Cox model with interval‐censored covariate in cohort studies

In cohort studies the outcome is often time to a particular event, and subjects are followed at regular intervals. Periodic visits may also monitor a secondary irreversible event influencing the event of primary interest, and a significant proportion of subjects develop the secondary event over the period of follow‐up. The status of the secondary event serves as a time‐varying covariate, but is recorded only at the times of the scheduled visits, generating incomplete time‐varying covariates. While information on a typical time‐varying covariate is missing for entire follow‐up period except the visiting times, the status of the secondary event are unavailable only between visits where the status has changed, thus interval‐censored. One may view interval‐censored covariate of the secondary event status as missing time‐varying covariates, yet missingness is partial since partial information is provided throughout the follow‐up period. Current practice of using the latest observed status produces biased estimators, and the existing missing covariate techniques cannot accommodate the special feature of missingness due to interval censoring. To handle interval‐censored covariates in the Cox proportional hazards model, we propose an available‐data estimator, a doubly robust‐type estimator as well as the maximum likelihood estimator via EM algorithm and present their asymptotic properties. We also present practical approaches that are valid. We demonstrate the proposed methods using our motivating example from the Northern Manhattan Study.     

Performance of the Peto odds ratio compared to the usual odds ratio estimator in the case of rare events

For the calculation of relative measures such as risk ratio (RR) and odds ratio (OR) in a single study, additional approaches are required for the case of zero events. In the case of zero events in one treatment arm, the Peto odds ratio (POR) can be calculated without continuity correction, and is currently the relative effect estimation method of choice for binary data with rare events. The aim of this simulation study is a variegated comparison of the estimated OR and estimated POR with the true OR in a single study with two parallel groups without confounders in data situations where the POR is currently recommended. This comparison was performed by means of several performance measures, that is the coverage, confidence interval (CI) width, mean squared error (MSE), and mean percentage error (MPE). We demonstrated that the estimator for the POR does not outperform the estimator for the OR for all the performance measures investigated. In the case of rare events, small treatment effects and similar group sizes, we demonstrated that the estimator for the POR performed better than the estimator for the OR only regarding the coverage and MPE, but not the CI width and MSE. For larger effects and unbalanced group size ratios, the coverage and MPE of the estimator for the POR were inappropriate. As in practice the true effect is unknown, the POR method should be applied only with the utmost caution.     

Design of validation studies for estimating the odds ratio of exposure-disease relationships when exposure is misclassified

We compared several validation study designs for estimating the odds ratio of disease with misclassified exposure. We assumed that the outcome and misclassified binary covariate are available and that the error-free binary covariate is measured in a subsample, the validation sample. We considered designs in which the total size of the validation sample is fixed and the probability of selection into the validation sample may depend on outcome and misclassified covariate values. Design comparisons were conducted for rare and common disease scenarios, where the optimal design is the one that minimizes the variance of the maximum likelihood estimator of the true log odds ratio relating the outcome to the exposure of interest. Misclassification rates were assumed to be independent of the outcome. We used a sensitivity analysis to assess the effect of misspecifying the misclassification rates. Under the scenarios considered, our results suggested that a balanced design, which allocates equal numbers of validation subjects into each of the four outcome/mismeasured covariate categories, is preferable for its simplicity and good performance. A user-friendly Fortran program is available from the second author, which calculates the optimal sampling fractions for all designs considered and the efficiencies of these designs relative to the optimal hybrid design for any scenario of interest.     

Applications of proportional odds ordinal logistic regression models and continuation ratio models in examining the association of physical inactivity with erectile dysfunction among type 2 diabetic patients

[Purpose]Many studies have observed a high prevalence of erectile dysfunction among individuals performing physical activity in less leisure-time. However, this relationship in patients with type 2 diabetic patients is not well studied. In exposure outcome studies with ordinal outcome variables, investigators often try to make the outcome variable dichotomous and lose information by collapsing categories. Several statistical models have been developed to make full use of all information in ordinal response data, but they have not been widely used in public health research. In this paper, we discuss the application of two statistical models to determine the association of physical inactivity with erectile dysfunction among patients with type 2 diabetes.[Methods]A total of 204 married men aged 20-60 years with a diagnosis of type 2 diabetes at the outpatient unit of the Department of Endocrinology at PSG hospitals during the months of May and June 2019 were studied. We examined the association between physical inactivity and erectile dysfunction using proportional odds ordinal logistic regression models and continuation ratio models.[Results]The proportional odds model revealed that patients with diabetes who perform leisure time physical activity for over 40 minutes per day have reduced odds of erectile dysfunction (odds ratio=0.38) across the severity categories of erectile dysfunction after adjusting for age and duration of diabetes.[Conclusion]The present study suggests that physical inactivity has a negative impact on erectile function. We observed that the simple logistic regression model had only 75% efficiency compared to the proportional odds model used here; hence, more valid estimates were obtained here.     

A partially parametric estimator of survival in the presence of randomly censored data

Many biological or medical experiments have as their goal to estimate the survival function of a specified population of subjects when the time to the specified event may be censored due to loss to follow-up, the occurrence of another event that precludes the occurrence of the event of interest, or the study being terminated before the event of interest occurs. This paper suggests an improvement of the Kaplan-Meier product-limit estimator when the censoring mechanism is random. The proposed estimator treats the uncensored observations nonparametrically and uses a parametric model only for the censored observations. One version of this proposed estimator always has a smaller bias and mean squared error than the product-limit estimator. An example estimating the survival function of patients enrolled in the Ohio State University Bone Marrow Transplant Program is presented.     

Bayesian semiparametric proportional odds models

Methodology for implementing the proportional odds regression model for survival data assuming a mixture of finite Polya trees (MPT) prior on baseline survival is presented. Extensions to frailties and generalized odds rates are discussed. Although all manner of censoring and truncation can be accommodated, we discuss model implementation, regression diagnostics, and model comparison for right-censored data. An advantage of the MPT model is the relative ease with which predictive densities, survival, and hazard curves are generated. Much discussion is devoted to practical implementation of the proposed models, and a novel MCMC algorithm based on an approximating parametric normal model is developed. A modest simulation study comparing the small sample behavior of the MPT model to a rank-based estimator and a real data example is presented.     

Semiparametric methods in the proportional odds model for ordinal response data with missing covariates

Summary We consider the estimation problem of a proportional odds model with missing covariates. Based on the validation and nonvalidation data sets, we propose a joint conditional method that is an extension of Wang et al. (2002, Statistica Sinica 12, 555–574). The proposed method is semiparametric since it requires neither an additional model for the missingness mechanism, nor the specification of the conditional distribution of missing covariates given observed variables. Under the assumption that the observed covariates and the surrogate variable are categorical, we derived the large sample property. The simulation studies show that in various situations, the joint conditional method is more efficient than the conditional estimation method and weighted method. We also use a real data set that came from a survey of cable TV satisfaction to illustrate the approaches.     

Applying a data duplication technique in linear regression analysis of waiting time to pregnancy

This analysis demonstrates the application of a data duplication technique in linear regression with censored observations of the waiting time to third pregnancy ending in two outcome types, using data from Malaysia. The linear model not only confirmed the results obtained by the Cox proportional hazards model, but also identified two additional significant factors. The method provides a useful alternative when Cox proportionality assumption of the hazards is violated.     

A Partitioning Deletion/Substitution/Addition Algorithm for Creating Survival Risk Groups

Summary Accurately assessing a patient’s risk of a given event is essential in making informed treatment decisions. One approach is to stratify patients into two or more distinct risk groups with respect to a specific outcome using both clinical and demographic variables. Outcomes may be categorical or continuous in nature; important examples in cancer studies might include level of toxicity or time to recurrence. Recursive partitioning methods are ideal for building such risk groups. Two such methods are Classification and Regression Trees (CART) and a more recent competitor known as the partitioning Deletion/Substitution/Addition (partDSA) algorithm, both of which also utilize loss functions (e.g., squared error for a continuous outcome) as the basis for building, selecting, and assessing predictors but differ in the manner by which regression trees are constructed. Recently, we have shown that partDSA often outperforms CART in so‐called “full data” settings (e.g., uncensored outcomes). However, when confronted with censored outcome data, the loss functions used by both procedures must be modified. There have been several attempts to adapt CART for right‐censored data. This article describes two such extensions for partDSA that make use of observed data loss functions constructed using inverse probability of censoring weights. Such loss functions are consistent estimates of their uncensored counterparts provided that the corresponding censoring model is correctly specified. The relative performance of these new methods is evaluated via simulation studies and illustrated through an analysis of clinical trial data on brain cancer patients. The implementation of partDSA for uncensored and right‐censored outcomes is publicly available in the R package, partDSA .     

Methods of estimation in log odds ratio regression models

McCullagh's (1984, Journal of the Royal Statistical Society, Series B 46, 250-256) approximation to the conditional maximum likelihood estimator in log odds ratio regression models is shown to have negligible asymptotic bias unless the odds ratios are large and the sample sizes in individual 2 X 2 tables are very small. In application to two sets of case-control data, it yields results virtually indistinguishable from those of the conditional analysis. A generalization of the Mantel-Haenszel estimator proposed by Davis (1985, Biometrics 41, 487-495) does not approximate the conditional results nearly as well.     

Optimal approximate conversions of odds ratios and hazard ratios to risk ratios

Odds ratios approximate risk ratios when the outcome under consideration is rare but can diverge substantially from risk ratios when the outcome is common. In this paper, we derive optimal analytic conversions of odds ratios and hazard ratios to risk ratios that are minimax for the bias ratio when outcome probabilities are specified to fall in any fixed interval. The results for hazard ratios are derived under a proportional hazard assumption for the exposure. For outcome probabilities specified to lie in symmetric intervals centered around 0.5, it is shown that the square-root transformation of the odds ratio is the optimal minimax conversion for the risk ratio. General results for any nonsymmetric interval are given both for odds ratio and for hazard ratio conversions. The results are principally useful when odds ratios or hazard ratios are reported in papers, and the reader does not have access to the data or to information about the overall outcome prevalence.     

A comparison of several point estimators of the odds ratio in a single 2 x 2 contingency table.

The relative performance of the unconditioned maximum likelihood estimators (UMLEs), conditional MLEs (CMLEs), and Jewell-type estimators of the odds ratio (OR) and its logarithm were investigated in sets of single 2 x 2 contingency tables. The tables were generated by complete enumeration of all possible cell frequencies consistent with a single fixed margin. The bias, mean squared error (MSE), and average absolute error (AAE) were computed for all estimators using the individual table probabilities as weights. The results showed that, for the OR, Jewell's estimator usually had smaller bias, MSE, and AAE than either of the MLEs. While the differences were often slight for MSE and AAE, for bias it was sometimes substantial. For the log(OR), the UMLE usually had the lowest bias, and its MSE and AAE were only slightly greater than those for the other estimators. Overall, we recommend estimation on the log scale using the UMLE. If OR is to be estimated, Jewell's method had strong merit, although it is nonsymmetric with respect to the table orientation. In view of this, the UMLE may again be favoured in some situations.     

Prediction in censored survival data: a comparison of the proportional hazards and linear regression models.

Although the analysis of censored survival data using the proportional hazards and linear regression models is common, there has been little work examining the ability of these estimators to predict time to failure. This is unfortunate, since a predictive plot illustrating the relationship between time to failure and a continuous covariate can be far more informative regarding the risk associated with the covariate than a Kaplan-Meier plot obtained by discretizing the variable. In this paper the predictive power of the Cox (1972, Journal of the Royal Statistical Society, Series B 34, 187-202) proportional hazards estimator and the Buckley-James (1979, Biometrika 66, 429-436) censored regression estimator are compared. Using computer simulations and heuristic arguments, it is shown that the choice of method depends on the censoring proportion, strength of the regression, the form of the censoring distribution, and the form of the failure distribution. Several examples are provided to illustrate the usefulness of the methods.     

On protected estimation of an odds ratio model with missing binary exposure and confounders

We describe an estimator of the parameter indexing a model for the conditional odds ratio between a binary exposure and a binary outcome given a high-dimensional vector of confounders, when the exposure and a subset of the confounders are missing, not necessarily simultaneously, in a subsample. We argue that a recently proposed estimator restricted to complete-cases confers more protection to model misspecification than existing ones in the sense that the set of data laws under which it is consistent strictly contains each set of data laws under which each of the previous estimators are consistent.     

Notes in Case-Control Studies with Matched Pairs under Inverse Sampling

In case-control studies with matched pairs, the traditional point estimator of odds ratio (OR) is well-known to be biased with no exact finite variance under binomial sampling. In this paper, we consider use of inverse sampling in which we continue to sample subjects to form matched pairs until we obtain a pre-determined number (>0) of index pairs with the case unexposed but the control exposed. In contrast to use of binomial sampling, we show that the uniformly minimum variance unbiased estimator (UMVUE) of OR does exist under inverse sampling. We further derive an exact confidence interval of OR in closed form. Finally, we develop an exact test and an asymptotic test for testing the null hypothesis H₀: OR = 1, as well as discuss sample size determination on the minimum required number of index pairs for a desired power at α-level.     

Estimation of a common odds ratio in case-control studies of familial aggregation

A new estimator of a common odds ratio is proposed for case-control studies of familial aggregation. The proposed estimator is a modification to the usual Mantel-Haenszel estimator that relies on an empirical adjustment for the within-family clustering which is typical of such designs. A simulation study shows that the estimator tends to have smaller mean squared error than the unmodified Mantel-Haenszel estimator under conditions likely to arise in practice. The construction of confidence intervals is also discussed.     

Semiparametric bayes' proportional odds models for current status data with underreporting

Current status data are a type of interval-censored event time data in which all the individuals are either left or right censored. For example, our motivation is drawn from a cross-sectional study, which measured whether or not fibroid onset had occurred by the age of an ultrasound exam for each woman. We propose a semiparametric Bayesian proportional odds model in which the baseline event time distribution is estimated nonparametrically by using adaptive monotone splines in a logistic regression model and the potential risk factors are included in the parametric part of the mean structure. The proposed approach has the advantage of being straightforward to implement using a simple and efficient Gibbs sampler, whereas alternative semiparametric Bayes' event time models encounter problems for current status data. The model is generalized to allow systematic underreporting in a subset of the data, and the methods are applied to an epidemiologic study of uterine fibroids.     

Effects of censoring on parameter estimates and power in genetic modeling.

Genetic and environmental influences on variance in phenotypic traits may be estimated with normal theory Maximum Likelihood (ML). However, when the assumption of multivariate normality is not met, this method may result in biased parameter estimates and incorrect likelihood ratio tests. We simulated multivariate normal distributed twin data under the assumption of three different genetic models. Genetic model fitting was performed in six data sets: multivariate normal data, discrete uncensored data, censored data, square root transformed censored data, normal scores of censored data, and categorical data. Estimates were obtained with normal theory ML (data sets 1-5) and with categorical data analysis (data set 6). Statistical power was examined by fitting reduced models to the data. When fitting an ACE model to censored data, an unbiased estimate of the additive genetic effect was obtained. However, the common environmental effect was underestimated and the unique environmental effect was overestimated. Transformations did not remove this bias. When fitting an ADE model, the additive genetic effect was underestimated while the dominant and unique environmental effects were overestimated. In all models, the correct parameter estimates were recovered with categorical data analysis. However, with categorical data analysis, the statistical power decreased. The analysis of L-shaped distributed data with normal theory ML results in biased parameter estimates. Unbiased parameter estimates are obtained with categorical data analysis, but the power decreases.     

A comparative study of conditional maximum likelihood estimation of a common odds ratio

The finite-sample properties of various point estimators of a common odds ratio from multiple 2 X 2 tables have been considered in a number of simulation studies. However, the conditional maximum likelihood estimator has received only limited attention. That omission is partially rectified here for cases of relatively small numbers of tables and moderate to large within-table sample sizes. The conditional maximum likelihood estimator is found to be superior to the unconditional maximum likelihood estimator, and equal or superior to the Mantel-Haenszel estimator in both bias and precision.