Random effects models for estimation of the probability and time to progression of a continuous biomarker

Biomarkers play a key role in the monitoring of disease progression. The time taken for an individual to reach a biomarker exceeding or lower than a meaningful threshold is often of interest. Due to the inherent variability of biomarkers, persistence criteria are sometimes included in the definitions of progression, such that only two consecutive measurements above or below the relevant threshold signal that “true” progression has occurred. In previous work, a novel approach was developed, which allowed estimation of the time to threshold using the parameters from a linear mixed model where the residual variance was assumed to be pure measurement error. In this paper, we extend this methodology so that serial correlation can be accommodated. Assuming that the Markov property holds and applying the chain rule of probabilities, we found that the probability of progression at each timepoint can be expressed simply as the product of conditional probabilities. The methodology is applied to a cohort of HIV positive individuals, where the time to reach a CD4 count threshold is estimated. The second application we present is based on a study on abdominal aortic aneurysms, where the time taken for an individual to reach a diameter exceeding 55 mm is studied. We observed that erroneously ignoring the residual correlation when it is strong may result in substantial overestimation of the time to threshold. The estimated probability of the biomarker reaching a threshold of interest, expected time to threshold, and confidence intervals are presented for selected patients in both applications.     

On the assessment of various factors effecting the improvement in CD4 count of aids patients undergoing antiretroviral therapy using generalized Poisson regression

An important marker for identifying the progression of human immunodeficiency virus (HIV) infection in an individual is the CD4 cell count. Antiretroviral therapy (ART) is a treatment for HIV/AIDS (AIDS, acquired immune-deficiency syndrome) which prolongs and improves the lives of patients by improving the CD4 cell count and strengthen the immune system. This strengthening of the immune system in terms of CD4 count, not only depends on various biological factors, but also other behavioral factors. Previous studies have shown the effect of CD4 count on the mortality, but nobody has attempted to study the factors which are likely to influence the improvement in CD4 count of patients diagnosed of AIDS and undergoing ART. In this paper, we use Poisson regression model (GPR) for exploring the effect of various socio-demographic covariates such as age, gender, geographical location, and drug usage on the improvement in the CD4 count of AIDS patients. However, if the CD4 count data suffers from under or overdispersion, we use GPR model and compare it with negative binomial distribution. Finally, the model is applied for the analysis of data on patients undergoing the ART in the Ram Manohar Lohia Hospital, Delhi, India. The data exhibited overdispersion and hence, GPR model provided the best fit.     

Quantile Regression Methods for Longitudinal Data with Drop-outs: Application to CD4 Cell Counts of Patients Infected with the Human Immunodeficiency Virus

Patients infected with the human immunodeficiency virus (HIV) generally experience a decline in their CD4 cell count (a count of certain white blood cells). We describe the use of quantile regression methods to analyse longitudinal data on CD4 cell counts from 1300 patients who participated in clinical trials that compared two therapeutic treatments: zidovudine and didanosine. It is of scientific interest to determine any treatment differences in the CD4 cell counts over a short treatment period. However, the analysis of the CD4 data is complicated by drop-outs: patients with lower CD4 cell counts at the base-line appear more likely to drop out at later measurement occasions. Motivated by this example, we describe the use of `weighted' estimating equations in quantile regression models for longitudinal data with drop-outs. In particular, the conventional estimating equations for the quantile regression parameters are weighted inversely proportionally to the probability of drop-out. This approach requires the process generating the missing data to be estimable but makes no assumptions about the distribution of the responses other than those imposed by the quantile regression model. This method yields consistent estimates of the quantile regression parameters provided that the model for drop-out has been correctly specified. The methodology proposed is applied to the CD4 cell count data and the results are compared with those obtained from an `unweighted' analysis. These results demonstrate how an analysis that fails to account for drop-outs can mislead.     

A protective estimator for longitudinal binary data subject to non-ignorable non-monotone missingness

Summary.  In longitudinal studies missing data are the rule not the exception. We consider the analysis of longitudinal binary data with non-monotone missingness that is thought to be non-ignorable. In this setting a full likelihood approach is complicated algebraically and can be computationally prohibitive when there are many measurement occasions. We propose a 'protective' estimator that assumes that the probability that a response is missing at any occasion depends, in a completely unspecified way, on the value of that variable alone. Relying on this 'protectiveness' assumption, we describe a pseudolikelihood estimator of the regression parameters under non-ignorable missingness, without having to model the missing data mechanism directly. The method proposed is applied to CD4 cell count data from two longitudinal clinical trials of patients infected with the human immunodeficiency virus.     

Semiparametric models of longitudinal and time-to-event data with applications to HIV viral dynamics and CD4 counts

We propose a semiparametric approach based on proportional hazards and copula method to jointly model longitudinal outcomes and the time-to-event. The dependence between the longitudinal outcomes on the covariates is modeled by a copula-based times series, which allows non-Gaussian random effects and overcomes the limitation of the parametric assumptions in existing linear and nonlinear random effects models. A modified partial likelihood method using estimated covariates at failure times is employed to draw statistical inference. The proposed model and method are applied to analyze a set of progression to AIDS data in a study of the association between the human immunodeficiency virus viral dynamics and the time trend in the CD4/CD8 ratio with measurement errors. Simulations are also reported to evaluate the proposed model and method.     

Effectiveness of potent antiretroviral therapy on progression of human immunodeficiency virus: Bayesian modelling and model checking via counterfactual replicates

Summary.  We analyse data from a seroincident cohort of 457 homosexual men who were infected with the human immunodeficiency virus, followed within the multicentre Italian Seroconversion Study. These data include onset times to acquired immune deficiency syndrome (AIDS), longitudinal measurements of CD4⁺ T-cell counts taken on each subject during the AIDS-free period of observation and the period of administration of a highly active antiretro- viral therapy (HAART), for the subset of individuals who received it. The aim of the study is to assess the effect of HAART on the course of the disease. We analyse the data by a Bayesian model in which the sequence of longitudinal CD4⁺ cell count observations and the associated time to AIDS are jointly modelled at an individual subject's level as depending on the treatment. We discuss the inferences obtained about the efficacy of HAART, as well as modelling and computation difficulties that were encountered in the analysis. These latter motivate a model criticism stage of the analysis, in which the model specification of CD4⁺ cell count progression and of the effect of treatment are checked. Our approach to model criticism is based on the notion of a counterfactual replicate data set Z ^c . This is a data set with the same shape and size as the observed data, which we might have observed by rerunning the study in exactly the same conditions as the actual study if the treated patients had not been treated at all. We draw samples of Z ^c from a null model M ₀, which assumes absence of treatment effect, conditioning on data collected in each subject before initiation of treatment. Model checking is performed by comparing the observed data with a set of samples of Z ^c drawn from M ₀.     

Prediction based classification for longitudinal biomarkers

Assessment of circulating CD4 count change over time in HIV-infected subjects on antiretroviral therapy (ART) is a central component of disease monitoring. The increasing number of HIV-infected subjects starting therapy and the limited capacity to support CD4 count testing within resource-limited settings have fueled interest in identifying correlates of CD4 count change such as total lymphocyte count, among others. The application of modeling techniques will be essential to this endeavor due to the typically non-linear CD4 trajectory over time and the multiple input variables necessary for capturing CD4 variability. We propose a prediction based classification approach that involves first stage modeling and subsequent classification based on clinically meaningful thresholds. This approach draws on existing analytical methods described in the receiver operating characteristic curve literature while presenting an extension for handling a continuous outcome. Application of this method to an independent test sample results in greater than 98% positive predictive value for CD4 count change. The prediction algorithm is derived based on a cohort of n = 270 HIV-1 infected individuals from the Royal Free Hospital, London who were followed for up to three years from initiation of ART. A test sample comprised of n = 72 individuals from Philadelphia and followed for a similar length of time is used for validation. Results suggest that this approach may be a useful tool for prioritizing limited laboratory resources for CD4 testing after subjects start antiretroviral therapy.     

Models for residual time to AIDS

The distributions of the time from Human Immunodeficiency Virus (HIV) infection to the onset of Acquired Immune Deficiency Syndrome (AIDS) and of the residual time to AIDS diagnosis are important for modeling the growth of the AIDS epidemic and for predicting onset of the disease in an individual. Markers such as CD4 counts carry valuable information about disease progression and therefore about the two survival distributions. Building on the framework set out by Jewell and Kalbfleisch (1992), we study these two survival distributions based on stochastic models for the marker process (X(t)) and a marker-dependent hazard (h()). We examine various plausible CD4 marker processes and marker-dependent hazard functions for AIDS proposed in recent literature. For a random effects plus Brownian motion marker process X(t)=(a+bt+BM(t))⁴, where a has a normal distribution, b<0 is an unknown parameter and BM(t) is Brownian motion, and marker-dependent hazard h(X(t)), we prove that, given CD4 cell count X(t), the residual time to AIDS distribution does not depend on the time since infection t. Using simulation and numerical integration, we find the marginal incubation period distribution, the marginal hazard and the residual time distribution for several combinations of marker processes and marker-dependent hazards. An example using data from the Multicenter AIDS Cohort Study is given. A simple regression model relating the cube root of residual time to AIDS to CD4 count is suggested.     

Application of sensitivity analysis to incomplete longitudinal CD4 count data

In this paper, we investigate the effect of tuberculosis pericarditis (TBP) treatment on CD4 count changes over time and draw inferences in the presence of missing data. We accounted for missing data and conducted sensitivity analyses to assess whether inferences under missing at random (MAR) assumption are sensitive to not missing at random (NMAR) assumptions using the selection model (SeM) framework. We conducted sensitivity analysis using the local influence approach and stress-testing analysis. Our analyses showed that the inferences from the MAR are robust to the NMAR assumption and influential subjects do not overturn the study conclusions about treatment effects and the dropout mechanism. Therefore, the missing CD4 count measurements are likely to be MAR. The results also revealed that TBP treatment does not interact with HIV/AIDS treatment and that TBP treatment has no significant effect on CD4 count changes over time. Although the methods considered were applied to data in the IMPI trial setting, the methods can also be applied to clinical trials with similar settings.     

A three-state continuous time Markov chain model for HIV disease burden

Plasma HIV viral load (VL) is the clinical indicator used to evaluate disease burden for HIV-infected patients. We developed a covariate-adjusted, three-state, homogenous continuous time Markov chain model for HIV/AIDS disease burden among subgroups. We defined Detectable and Undetectable HIV VL levels as two transient states and Death as the third absorbing state. We implemented the exact maximum likelihood method to estimate the parameters with related asymptotic distribution to conduct hypothesis testing. We evaluated the proposed model using HIV-infected individuals from South Carolina (SC) HIV surveillance data. Using the developed model, we estimated and compared the transition hazards, transition probabilities, and the state-specific duration for HIV-infected individuals. We examined gender, race/ethnicity, age, CD4 count, place of residence, and antiretroviral treatment regimen prescribed at the beginning of the study period. We found that patients with a higher CD4 count, increased age, heterosexual orientation, white, and single tablet regimen users were associated with reduced risk of transitioning to a Detectable VL from an Undetectable VL, whereas shorter time since diagnosis, being male, and injection drug use increased the risk of the same transition.     

On evaluating how well a biomarker can predict treatment response with survival data

One of the objectives of personalized medicine is to take treatment decisions based on a biomarker measurement. Therefore, it is often interesting to evaluate how well a biomarker can predict the response to a treatment. To do so, a popular methodology consists of using a regression model and testing for an interaction between treatment assignment and biomarker. However, the existence of an interaction is not sufficient for a biomarker to be predictive. It is only necessary. Hence, the use of the marker‐by‐treatment predictiveness curve has been recommended. In addition to evaluate how well a single continuous biomarker predicts treatment response, it can further help to define an optimal threshold. This curve displays the risk of a binary outcome as a function of the quantiles of the biomarker, for each treatment group. Methods that assume a binary outcome or rely on a proportional hazard model for a time‐to‐event outcome have been proposed to estimate this curve. In this work, we propose some extensions for censored data. They rely on a time‐dependent logistic model, and we propose to estimate this model via inverse probability of censoring weighting. We present simulations results and three applications to prostate cancer, liver cirrhosis, and lung cancer data. They suggest that a large number of events need to be observed to define a threshold with sufficient accuracy for clinical usefulness. They also illustrate that when the treatment effect varies with the time horizon which defines the outcome, then the optimal threshold also depends on this time horizon.     

Using a Box–Cox transformation in the analysis of longitudinal data with incomplete responses

We analyse longitudinal data on CD4 cell counts from patients who participated in clinical trials that compared two therapeutic treatments: zidovudine and didanosine. The investigators were interested in modelling the CD4 cell count as a function of treatment, age at base-line and disease stage at base-line. Serious concerns can be raised about the normality assumption of CD4 cell counts that is implicit in many methods and therefore an analysis may have to start with a transformation. Instead of assuming that we know the transformation (e.g. logarithmic) that makes the outcome normal and linearly related to the covariates, we estimate the transformation, by using maximum likelihood, within the Box–Cox family. There has been considerable work on the Box–Cox transformation for univariate regression models. Here, we discuss the Box–Cox transformation for longitudinal regression models when the outcome can be missing over time, and we also implement a maximization method for the likelihood, assumming that the missing data are missing at random.     

Bivariate modelling of longitudinal measurements of two human immunodeficiency type 1 disease progression markers in the presence of informative drop-outs

Summary.  The main statistical problem in many epidemiological studies which involve repeated measurements of surrogate markers is the frequent occurrence of missing data. Standard likelihood-based approaches like the linear random-effects model fail to give unbiased estimates when data are non-ignorably missing. In human immunodeficiency virus (HIV) type 1 infection, two markers which have been widely used to track progression of the disease are CD4 cell counts and HIV–ribonucleic acid (RNA) viral load levels. Repeated measurements of these markers tend to be informatively censored, which is a special case of non-ignorable missingness. In such cases, we need to apply methods that jointly model the observed data and the missingness process. Despite their high correlation, longitudinal data of these markers have been analysed independently by using mainly random-effects models. Touloumi and co-workers have proposed a model termed the joint multivariate random-effects model which combines a linear random-effects model for the underlying pattern of the marker with a log-normal survival model for the drop-out process. We extend the joint multivariate random-effects model to model simultaneously the CD4 cell and viral load data while adjusting for informative drop-outs due to disease progression or death. Estimates of all the model's parameters are obtained by using the restricted iterative generalized least squares method or a modified version of it using the EM algorithm as a nested algorithm in the case of censored survival data taking also into account non-linearity in the HIV–RNA trend. The method proposed is evaluated and compared with simpler approaches in a simulation study. Finally the method is applied to a subset of the data from the 'Concerted action on seroconversion to AIDS and death in Europe' study.     

Measurement error and outcomes defined by exceeding a threshold: biased findings in comparative effectiveness trials

In medical studies, the long‐term level of a risk factor exceeding a threshold is often an outcome of interest. In practice, such a risk factor may not be directly measurable. Instead, outcome variables are based on a single or multiple biomedical measurements that have substantial variability. This variability is due to measurement error in a strict sense, true day‐to‐day variability, or a combination of the two. Estimates of prevalence based on such outcomes are biased; some individuals with long‐term levels below the threshold will be diagnosed, and some with long‐term levels above the threshold will not be diagnosed. From a public health point of view, this is a relatively minor concern; it is much less important than the fact that many individuals are not tested at all. However, in comparative effectiveness research studies, such as clinical trials evaluating a new treatment as compared with a placebo or a gold standard treatment, the combination of a noisy measurement and a threshold can distort the studies’ conclusions in important ways. Using simulations and theoretical formulas, we systematically describe the bias of prevalence difference and prevalence ratio when comparing arms and its effect on trial conclusions. Copyright © 2012 John Wiley & Sons, Ltd.     

Cofactors and markers of disease progression in human immunodeficiency virus infection

The identification of factors which are related to human immunodeficiency virus (HIV) disease progression, either by a direct interaction with HIV to increase the rate of disease progression or by providing an indication of an infected individual's likely prognosis, can have great value when understanding HIV pathogenesis and in the development of novel therapeutic approaches. This paper describes the roles of the CD4 cell count and the viral load as markers of disease progression and discusses the recent findings on chemokine receptors in HIV infection. Our current knowledge on these factors is summarized and unresolved statistical issues are highlighted.     

Composite Estimation for Single‐Index Models with Responses Subject to Detection Limits

We propose a semiparametric estimator for single‐index models with censored responses due to detection limits. In the presence of left censoring, the mean function cannot be identified without any parametric distributional assumptions, but the quantile function is still identifiable at upper quantile levels. To avoid parametric distributional assumption, we propose to fit censored quantile regression and combine information across quantile levels to estimate the unknown smooth link function and the index parameter. Under some regularity conditions, we show that the estimated link function achieves the non‐parametric optimal convergence rate, and the estimated index parameter is asymptotically normal. The simulation study shows that the proposed estimator is competitive with the omniscient least squares estimator based on the latent uncensored responses for data with normal errors but much more efficient for heavy‐tailed data under light and moderate censoring. The practical value of the proposed method is demonstrated through the analysis of a human immunodeficiency virus antibody data set.     

On a Unified Generalized Quasi–likelihood Approach for Familial–Longitudinal Non‐Stationary Count Data

Abstract. In this paper, conditional on random family effects, we consider an auto‐regression model for repeated count data and their corresponding time‐dependent covariates, collected from the members of a large number of independent families. The count responses, in such a set up, unconditionally exhibit a non‐stationary familial–longitudinal correlation structure. We then take this two‐way correlation structure into account, and develop a generalized quasilikelihood (GQL) approach for the estimation of the regression effects and the familial correlation index parameter, whereas the longitudinal correlation parameter is estimated by using the well‐known method of moments. The performance of the proposed estimation approach is examined through a simulation study. Some model mis‐specification effects are also studied. The estimation methodology is illustrated by analysing real life healthcare utilization count data collected from 36 families of size four over a period of 4 years.     

Joint generalized estimating equations for multivariate longitudinal binary outcomes with missing data: an application to acquired immune deficiency syndrome data

Summary.  In a large, prospective longitudinal study designed to monitor cardiac abnormalities in children born to women who are infected with the human immunodeficiency virus, instead of a single outcome variable, there are multiple binary outcomes (e.g. abnormal heart rate, abnormal blood pressure and abnormal heart wall thickness) considered as joint measures of heart function over time. In the presence of missing responses at some time points, longitudinal marginal models for these multiple outcomes can be estimated by using generalized estimating equations (GEEs), and consistent estimates can be obtained under the assumption of a missingness completely at random mechanism. When the missing data mechanism is missingness at random, i.e. the probability of missing a particular outcome at a time point depends on observed values of that outcome and the remaining outcomes at other time points, we propose joint estimation of the marginal models by using a single modified GEE based on an EM-type algorithm. The method proposed is motivated by the longitudinal study of cardiac abnormalities in children who were born to women infected with the human immunodeficiency virus, and analyses of these data are presented to illustrate the application of the method. Further, in an asymptotic study of bias, we show that, under a missingness at random mechanism in which missingness depends on all observed outcome variables, our joint estimation via the modified GEE produces almost unbiased estimates, provided that the correlation model has been correctly specified, whereas estimates from standard GEEs can lead to substantial bias.     

A model for markers and latent health status

We extend the bivariate Wiener process considered by Whitmore and co-workers and model the joint process of a marker and health status. The health status process is assumed to be latent or unobservable. The time to reach the primary end point or failure (death, onset of disease, etc.) is the time when the latent health status process first crosses a failure threshold level. Inferences for the model are based on two kinds of data: censored survival data and marker measurements. Covariates, such as treatment variables, risk factors and base-line conditions, are related to the model parameters through generalized linear regression functions. The model offers a much richer potential for the study of treatment efficacy than do conventional models. Treatment effects can be assessed in terms of their influence on both the failure threshold and the health status process parameters. We derive an explicit formula for the prediction of residual failure times given the current marker level. Also we discuss model validation. This model does not require the proportional hazards assumption and hence can be widely used. To demonstrate the usefulness of the model, we apply the methods in analysing data from the protocol 116a of the AIDS Clinical Trials Group.