Analysis of Longitudinal Clinical Trials with Missing Data Using Multiple Imputation in Conjunction with Robust Regression

Summary In a typical randomized clinical trial, a continuous variable of interest (e.g., bone density) is measured at baseline and fixed postbaseline time points. The resulting longitudinal data, often incomplete due to dropouts and other reasons, are commonly analyzed using parametric likelihood‐based methods that assume multivariate normality of the response vector. If the normality assumption is deemed untenable, then semiparametric methods such as (weighted) generalized estimating equations are considered. We propose an alternate approach in which the missing data problem is tackled using multiple imputation, and each imputed dataset is analyzed using robust regression (M‐estimation; Huber, 1973 , Annals of Statistics 1, 799–821.) to protect against potential non‐normality/outliers in the original or imputed dataset. The robust analysis results from each imputed dataset are combined for overall estimation and inference using either the simple Rubin (1987 , Multiple Imputation for Nonresponse in Surveys, New York: Wiley) method, or the more complex but potentially more accurate Robins and Wang (2000 , Biometrika 87, 113–124.) method. We use simulations to show that our proposed approach performs at least as well as the standard methods under normality, but is notably better under both elliptically symmetric and asymmetric non‐normal distributions. A clinical trial example is used for illustration.     

Addressing an Idiosyncrasy in Estimating Survival Curves Using Double Sampling in the Presence of Self-Selected Right Censoring

We investigate the use of follow-up samples of individuals to estimate survival curves from studies that are subject to right censoring from two sources: (i) early termination of the study, namely, administrative censoring, or (ii) censoring due to lost data prior to administrative censoring, so-called dropout. We assume that, for the full cohort of individuals, administrative censoring times are independent of the subjects' inherent characteristics, including survival time. To address the loss to censoring due to dropout, which we allow to be possibly selective, we consider an intensive second phase of the study where a representative sample of the originally lost subjects is subsequently followed and their data recorded. As with double-sampling designs in survey methodology, the objective is to provide data on a representative subset of the dropouts. Despite assumed full response from the follow-up sample, we show that, in general in our setting, administrative censoring times are not independent of survival times within the two subgroups, nondropouts and sampled dropouts. As a result, the stratified Kaplan-Meier estimator is not appropriate for the cohort survival curve. Moreover, using the concept of potential outcomes, as opposed to observed outcomes, and thereby explicitly formulating the problem as a missing data problem, reveals and addresses these complications. We present an estimation method based on the likelihood of an easily observed subset of the data and study its properties analytically for large samples. We evaluate our method in a realistic situation by simulating data that match published margins on survival and dropout from an actual hip-replacement study. Limitations and extensions of our design and analytic method are discussed.     

The need for double-sampling designs in survival studies: an application to monitor PEPFAR

Summary .  In 2007, there were 33.2 million people around the world living with HIV/AIDS ( UNAIDS/WHO, 2007 ). In May 2003, the U.S. President announced a global program, known as the President's Emergency Plan for AIDS Relief (PEPFAR), to address this epidemic. We seek to estimate patient mortality in PEPFAR in an effort to monitor and evaluate this program. This effort, however, is hampered by loss to follow-up that occurs at very high rates. As a consequence, standard survival data and analysis on observed nondropout data are generally biased, and provide no objective evidence to correct the potential bias. In this article, we apply double-sampling designs and methodology to PEPFAR data, and we obtain substantially different and more plausible estimates compared with standard methods (1-year mortality estimate of 9.6% compared to 1.7%). The results indicate that a double-sampling design is critical in providing objective evidence of possible nonignorable dropout and, thus, in obtaining accurate data in PEPFAR. Moreover, we show the need for appropriate analysis methods coupled with double-sampling designs.     

Efficient estimation for patient-specific rates of disease progression using nonnormal linear mixed models

Summary .  This article presents a new class of nonnormal linear mixed models that provide an efficient estimation of subject-specific disease progression in the analysis of longitudinal data from the Modification of Diet in Renal Disease (MDRD) trial. This new analysis addresses the previously reported finding that the distribution of the random effect characterizing disease progression is negatively skewed. We assume a log-gamma distribution for the random effects and provide the maximum likelihood inference for the proposed nonnormal linear mixed model. We derive the predictive distribution of patient-specific disease progression rates, which demonstrates rather different individual progression profiles from those obtained from the normal linear mixed model analysis. To validate the adequacy of the log-gamma assumption versus the usual normality assumption for the random effects, we propose a lack-of-fit test that clearly indicates a better fit for the log-gamma modeling in the analysis of the MDRD data. The full maximum likelihood inference is also advantageous in dealing with the missing at random (MAR) type of dropouts encountered in the MDRD data.     

Sample size determination for hierarchical longitudinal designs with differential attrition rates

Summary .   We consider the problem of sample size determination for three-level mixed-effects linear regression models for the analysis of clustered longitudinal data. Three-level designs are used in many areas, but in particular, multicenter randomized longitudinal clinical trials in medical or health-related research. In this case, level 1 represents measurement occasion, level 2 represents subject, and level 3 represents center. The model we consider involves random effects of the time trends at both the subject level and the center level. In the most common case, we have two random effects (constant and a single trend), at both subject and center levels. The approach presented here is general with respect to sampling proportions, number of groups, and attrition rates over time. In addition, we also develop a cost model, as an aid in selecting the most parsimonious of several possible competing models (i.e., different combinations of centers, subjects within centers, and measurement occasions). We derive sample size requirements (i.e., power characteristics) for a test of treatment-by-time interaction(s) for designs based on either subject-level or cluster-level randomization. The general methodology is illustrated using two characteristic examples.     

A Model for the Censoring Process in Incomplete Repeated Measurement Experiments

Premature terminations or dropouts occur often in repeated measurement experiments. A number of methods have been proposed to analyze such data but most of them assume that the censoring mechanism is, within each group, unaffected by the mechanism generating the response variables. In this paper, we propose a model for the censoring mechanism that generates dropouts. We then show how this model can be used to check whether the censoring mechanism is affected by the response variables and other covariates. Finally, the methods of the paper are applied to the “Halothane” data set.