Hazard ratio inference in stratified clinical trials with time‐to‐event endpoints and limited sample size

The stratified Cox model is commonly used for stratified clinical trials with time‐to‐event endpoints. The estimated log hazard ratio is approximately a weighted average of corresponding stratum‐specific Cox model estimates using inverse‐variance weights; the latter are optimal only under the (often implausible) assumption of a constant hazard ratio across strata. Focusing on trials with limited sample sizes (50‐200 subjects per treatment), we propose an alternative approach in which stratum‐specific estimates are obtained using a refined generalized logrank (RGLR) approach and then combined using either sample size or minimum risk weights for overall inference. Our proposal extends the work of Mehrotra et al, to incorporate the RGLR statistic, which outperforms the Cox model in the setting of proportional hazards and small samples. This work also entails development of a remarkably accurate plug‐in formula for the variance of RGLR‐based estimated log hazard ratios. We demonstrate using simulations that our proposed two‐step RGLR analysis delivers notably better results through smaller estimation bias and mean squared error and larger power than the stratified Cox model analysis when there is a treatment‐by‐stratum interaction, with similar performance when there is no interaction. Additionally, our method controls the type I error rate while the stratified Cox model does not in small samples. We illustrate our method using data from a clinical trial comparing two treatments for colon cancer.     

A Proportional Hazards Regression Model for the Subdistribution with Covariates‐adjusted Censoring Weight for Competing Risks Data

With competing risks data, one often needs to assess the treatment and covariate effects on the cumulative incidence function. Fine and Gray proposed a proportional hazards regression model for the subdistribution of a competing risk with the assumption that the censoring distribution and the covariates are independent. Covariate‐dependent censoring sometimes occurs in medical studies. In this paper, we study the proportional hazards regression model for the subdistribution of a competing risk with proper adjustments for covariate‐dependent censoring. We consider a covariate‐adjusted weight function by fitting the Cox model for the censoring distribution and using the predictive probability for each individual. Our simulation study shows that the covariate‐adjusted weight estimator is basically unbiased when the censoring time depends on the covariates, and the covariate‐adjusted weight approach works well for the variance estimator as well. We illustrate our methods with bone marrow transplant data from the Center for International Blood and Marrow Transplant Research. Here, cancer relapse and death in complete remission are two competing risks.     

A Cox‐Aalen Model for Interval‐censored Data

The Cox‐Aalen model, obtained by replacing the baseline hazard function in the well‐known Cox model with a covariate‐dependent Aalen model, allows for both fixed and dynamic covariate effects. In this paper, we examine maximum likelihood estimation for a Cox‐Aalen model based on interval‐censored failure times with fixed covariates. The resulting estimator globally converges to the truth slower than the parametric rate, but its finite‐dimensional component is asymptotically efficient. Numerical studies show that estimation via a constrained Newton method performs well in terms of both finite sample properties and processing time for moderate‐to‐large samples with few covariates. We conclude with an application of the proposed methods to assess risk factors for disease progression in psoriatic arthritis.     

Efficient estimation for case‐cohort studies

The author considers time‐to‐event data from case‐cohort designs. As existing methods are either inefficient or based on restrictive assumptions concerning the censoring mechanism, he proposes a semi‐parametrically efficient estimator under the usual assumptions for Cox regression models. The estimator in question is obtained by a one‐step Newton‐Raphson approximation that solves the efficient score equations with initial value obtained from an existing method. The author proves that the estimator is consistent, asymptotically efficient and normally distributed in the limit. He also resorts to simulations to show that the proposed estimator performs well in finite samples and that it considerably improves the efficiency of existing pseudo‐likelihood estimators when a correlate of the missing covariate is available. Although he focuses on the situation where covariates are discrete, the author also explores how the method can be applied to models with continuous covariates.     

Covariate-adjusted cost–effectiveness ratios

We describe a method for estimating the marginal cost–effectiveness ratio (CER) of two competing treatments or intervention strategies after adjusting for covariates that may influence the primary endpoint of survival. A Cox regression model is used for modeling covariates and estimates of both the cost and effectiveness parameters, which depend on the survival curve, are obtained from the estimated survival functions for each treatment at a specified covariate. Confidence intervals for the covariate-adjusted CER are presented.     

Bayesian density regression for discrete outcomes

We develop Bayesian models for density regression with emphasis on discrete outcomes. The problem of density regression is approached by considering methods for multivariate density estimation of mixed scale variables, and obtaining conditional densities from the multivariate ones. The approach to multivariate mixed scale outcome density estimation that we describe represents discrete variables, either responses or covariates, as discretised versions of continuous latent variables. We present and compare several models for obtaining these thresholds in the challenging context of count data analysis where the response may be over‐ and/or under‐dispersed in some of the regions of the covariate space. We utilise a nonparametric mixture of multivariate Gaussians to model the directly observed and the latent continuous variables. The paper presents a Markov chain Monte Carlo algorithm for posterior sampling, sufficient conditions for weak consistency, and illustrations on density, mean and quantile regression utilising simulated and real datasets.     

A dependent Dirichlet process model for survival data with competing risks

In this paper, we first propose a dependent Dirichlet process (DDP) model using a mixture of Weibull models with each mixture component resembling a Cox model for survival data. We then build a Dirichlet process mixture model for competing risks data without regression covariates. Next we extend this model to a DDP model for competing risks regression data by using a multiplicative covariate effect on subdistribution hazards in the mixture components. Though built on proportional hazards (or subdistribution hazards) models, the proposed nonparametric Bayesian regression models do not require the assumption of constant hazard (or subdistribution hazard) ratio. An external time-dependent covariate is also considered in the survival model. After describing the model, we discuss how both cause-specific and subdistribution hazard ratios can be estimated from the same nonparametric Bayesian model for competing risks regression. For use with the regression models proposed, we introduce an omnibus prior that is suitable when little external information is available about covariate effects. Finally we compare the models’ performance with existing methods through simulations. We also illustrate the proposed competing risks regression model with data from a breast cancer study. An R package “DPWeibull” implementing all of the proposed methods is available at CRAN.

     

To adjust or not to adjust for baseline when analyzing repeated binary responses? The case of complete data when treatment comparison at study end is of interest

The benefits of adjusting for baseline covariates are not as straightforward with repeated binary responses as with continuous response variables. Therefore, in this study, we compared different methods for analyzing repeated binary data through simulations when the outcome at the study endpoint is of interest. Methods compared included chi‐square, Fisher's exact test, covariate adjusted/unadjusted logistic regression (Adj.logit/Unadj.logit), covariate adjusted/unadjusted generalized estimating equations (Adj.GEE/Unadj.GEE), covariate adjusted/unadjusted generalized linear mixed model (Adj.GLMM/Unadj.GLMM). All these methods preserved the type I error close to the nominal level. Covariate adjusted methods improved power compared with the unadjusted methods because of the increased treatment effect estimates, especially when the correlation between the baseline and outcome was strong, even though there was an apparent increase in standard errors. Results of the Chi‐squared test were identical to those for the unadjusted logistic regression. Fisher's exact test was the most conservative test regarding the type I error rate and also with the lowest power. Without missing data, there was no gain in using a repeated measures approach over a simple logistic regression at the final time point. Analysis of results from five phase III diabetes trials of the same compound was consistent with the simulation findings. Therefore, covariate adjusted analysis is recommended for repeated binary data when the study endpoint is of interest. Copyright © 2015 John Wiley & Sons, Ltd.     

Modelling Survival Events with Longitudinal Covariates Measured with Error

In survival analysis, time-dependent covariates are usually present as longitudinal data collected periodically and measured with error. The longitudinal data can be assumed to follow a linear mixed effect model and Cox regression models may be used for modelling of survival events. The hazard rate of survival times depends on the underlying time-dependent covariate measured with error, which may be described by random effects. Most existing methods proposed for such models assume a parametric distribution assumption on the random effects and specify a normally distributed error term for the linear mixed effect model. These assumptions may not be always valid in practice. In this article, we propose a new likelihood method for Cox regression models with error-contaminated time-dependent covariates. The proposed method does not require any parametric distribution assumption on random effects and random errors. Asymptotic properties for parameter estimators are provided. Simulation results show that under certain situations the proposed methods are more efficient than the existing methods.     

Evaluation strategies for case series: is Cox regression an alternative to the self controlled case series method for terminal events?

In this paper, we deal with the analysis of case series. The self-controlled case series method (SCCS) was developed to analyse the temporal association between time-varying exposure and an outcome event. We apply the SCCS method to the vaccination data of the German Examination Survey for Children and Adolescents (KiGGS). We illustrate that the standard SCCS method cannot be applied to terminal events such as death. In this situation, an extension of SCCS adjusted for terminal events gives unbiased point estimators. The key question of this paper is whether the general Cox regression model for time-dependent covariates may be an alternative to the adjusted SCCS method for terminal events. In contrast to the SCCS method, Cox regression is included in most software packages (SPSS, SAS, STATA, R, …) and it is easy to use. We can show that Cox regression is applicable to test the null hypothesis. In our KiGGS example without censored data, the Cox regression and the adjusted SCCS method yield point estimates almost identical to the standard SCCS method. We have conducted several simulation studies to complete the comparison of the two methods. The Cox regression shows a tendency to underestimate the true effect with prolonged risk periods and strong effects (Relative Incidence >2). If risk of the event is strongly affected by the age, the adjusted SCCS method slightly overestimates the predefined exposure effect. Cox regression has the same efficiency as the adjusted SCCS method in the simulation.     

A Semi‐parametric Transformation Frailty Model for Semi‐competing Risks Survival Data

In the analysis of semi‐competing risks data interest lies in estimation and inference with respect to a so‐called non‐terminal event, the observation of which is subject to a terminal event. Multi‐state models are commonly used to analyse such data, with covariate effects on the transition/intensity functions typically specified via the Cox model and dependence between the non‐terminal and terminal events specified, in part, by a unit‐specific shared frailty term. To ensure identifiability, the frailties are typically assumed to arise from a parametric distribution, specifically a Gamma distribution with mean 1.0 and variance, say, σ². When the frailty distribution is misspecified, however, the resulting estimator is not guaranteed to be consistent, with the extent of asymptotic bias depending on the discrepancy between the assumed and true frailty distributions. In this paper, we propose a novel class of transformation models for semi‐competing risks analysis that permit the non‐parametric specification of the frailty distribution. To ensure identifiability, the class restricts to parametric specifications of the transformation and the error distribution; the latter are flexible, however, and cover a broad range of possible specifications. We also derive the semi‐parametric efficient score under the complete data setting and propose a non‐parametric score imputation method to handle right censoring; consistency and asymptotic normality of the resulting estimators is derived and small‐sample operating characteristics evaluated via simulation. Although the proposed semi‐parametric transformation model and non‐parametric score imputation method are motivated by the analysis of semi‐competing risks data, they are broadly applicable to any analysis of multivariate time‐to‐event outcomes in which a unit‐specific shared frailty is used to account for correlation. Finally, the proposed model and estimation procedures are applied to a study of hospital readmission among patients diagnosed with pancreatic cancer.     

A longitudinal study of children's aggressive behaviours based on multivariate mixed models with incomplete data

The authors consider children's behavioural and emotional problems and their relationships with possible predictors. They propose a multivariate transitional mixed‐effects model for a longitudinal study and simultaneously address non‐ignorable missing data in responses and covariates, measurement errors in covariates, and multivariate modelling of the responses and covariate processes. A real dataset is analysed in details using the proposed method with some interesting results. The Canadian Journal of Statistics 37: 435–452; 2009 © 2009 Statistical Society of Canada     

Estimation of group means when adjusting for covariates in generalized linear models

Generalized linear models are commonly used to analyze categorical data such as binary, count, and ordinal outcomes. Adjusting for important prognostic factors or baseline covariates in generalized linear models may improve the estimation efficiency. The model‐based mean for a treatment group produced by most software packages estimates the response at the mean covariate, not the mean response for this treatment group for the studied population. Although this is not an issue for linear models, the model‐based group mean estimates in generalized linear models could be seriously biased for the true group means. We propose a new method to estimate the group mean consistently with the corresponding variance estimation. Simulation showed the proposed method produces an unbiased estimator for the group means and provided the correct coverage probability. The proposed method was applied to analyze hypoglycemia data from clinical trials in diabetes. Copyright © 2014 John Wiley & Sons, Ltd.     

Generalizing the standardized hazard ratio to multivariate proportional hazards regression,with an application to clinical~genomic studies

The standardized hazard ratio for univariate proportional hazards regression is generalized as a scalar to multivariate proportional hazards regression. Estimators of the standardized log hazard ratio are developed, with corrections for bias and for regression to the mean in high-dimensional analyses. Tests of point and interval null hypotheses and confidence intervals are constructed. Cohort sampling study designs, commonly used in prospective–retrospective clinical genomic studies, are accommodated.     

Cox Regression with Incomplete Covariate Measurements using the EM-algorithm

Ibrahim (1990) used the EM-algorithm to obtain maximum likelihood estimates of the regression parameters in generalized linear models with partially missing covariates. The technique was termed EM by the method of weights. In this paper, we generalize this technique to Cox regression analysis with missing values in the covariates. We specify a full model letting the unobserved covariate values be random and then maximize the observed likelihood. The asymptotic covariance matrix is estimated by the inverse information matrix. The missing data are allowed to be missing at random but also the non-ignorable non-response situation may in principle be considered. Simulation studies indicate that the proposed method is more efficient than the method suggested by Paik & Tsai (1997). We apply the procedure to a clinical trials example with six covariates with three of them having missing values.     

ACCELERATED FAILURE TIME MODELS WITH NONLINEAR COVARIATES EFFECTS

As a flexible alternative to the Cox model, the accelerated failure time (AFT) model assumes that the event time of interest depends on the covariates through a regression function. The AFT model with non‐parametric covariate effects is investigated, when variable selection is desired along with estimation. Formulated in the framework of the smoothing spline analysis of variance model, the proposed method based on the Stute estimate ( Stute, 1993 [Consistent estimation under random censorship when covariables are present, J. Multivariate Anal. 45 , 89–103]) can achieve a sparse representation of the functional decomposition, by utilizing a reproducing kernel Hilbert norm penalty. Computational algorithms and theoretical properties of the proposed method are investigated. The finite sample size performance of the proposed approach is assessed via simulation studies. The primary biliary cirrhosis data is analyzed for demonstration.     

Dynamic path analysis—a new approach to analyzing time-dependent covariates

In this article we introduce a general approach to dynamic path analysis. This is an extension of classical path analysis to the situation where variables may be time-dependent and where the outcome of main interest is a stochastic process. In particular we will focus on the survival and event history analysis setting where the main outcome is a counting process. Our approach will be especially fruitful for analyzing event history data with internal time-dependent covariates, where an ordinary regression analysis may fail. The approach enables us to describe how the effect of a fixed covariate partly is working directly and partly indirectly through internal time-dependent covariates. For the sequence of times of event, we define a sequence of path analysis models. At each time of an event, ordinary linear regression is used to estimate the relation between the covariates, while the additive hazard model is used for the regression of the counting process on the covariates. The methodology is illustrated using data from a randomized trial on survival for patients with liver cirrhosis.     

Self‐modelling regression for longitudinal data with time‐invariant covariates

The authors propose the use of self‐modelling regression to analyze longitudinal data with time invariant covariates. They model the population time curve with a penalized regression spline and use a linear mixed model for transformation of the time and response scales to fit the individual curves. Fitting is done by an iterative algorithm using off‐the‐shelf linear and nonlinear mixed model software. Their method is demonstrated in a simulation study and in the analysis of tree swallow nestling growth from an experiment that includes an experimentally controlled treatment, an observational covariate and multi‐level sampling.     

Cox regression with missing covariate data using a modified partial likelihood method

Missing covariate values is a common problem in survival analysis. In this paper we propose a novel method for the Cox regression model that is close to maximum likelihood but avoids the use of the EM-algorithm. It exploits that the observed hazard function is multiplicative in the baseline hazard function with the idea being to profile out this function before carrying out the estimation of the parameter of interest. In this step one uses a Breslow type estimator to estimate the cumulative baseline hazard function. We focus on the situation where the observed covariates are categorical which allows us to calculate estimators without having to assume anything about the distribution of the covariates. We show that the proposed estimator is consistent and asymptotically normal, and derive a consistent estimator of the variance–covariance matrix that does not involve any choice of a perturbation parameter. Moderate sample size performance of the estimators is investigated via simulation and by application to a real data example.     

Cox Regression with Covariate Measurement Error

This article deals with parameter estimation in the Cox proportional hazards model when covariates are measured with error. We consider both the classical additive measurement error model and a more general model which represents the mis-measured version of the covariate as an arbitrary linear function of the true covariate plus random noise. Only moment conditions are imposed on the distributions of the covariates and measurement error. Under the assumption that the covariates are measured precisely for a validation set, we develop a class of estimating equations for the vector-valued regression parameter by correcting the partial likelihood score function. The resultant estimators are proven to be consistent and asymptotically normal with easily estimated variances. Furthermore, a corrected version of the Breslow estimator for the cumulative hazard function is developed, which is shown to be uniformly consistent and, upon proper normalization, converges weakly to a zero-mean Gaussian process. Simulation studies indicate that the asymptotic approximations work well for practical sample sizes. The situation in which replicate measurements (instead of a validation set) are available is also studied.