coping strategies.
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Affiliation(s)
- Boris Cheval
- Quality of Care Service, Department of Readaptation and Geriatrics, University of Geneva, Switzerland; Swiss NCCR "LIVES: Overcoming Vulnerability: Life Course Perspectives", University of Geneva, Switzerland.
| | - Denis Mongin
- Quality of Care Service, Department of Readaptation and Geriatrics, University of Geneva, Switzerland
| | - Stéphane Cullati
- Quality of Care Service, Department of Readaptation and Geriatrics, University of Geneva, Switzerland; Population Health Laboratory, University of Fribourg, Switzerland
| | - Adriana Uribe
- Quality of Care Service, Department of Readaptation and Geriatrics, University of Geneva, Switzerland
| | - Jesper Pihl-Thingvad
- Department of Occupational and Environmental Medicine, Odense University Hospital, Denmark; National Center of Psychotraumatology, University of Southern Denmark, Denmark
| | - Pierre Chopard
- Quality of Care Service, Department of Readaptation and Geriatrics, University of Geneva, Switzerland
| | - Delphine S Courvoisier
- Quality of Care Service, Department of Readaptation and Geriatrics, University of Geneva, Switzerland
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15
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Wijesuriya R, Moreno-Betancur M, Carlin JB, Lee KJ. Evaluation of approaches for multiple imputation of three-level data. BMC Med Res Methodol 2020; 20:207. [PMID: 32787781 PMCID: PMC7422505 DOI: 10.1186/s12874-020-01079-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 07/12/2020] [Indexed: 12/30/2022] Open
Abstract
Background Three-level data arising from repeated measures on individuals who are clustered within larger units are common in health research studies. Missing data are prominent in such longitudinal studies and multiple imputation (MI) is a popular approach for handling missing data. Extensions of joint modelling and fully conditional specification MI approaches based on multilevel models have been developed for imputing three-level data. Alternatively, it is possible to extend single- and two-level MI methods to impute three-level data using dummy indicators and/or by analysing repeated measures in wide format. However, most implementations, evaluations and applications of these approaches focus on the context of incomplete two-level data. It is currently unclear which approach is preferable for imputing three-level data. Methods In this study, we investigated the performance of various MI methods for imputing three-level incomplete data when the target analysis model is a three-level random effects model with a random intercept for each level. The MI methods were evaluated via simulations and illustrated using empirical data, based on a case study from the Childhood to Adolescence Transition Study, a longitudinal cohort collecting repeated measures on students who were clustered within schools. In our simulations we considered a number of different scenarios covering a range of different missing data mechanisms, missing data proportions and strengths of level-2 and level-3 intra-cluster correlations. Results We found that all of the approaches considered produced valid inferences about both the regression coefficient corresponding to the exposure of interest and the variance components under the various scenarios within the simulation study. In the case study, all approaches led to similar results. Conclusion Researchers may use extensions to the single- and two-level approaches, or the three-level approaches, to adequately handle incomplete three-level data. The two-level MI approaches with dummy indicator extension or the MI approaches based on three-level models will be required in certain circumstances such as when there are longitudinal data measured at irregular time intervals. However, the single- and two-level approaches with the DI extension should be used with caution as the DI approach has been shown to produce biased parameter estimates in certain scenarios.
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Affiliation(s)
- Rushani Wijesuriya
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia. .,Clinical Epidemiology and Biostatistics Unit, Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia.
| | - Margarita Moreno-Betancur
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia.,Clinical Epidemiology and Biostatistics Unit, Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia
| | - John B Carlin
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia.,Clinical Epidemiology and Biostatistics Unit, Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Katherine J Lee
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia.,Clinical Epidemiology and Biostatistics Unit, Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia
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16
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Levin ME, Krafft J, Hicks ET, Pierce B, Twohig MP. A randomized dismantling trial of the open and engaged components of acceptance and commitment therapy in an online intervention for distressed college students. Behav Res Ther 2020; 126:103557. [DOI: 10.1016/j.brat.2020.103557] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 01/09/2020] [Accepted: 01/15/2020] [Indexed: 10/25/2022]
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17
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Kaltenbrunner M, Bengtsson L, Mathiassen SE, Högberg H, Engström M. Staff perception of Lean, care-giving, thriving and exhaustion: a longitudinal study in primary care. BMC Health Serv Res 2019; 19:652. [PMID: 31500624 PMCID: PMC6734292 DOI: 10.1186/s12913-019-4502-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 08/30/2019] [Indexed: 11/30/2022] Open
Abstract
Background Lean is commonly adopted in healthcare to increase quality of care and efficiency. Few studies of Lean involve staff-related outcomes, and few have a longitudinal design. Thus, the aim was to examine the extent to which changes over time in Lean maturity are associated with changes over time in care-giving, thriving and exhaustion, as perceived by staff, with a particular emphasis on the extent to which job demands and job resources, as perceived by staff, have a moderated mediation effect. Method A longitudinal study with a correlational design was used. In total, 260 staff at 46 primary care units responded to a web survey in 2015 and 2016. All variables in the study were measured using staff ratings. Ratings of Lean maturity reflect participants’ judgements regarding the entire unit; ratings of care-giving, thriving, exhaustion and job demands and resources reflect participants’ judgements regarding their own situation. Results First, over time, increased Lean maturity was associated with increased staff satisfaction with their care-giving and increased thriving, mediated by increased job resources. Second, over time, increased Lean maturity was associated with decreased staff exhaustion, mediated by decreased job demands. No evidence was found showing that job demands and job resources had a moderated mediation effect. Conclusion The results indicate that primary care staff may benefit from working in organizations characterized by high levels of Lean maturity and that caregiving may also be improved as perceived by staff. Electronic supplementary material The online version of this article (10.1186/s12913-019-4502-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Monica Kaltenbrunner
- Department of Occupational Health Sciences and Psychology, Faculty of Health and Occupational Studies, University of Gävle, 801 76, Gävle, Sweden.
| | - Lars Bengtsson
- Department of Industrial Management, Industrial Design and Mechanical Engineering, Faculty of Engineering and Sustainable Development, University of Gävle, 801 76, Gävle, Sweden
| | - Svend Erik Mathiassen
- Department of Occupational Health Sciences and Psychology, Faculty of Health and Occupational Studies, University of Gävle, 801 76, Gävle, Sweden
| | - Hans Högberg
- Department of Caring Science, Faculty of Health and Occupational Studies, University of Gävle, 801 76, Gävle, Sweden
| | - Maria Engström
- Department of Caring Science, Faculty of Health and Occupational Studies, University of Gävle, 801 76, Gävle, Sweden.,Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden.,Nursing Department, Medicine and Health College, Lishui University, Lishui, China
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18
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Heyder A, Brunner M. Teachers' aptitude beliefs as a predictor of helplessness in low-achieving students: Commonalities and differences between academic domains. LEARNING AND INDIVIDUAL DIFFERENCES 2018. [DOI: 10.1016/j.lindif.2018.01.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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19
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Patrick ME, Griffin J, Huntley ED, Maggs JL. Energy Drinks and Binge Drinking Predict College Students' Sleep Quantity, Quality, and Tiredness. Behav Sleep Med 2018; 16:92-105. [PMID: 27183506 PMCID: PMC5435568 DOI: 10.1080/15402002.2016.1173554] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
This study examines whether energy drink use and binge drinking predict sleep quantity, sleep quality, and next-day tiredness among college students. Web-based daily data on substance use and sleep were collected across four semesters in 2009 and 2010 from 667 individuals for up to 56 days each, yielding information on 25,616 person-days. Controlling for average levels of energy drink use and binge drinking (i.e., 4+ drinks for women, 5+ drinks for men), on days when students consumed energy drinks, they reported lower sleep quantity and quality that night, and greater next-day tiredness, compared to days they did not use energy drinks. Similarly, on days when students binge drank, they reported lower sleep quantity and quality that night, and greater next-day tiredness, compared to days they did not binge drink. There was no significant interaction effect between binge drinking and energy drink use on the outcomes.
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Affiliation(s)
- Megan E. Patrick
- University of Michigan, Institute for Social Research,Address correspondence to: Megan E. Patrick, Institute for Social Research, University of Michigan, 426 Thompson Street, Ann Arbor, MI 48106-1248. Phone 1-734-763-7107, Fax 1-734-936-0043,
| | - Jamie Griffin
- University of Michigan, Institute for Social Research
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20
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Aydin B, Leite WL, Algina J. The Effects of Including Observed Means or Latent Means as Covariates in Multilevel Models for Cluster Randomized Trials. EDUCATIONAL AND PSYCHOLOGICAL MEASUREMENT 2016; 76:803-823. [PMID: 29795889 PMCID: PMC5965534 DOI: 10.1177/0013164415618705] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
We investigated methods of including covariates in two-level models for cluster randomized trials to increase power to detect the treatment effect. We compared multilevel models that included either an observed cluster mean or a latent cluster mean as a covariate, as well as the effect of including Level 1 deviation scores in the model. A Monte Carlo simulation study was performed manipulating effect sizes, cluster sizes, number of clusters, intraclass correlation of the outcome, patterns of missing data, and the squared correlations between Level 1 and Level 2 covariates and the outcome. We found no substantial difference between models with observed means or latent means with respect to convergence, Type I error rates, coverage, and bias. However, coverage could fall outside of acceptable limits if a latent mean is included as a covariate when cluster sizes are small. In terms of statistical power, models with observed means performed similarly to models with latent means, but better when cluster sizes were small. A demonstration is provided using data from a study of the Tools for Getting Along intervention.
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21
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Levin ME, Haeger JA, Pierce BG, Twohig MP. Web-Based Acceptance and Commitment Therapy for Mental Health Problems in College Students: A Randomized Controlled Trial. Behav Modif 2016; 41:141-162. [PMID: 27440189 DOI: 10.1177/0145445516659645] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There are significant challenges in addressing the mental health needs of college students. The current study tested an acceptance and commitment therapy (ACT), web-based self-help program to treat a broad range of psychological problems students struggle with. A sample of 79 college students was randomized to web-based ACT or a waitlist condition, with assessments at baseline and posttreatment. Results indicated adequate acceptability and program engagement for the ACT website. Relative to waitlist, participants receiving ACT improved on overall distress, general anxiety, social anxiety, depression, academic concerns, and positive mental health. There were no between-group effects on eating concerns, alcohol use, or hostility, or on some key ACT process of change measures. ACT participants improved more on mindful acceptance and obstruction to valued living, both of which mediated treatment outcomes. Results are discussed in the context of lessons learned with the website prototype, and areas for further research are presented.
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22
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Gomes M, Díaz-Ordaz K, Grieve R, Kenward MG. Multiple imputation methods for handling missing data in cost-effectiveness analyses that use data from hierarchical studies: an application to cluster randomized trials. Med Decis Making 2013; 33:1051-63. [PMID: 23913915 DOI: 10.1177/0272989x13492203] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Multiple imputation (MI) has been proposed for handling missing data in cost-effectiveness analyses (CEAs). In CEAs that use cluster randomized trials (CRTs), the imputation model, like the analysis model, should recognize the hierarchical structure of the data. This paper contrasts a multilevel MI approach that recognizes clustering, with single-level MI and complete case analysis (CCA) in CEAs that use CRTs. METHODS We consider a multilevel MI approach compatible with multilevel analytical models for CEAs that use CRTs. We took fully observed data from a CEA that evaluated an intervention to improve diagnosis of active labor in primiparous women using a CRT (2078 patients, 14 clusters). We generated scenarios with missing costs and outcomes that differed, for example, according to the proportion with missing data (10%-50%), the covariates that predicted missing data (individual, cluster-level), and the missingness mechanism: missing completely at random (MCAR), missing at random (MAR), or missing not at random (MNAR). We estimated incremental net benefits (INBs) for each approach and compared them with the estimates from the fully observed data, the "true" INBs. RESULTS When costs and outcomes were assumed to be MCAR, the INBs for each approach were similar to the true estimates. When data were MAR, the point estimates from the CCA differed from the true estimates. Multilevel MI provided point estimates and standard errors closer to the true values than did single-level MI across all settings, including those in which a high proportion of observations had cost and outcome data MAR and when data were MNAR. CONCLUSIONS Multilevel MI accommodates the multilevel structure of the data in CEAs that use cluster trials and provides accurate cost-effectiveness estimates across the range of circumstances considered.
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Affiliation(s)
- Manuel Gomes
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (MG, KD, RG)
| | - Karla Díaz-Ordaz
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (MG, KD, RG)
| | - Richard Grieve
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK (MG, KD, RG)
| | - Michael G Kenward
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK (MGK)
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