Analysis of multivariate recurrent event data with time‐dependent covariates and informative censoring

Multivariate recurrent event data are usually encountered in many clinical and longitudinal studies in which each study subject may experience multiple recurrent events. For the analysis of such data, most existing approaches have been proposed under the assumption that the censoring times are noninformative, which may not be true especially when the observation of recurrent events is terminated by a failure event. In this article, we consider regression analysis of multivariate recurrent event data with both time‐dependent and time‐independent covariates where the censoring times and the recurrent event process are allowed to be correlated via a frailty. The proposed joint model is flexible where both the distributions of censoring and frailty variables are left unspecified. We propose a pairwise pseudolikelihood approach and an estimating equation‐based approach for estimating coefficients of time‐dependent and time‐independent covariates, respectively. The large sample properties of the proposed estimates are established, while the finite‐sample properties are demonstrated by simulation studies. The proposed methods are applied to the analysis of a set of bivariate recurrent event data from a study of platelet transfusion reactions.     

Logistic regression when covariates are random effects from a non‐linear mixed model

In many studies, the association of longitudinal measurements of a continuous response and a binary outcome are often of interest. A convenient framework for this type of problems is the joint model, which is formulated to investigate the association between a binary outcome and features of longitudinal measurements through a common set of latent random effects. The joint model, which is the focus of this article, is a logistic regression model with covariates defined as the individual‐specific random effects in a non‐linear mixed‐effects model (NLMEM) for the longitudinal measurements. We discuss different estimation procedures, which include two‐stage, best linear unbiased predictors, and various numerical integration techniques. The proposed methods are illustrated using a real data set where the objective is to study the association between longitudinal hormone levels and the pregnancy outcome in a group of young women. The numerical performance of the estimating methods is also evaluated by means of simulation.     

A joint model for longitudinal continuous and time‐to‐event outcomes with direct marginal interpretation

Joint modeling of various longitudinal sequences has received quite a bit of attention in recent times. This paper proposes a so‐called marginalized joint model for longitudinal continuous and repeated time‐to‐event outcomes on the one hand and a marginalized joint model for bivariate repeated time‐to‐event outcomes on the other. The model has several appealing features. It flexibly allows for association among measurements of the same outcome at different occasions as well as among measurements on different outcomes recorded at the same time. The model also accommodates overdispersion. The time‐to‐event outcomes are allowed to be censored. While the model builds upon the generalized linear mixed model framework, it is such that model parameters enjoy a direct marginal interpretation. All of these features have been considered before, but here we bring them together in a unified, flexible framework. The model framework's properties are scrutinized using a simulation study. The models are applied to data from a chronic heart failure study and to a so‐called comet assay, encountered in preclinical research. Almost surprisingly, the models can be fitted relatively easily using standard statistical software.     

A Bayesian Semiparametric Survival Model with Longitudinal Markers

Summary We consider inference for data from a clinical trial of treatments for metastatic prostate cancer. Patients joined the trial with diverse prior treatment histories. The resulting heterogeneous patient population gives rise to challenging statistical inference problems when trying to predict time to progression on different treatment arms. Inference is further complicated by the need to include a longitudinal marker as a covariate. To address these challenges, we develop a semiparametric model for joint inference of longitudinal data and an event time. The proposed approach includes the possibility of cure for some patients. The event time distribution is based on a nonparametric Pólya tree prior. For the longitudinal data we assume a mixed effects model. Incorporating a regression on covariates in a nonparametric event time model in general, and for a Pólya tree model in particular, is a challenging problem. We exploit the fact that the covariate itself is a random variable. We achieve an implementation of the desired regression by factoring the joint model for the event time and the longitudinal outcome into a marginal model for the event time and a regression of the longitudinal outcomes on the event time, i.e., we implicitly model the desired regression by modeling the reverse conditional distribution.     

Semiparametric modeling of longitudinal measurements and time-to-event data--a two-stage regression calibration approach

SUMMARY: In this article we investigate regression calibration methods to jointly model longitudinal and survival data using a semiparametric longitudinal model and a proportional hazards model. In the longitudinal model, a biomarker is assumed to follow a semiparametric mixed model where covariate effects are modeled parametrically and subject-specific time profiles are modeled nonparametrially using a population smoothing spline and subject-specific random stochastic processes. The Cox model is assumed for survival data by including both the current measure and the rate of change of the underlying longitudinal trajectories as covariates, as motivated by a prostate cancer study application. We develop a two-stage semiparametric regression calibration (RC) method. Two variations of the RC method are considered, risk set regression calibration and a computationally simpler ordinary regression calibration. Simulation results show that the two-stage RC approach performs well in practice and effectively corrects the bias from the naive method. We apply the proposed methods to the analysis of a dataset for evaluating the effects of the longitudinal biomarker PSA on the recurrence of prostate cancer.     

A characterization of missingness at random in a generalized shared‐parameter joint modeling framework for longitudinal and time‐to‐event data,and sensitivity analysis

We consider a conceptual correspondence between the missing data setting, and joint modeling of longitudinal and time‐to‐event outcomes. Based on this, we formulate an extended shared random effects joint model. Based on this, we provide a characterization of missing at random, which is in line with that in the missing data setting. The ideas are illustrated using data from a study on liver cirrhosis, contrasting the new framework with conventional joint models.     

Hierarchical Modeling for Estimating Relative Risks of Rare Genetic Variants: Properties of the Pseudo‐Likelihood Method

Summary Many major genes have been identified that strongly influence the risk of cancer. However, there are typically many different mutations that can occur in the gene, each of which may or may not confer increased risk. It is critical to identify which specific mutations are harmful, and which ones are harmless, so that individuals who learn from genetic testing that they have a mutation can be appropriately counseled. This is a challenging task, since new mutations are continually being identified, and there is typically relatively little evidence available about each individual mutation. In an earlier article, we employed hierarchical modeling ( Capanu et al., 2008 , Statistics in Medicine 27 , 1973–1992) using the pseudo‐likelihood and Gibbs sampling methods to estimate the relative risks of individual rare variants using data from a case–control study and showed that one can draw strength from the aggregating power of hierarchical models to distinguish the variants that contribute to cancer risk. However, further research is needed to validate the application of asymptotic methods to such sparse data. In this article, we use simulations to study in detail the properties of the pseudo‐likelihood method for this purpose. We also explore two alternative approaches: pseudo‐likelihood with correction for the variance component estimate as proposed by Lin and Breslow (1996, Journal of the American Statistical Association 91 , 1007–1016) and a hybrid pseudo‐likelihood approach with Bayesian estimation of the variance component. We investigate the validity of these hierarchical modeling techniques by looking at the bias and coverage properties of the estimators as well as at the efficiency of the hierarchical modeling estimates relative to that of the maximum likelihood estimates. The results indicate that the estimates of the relative risks of very sparse variants have small bias, and that the estimated 95% confidence intervals are typically anti‐conservative, though the actual coverage rates are generally above 90%. The widths of the confidence intervals narrow as the residual variance in the second‐stage model is reduced. The results also show that the hierarchical modeling estimates have shorter confidence intervals relative to estimates obtained from conventional logistic regression, and that these relative improvements increase as the variants become more rare.     

Mixed‐Effects State‐Space Models for Analysis of Longitudinal Dynamic Systems

Summary The rapid development of new biotechnologies allows us to deeply understand biomedical dynamic systems in more detail and at a cellular level. Many of the subject‐specific biomedical systems can be described by a set of differential or difference equations that are similar to engineering dynamic systems. In this article, motivated by HIV dynamic studies, we propose a class of mixed‐effects state‐space models based on the longitudinal feature of dynamic systems. State‐space models with mixed‐effects components are very flexible in modeling the serial correlation of within‐subject observations and between‐subject variations. The Bayesian approach and the maximum likelihood method for standard mixed‐effects models and state‐space models are modified and investigated for estimating unknown parameters in the proposed models. In the Bayesian approach, full conditional distributions are derived and the Gibbs sampler is constructed to explore the posterior distributions. For the maximum likelihood method, we develop a Monte Carlo EM algorithm with a Gibbs sampler step to approximate the conditional expectations in the E‐step. Simulation studies are conducted to compare the two proposed methods. We apply the mixed‐effects state‐space model to a data set from an AIDS clinical trial to illustrate the proposed methodologies. The proposed models and methods may also have potential applications in other biomedical system analyses such as tumor dynamics in cancer research and genetic regulatory network modeling.     

A Joint Modeling Approach for Longitudinal Data with Informative Observation Times and a Terminal Event

In this article, we propose a new joint modeling approach for the analysis of longitudinal data with informative observation times and a dependent terminal event. We specify a semiparametric mixed effects model for the longitudinal process, a proportional rate frailty model for the observation process, and a proportional hazards frailty model for the terminal event. The association among the three related processes is modeled via two latent variables. Estimating equation approaches are developed for parameter estimation, and the asymptotic properties of the proposed estimators are established. The finite sample performance of the proposed estimators is examined through simulation studies, and an application to a medical cost study of chronic heart failure patients is illustrated.     

A zero‐augmented generalized gamma regression calibration to adjust for covariate measurement error: A case of an episodically consumed dietary intake

Measurement error in exposure variables is a serious impediment in epidemiological studies that relate exposures to health outcomes. In nutritional studies, interest could be in the association between long‐term dietary intake and disease occurrence. Long‐term intake is usually assessed with food frequency questionnaire (FFQ), which is prone to recall bias. Measurement error in FFQ‐reported intakes leads to bias in parameter estimate that quantifies the association. To adjust for bias in the association, a calibration study is required to obtain unbiased intake measurements using a short‐term instrument such as 24‐hour recall (24HR). The 24HR intakes are used as response in regression calibration to adjust for bias in the association. For foods not consumed daily, 24HR‐reported intakes are usually characterized by excess zeroes, right skewness, and heteroscedasticity posing serious challenge in regression calibration modeling. We proposed a zero‐augmented calibration model to adjust for measurement error in reported intake, while handling excess zeroes, skewness, and heteroscedasticity simultaneously without transforming 24HR intake values. We compared the proposed calibration method with the standard method and with methods that ignore measurement error by estimating long‐term intake with 24HR and FFQ‐reported intakes. The comparison was done in real and simulated datasets. With the 24HR, the mean increase in mercury level per ounce fish intake was about 0.4; with the FFQ intake, the increase was about 1.2. With both calibration methods, the mean increase was about 2.0. Similar trend was observed in the simulation study. In conclusion, the proposed calibration method performs at least as good as the standard method.     

A joint model for repeated events of different types and multiple longitudinal outcomes with application to a follow‐up study of patients after kidney transplant

This paper presents an extension of the joint modeling strategy for the case of multiple longitudinal outcomes and repeated infections of different types over time, motivated by postkidney transplantation data. Our model comprises two parts linked by shared latent terms. On the one hand is a multivariate mixed linear model with random effects, where a low‐rank thin‐plate spline function is incorporated to collect the nonlinear behavior of the different profiles over time. On the other hand is an infection‐specific Cox model, where the dependence between different types of infections and the related times of infection is through a random effect associated with each infection type to catch the within dependence and a shared frailty parameter to capture the dependence between infection types. We implemented the parameterization used in joint models which uses the fitted longitudinal measurements as time‐dependent covariates in a relative risk model. Our proposed model was implemented in OpenBUGS using the MCMC approach.     

Time‐Varying Latent Effect Model for Longitudinal Data with Informative Observation Times

Summary In analysis of longitudinal data, it is not uncommon that observation times of repeated measurements are subject‐specific and correlated with underlying longitudinal outcomes. Taking account of the dependence between observation times and longitudinal outcomes is critical under these situations to assure the validity of statistical inference. In this article, we propose a flexible joint model for longitudinal data analysis in the presence of informative observation times. In particular, the new procedure considers the shared random‐effect model and assumes a time‐varying coefficient for the latent variable, allowing a flexible way of modeling longitudinal outcomes while adjusting their association with observation times. Estimating equations are developed for parameter estimation. We show that the resulting estimators are consistent and asymptotically normal, with variance–covariance matrix that has a closed form and can be consistently estimated by the usual plug‐in method. One additional advantage of the procedure is that it provides a unified framework to test whether the effect of the latent variable is zero, constant, or time‐varying. Simulation studies show that the proposed approach is appropriate for practical use. An application to a bladder cancer data is also given to illustrate the methodology.     

On analyzing circadian rhythms data using nonlinear mixed models with harmonic terms

Wang, Ke, and Brown (2003, Biometrics59, 804-812) developed a smoothing-based approach for modeling circadian rhythms with random effects. Their approach is flexible in that fixed and random covariates can affect both the amplitude and phase shift of a nonparametrically smoothed periodic function. In motivating their approach, Wang et al. stated that a simple sinusoidal function is too restrictive. In addition, they stated that "although adding harmonics can improve the fit, it is difficult to decide how many harmonics to include in the model, and the results are difficult to interpret." We disagree with the notion that harmonic models cannot be a useful tool in modeling longitudinal circadian rhythm data. In this note, we show how nonlinear mixed models with harmonic terms allow for a simple and flexible alternative to Wang et al.'s approach. We show how to choose the number of harmonics using penalized likelihood to flexibly model circadian rhythms and to estimate the effect of covariates on the rhythms. We fit harmonic models to the cortisol circadian rhythm data presented by Wang et al. to illustrate our approach. Furthermore, we evaluate the properties of our procedure with a small simulation study. The proposed parametric approach provides an alternative to Wang et al.'s semiparametric approach and has the added advantage of being easy to implement in most statistical software packages.     

Semiparametric transformation models for interval‐censored data in the presence of a cure fraction

Mixed case interval‐censored data arise when the event of interest is known only to occur within an interval induced by a sequence of random examination times. Such data are commonly encountered in disease research with longitudinal follow‐up. Furthermore, the medical treatment has progressed over the last decade with an increasing proportion of patients being cured for many types of diseases. Thus, interest has grown in cure models for survival data which hypothesize a certain proportion of subjects in the population are not expected to experience the events of interest. In this article, we consider a two‐component mixture cure model for regression analysis of mixed case interval‐censored data. The first component is a logistic regression model that describes the cure rate, and the second component is a semiparametric transformation model that describes the distribution of event time for the uncured subjects. We propose semiparametric maximum likelihood estimation for the considered model. We develop an EM type algorithm for obtaining the semiparametric maximum likelihood estimators (SPMLE) of regression parameters and establish their consistency, efficiency, and asymptotic normality. Extensive simulation studies indicate that the SPMLE performs satisfactorily in a wide variety of settings. The proposed method is illustrated by the analysis of the hypobaric decompression sickness data from National Aeronautics and Space Administration.     

Analyzing Multiple‐Probe Microarray: Estimation and Application of Gene Expression Indexes

Summary Gene expression index estimation is an essential step in analyzing multiple probe microarray data. Various modeling methods have been proposed in this area. Amidst all, a popular method proposed in Li and Wong (2001) is based on a multiplicative model, which is similar to the additive model discussed in Irizarry et al. (2003a) at the logarithm scale. Along this line, Hu et al. (2006) proposed data transformation to improve expression index estimation based on an ad hoc entropy criteria and naive grid search approach. In this work, we re‐examined this problem using a new profile likelihood‐based transformation estimation approach that is more statistically elegant and computationally efficient. We demonstrate the applicability of the proposed method using a benchmark Affymetrix U95A spiked‐in experiment. Moreover, We introduced a new multivariate expression index and used the empirical study to shows its promise in terms of improving model fitting and power of detecting differential expression over the commonly used univariate expression index. As the other important content of the work, we discussed two generally encountered practical issues in application of gene expression index: normalization and summary statistic used for detecting differential expression. Our empirical study shows somewhat different findings from the MAQC project ( MAQC, 2006 ).     

Two‐stage estimation for multivariate recurrent event data with a dependent terminal event

Recurrent event data arise in longitudinal follow‐up studies, where each subject may experience the same type of events repeatedly. The work in this article is motivated by the data from a study of repeated peritonitis for patients on peritoneal dialysis. Due to the aspects of medicine and cost, the peritonitis cases were classified into two types: Gram‐positive and non‐Gram‐positive peritonitis. Further, since the death and hemodialysis therapy preclude the occurrence of recurrent events, we face multivariate recurrent event data with a dependent terminal event. We propose a flexible marginal model, which has three characteristics: first, we assume marginal proportional hazard and proportional rates models for terminal event time and recurrent event processes, respectively; second, the inter‐recurrences dependence and the correlation between the multivariate recurrent event processes and terminal event time are modeled through three multiplicative frailties corresponding to the specified marginal models; third, the rate model with frailties for recurrent events is specified only on the time before the terminal event. We propose a two‐stage estimation procedure for estimating unknown parameters. We also establish the consistency of the two‐stage estimator. Simulation studies show that the proposed approach is appropriate for practical use. The methodology is applied to the peritonitis cohort data that motivated this study.     

Joint model of recurrent events and a terminal event with time‐varying coefficients

Joint modeling of recurrent events and a terminal event has been studied extensively in the past decade. However, most of the previous works assumed constant regression coefficients. This paper proposes a joint model with time‐varying coefficients in both event components. The proposed model not only accommodates the correlation between the two type of events, but also characterizes the potential time‐varying covariate effects. It is especially useful for evaluating long‐term risk factors' effect that could vary with time. A Gaussian frailty is used to model the correlation between event times. The nonparametric time‐varying coefficients are modeled using cubic splines with penalty terms. A simulation study shows that the proposed estimators perform well. The model is used to analyze the readmission rate and mortality jointly for stroke patients admitted to Veterans Administration (VA) Hospitals.     

A Bayesian Approach to Joint Mixed‐Effects Models with a Skew‐Normal Distribution and Measurement Errors in Covariates

Summary In recent years, nonlinear mixed‐effects (NLME) models have been proposed for modeling complex longitudinal data. Covariates are usually introduced in the models to partially explain intersubject variations. However, one often assumes that both model random error and random effects are normally distributed, which may not always give reliable results if the data exhibit skewness. Moreover, some covariates such as CD4 cell count may be often measured with substantial errors. In this article, we address these issues simultaneously by jointly modeling the response and covariate processes using a Bayesian approach to NLME models with covariate measurement errors and a skew‐normal distribution. A real data example is offered to illustrate the methodologies by comparing various potential models with different distribution specifications. It is showed that the models with skew‐normality assumption may provide more reasonable results if the data exhibit skewness and the results may be important for HIV/AIDS studies in providing quantitative guidance to better understand the virologic responses to antiretroviral treatment.     

A semiparametric mixture cure survival model for left‐truncated and right‐censored data

In follow‐up studies, the disease event time can be subject to left truncation and right censoring. Furthermore, medical advancements have made it possible for patients to be cured of certain types of diseases. In this article, we consider a semiparametric mixture cure model for the regression analysis of left‐truncated and right‐censored data. The model combines a logistic regression for the probability of event occurrence with the class of transformation models for the time of occurrence. We investigate two techniques for estimating model parameters. The first approach is based on martingale estimating equations (EEs). The second approach is based on the conditional likelihood function given truncation variables. The asymptotic properties of both proposed estimators are established. Simulation studies indicate that the conditional maximum‐likelihood estimator (cMLE) performs well while the estimator based on EEs is very unstable even though it is shown to be consistent. This is a special and intriguing phenomenon for the EE approach under cure model. We provide insights into this issue and find that the EE approach can be improved significantly by assigning appropriate weights to the censored observations in the EEs. This finding is useful in overcoming the instability of the EE approach in some more complicated situations, where the likelihood approach is not feasible. We illustrate the proposed estimation procedures by analyzing the age at onset of the occiput‐wall distance event for patients with ankylosing spondylitis.     

Empirical‐likelihood‐based criteria for model selection on marginal analysis of longitudinal data with dropout missingness

Longitudinal data are common in clinical trials and observational studies, where missing outcomes due to dropouts are always encountered. Under such context with the assumption of missing at random, the weighted generalized estimating equation (WGEE) approach is widely adopted for marginal analysis. Model selection on marginal mean regression is a crucial aspect of data analysis, and identifying an appropriate correlation structure for model fitting may also be of interest and importance. However, the existing information criteria for model selection in WGEE have limitations, such as separate criteria for the selection of marginal mean and correlation structures, unsatisfactory selection performance in small‐sample setups, and so forth. In particular, there are few studies to develop joint information criteria for selection of both marginal mean and correlation structures. In this work, by embedding empirical likelihood into the WGEE framework, we propose two innovative information criteria named a joint empirical Akaike information criterion and a joint empirical Bayesian information criterion, which can simultaneously select the variables for marginal mean regression and also correlation structure. Through extensive simulation studies, these empirical‐likelihood‐based criteria exhibit robustness, flexibility, and outperformance compared to the other criteria including the weighted quasi‐likelihood under the independence model criterion, the missing longitudinal information criterion, and the joint longitudinal information criterion. In addition, we provide a theoretical justification of our proposed criteria, and present two real data examples in practice for further illustration.