Competing risk analysis in a large cardiovascular clinical trial: An APEX substudy

Competing risk methods are time‐to‐event analyses that account for fatal and/or nonfatal events that may potentially alter or prevent a subject from experiencing the primary endpoint. Competing risk methods may provide a more accurate and less biased estimate of the incidence of an outcome but are rarely applied in cardiology trials. APEX investigated the efficacy of extended‐duration betrixaban versus standard‐duration enoxaparin to prevent a composite of symptomatic deep‐vein thrombosis (proximal or distal), nonfatal pulmonary embolism, or venous thromboembolism (VTE)–related death in acute medically ill patients (n = 7513). The aim of the current analysis was to determine the efficacy of betrixaban vs standard‐duration enoxaparin accounting for non‐VTE–related deaths using the Fine and Gray method for competing risks. The proportion of non‐VTE–related death was similar in both the betrixaban (133, 3.6%) and enoxaparin (136, 3.7%) arms, P = .85. Both the traditional Kaplan‐Meier method and the Fine and Gray method accounting for non‐VTE–related death as a competing risk showed equal reduction of VTE events when comparing betrixaban to enoxaparin (HR/SHR = 0.65, 95% 0.42‐0.99, P = 0.046). Due to the similar proportion of non‐VTE–related deaths in both treatment arms and the use of a univariate model, the Fine and Gray method provided identical results to the traditional Cox model. Using the Fine and Gray method in addition to the traditional Cox proportional hazards method can indicate whether the presence of a competing risk, which is dependent of the outcome, altered the risk estimate.     

Ergodicity and truncation bounds for inhomogeneous birth and death processes with additional transitions from and to origin

ABSTRACT

In this paper, we present the extension of the analysis of time-dependent limiting characteristics the class of continuous-time birth and death processes defined on non-negative integers with special transitions from and to the origin. From the origin transitions can occur to any state. But being in any other state, besides ordinary transitions to neighboring states, a transition to the origin can occur. All possible transition intensities are assumed to be non-random functions of time and may depend on the state of the process. We improve previously known ergodicity and truncation bounds for this class of processes that were known only for the case when transitions from the origin decay exponentially (other intensities must have unique uniform upper bound). We show how the bounds can be obtained if the decay rate is slower than exponential. Numerical results are given in the queueing theory context.     

A Flexible Bayesian Model for Estimating Subnational Mortality

Reliable subnational mortality estimates are essential in the study of health inequalities within a country. One of the difficulties in producing such estimates is the presence of small populations among which the stochastic variation in death counts is relatively high, and thus the underlying mortality levels are unclear. We present a Bayesian hierarchical model to estimate mortality at the subnational level. The model builds on characteristic age patterns in mortality curves, which are constructed using principal components from a set of reference mortality curves. Information on mortality rates are pooled across geographic space and are smoothed over time. Testing of the model shows reasonable estimates and uncertainty levels when it is applied both to simulated data that mimic U.S. counties and to real data for French départements. The model estimates have direct applications to the study of subregional health patterns and disparities.     

The Interaction of Same-Sex Marriage Access With Sexual Minority Identity on Mental Health and Subjective Wellbeing

Previous psychological and public health research has highlighted the impact of legal recognition of same-sex relationships on individual identity and mental health. Using a sample of U.S. sexual minority (N = 313) and heterosexual (N = 214) adults, participants completed a battery of mental health inventories prior to the nationwide legalization of same-sex marriage. Analyses of covariance (ANCOVAs) examining identity revealed sexual minority participants living in states where same-sex marriage was banned experienced significantly higher levels of internalized homonegativity than sexual minority participants living in states where same-sex marriage was legal, even after controlling for state-level political climate. Mental health ANCOVAs revealed sexual minority participants residing in states without same-sex marriage experienced greater anxiety and lower subjective wellbeing compared to sexual minority participants residing in states with same-sex marriage and heterosexual participants residing in states with or without same-sex marriage. Implications for public policy and future research directions are discussed.     

The physical activity-mediated Demand–Control (pamDC) model: Linking work characteristics,leisure time physical activity,and well-being

Only recently has research begun to investigate the interplay between work characteristics, leisure time physical activity (LTPA), health, and well-being. So far, however, this research lacks a theoretical foundation. In this article, we introduce the physical activity-mediated Demand–Control (pamDC) model as a new theoretical framework. The two key ideas of the pamDC model are (1) that job demands and job control affect LTPA and (2) that LTPA partially mediates the effects of job demands and job control on health and well-being. We present eight propositions explaining how work characteristics affect LTPA, health, and well-being. For each of these propositions, we discuss empirical evidence and theoretical foundations. We then sketch a research agenda on how to adopt the pamDC model as a new theoretical framework for future research linking work characteristics, LTPA, and health. Finally, we discuss the practical implications of our new model.     

Confronting the Informal in Good Governance: The Case of Decentralised Education‐System Reform in Guinea

For twenty years, technocratic planning and management approaches have dominated good‐governance reforms in developing countries. This is true even for newer ‘participatory’ and ‘citizen‐driven’ reforms that still struggle to engage with powerful informal forces affecting public service delivery. This article presents evidence from a case study of decentralised education‐system reform in Guinea, revealing a wide range of influential dynamics outside the technical realm. These corroborate the argument for ‘good‐fit’ alternatives to traditional governance approaches and concrete measures to better capture the constructive and disable the destructive effects of informality on development.     

‘A Hidden Group of Children’: Support in Schools for Children who Experience Parental Imprisonment

Schools have been identified as playing a key role in supporting the children of prisoners. This paper reports on a study, which explored the support provision offered in schools to children who experience parental imprisonment. By interviewing school representatives, stakeholders, parents and children, we illustrate the support available in schools, the issues that arise and ways in which support provision can be strengthened. Our findings indicate that children of prisoners often constitute a ‘forgotten’ group in schools, and we suggest that an awareness of these children and the challenges they face needs to be raised amongst education practitioners and policy‐makers.     

Hitting the jackpot: the influence of monetary payout on gambling behaviour

Restrictions on monetary payout may promote player engagement in gambling as a form of entertainment rather than as a source of income. Our objective was to evaluate the effects of monetary prize magnitude upon gambling behaviour in a community sample, and the degree to which this association is moderated by gambling risk factors. One hundred and eighty-seven adults completed an online survey assessing motivation, impulsivity and affect. Participants were given a series of vignettes and asked to estimate how much they would gamble to win monetary prizes of increasing amounts with and without accrued gambling debt. Participants reported increased gambling in response to increased monetary payout. Debt moderated these outcomes, such that electronic gaming machine (EGM) and lottery expenditures and number of lottery games played decreased with increased debt; this effect was most pronounced at elevated monetary prizes. The association between duration of EGM play and monetary payout was moderated by gender only. Results suggest that self-reported gambling behaviours increased with monetary payout even across qualitatively different gambling products, and across gamblers with different motivations for gambling, levels of impulsivity, and negative affect. The restriction of monetary payouts warrants further research attention as a form of problem gambling prevention.     

The effects of adapting their home on the meaning of home for families with a disabled child

This article describes part of a mixed-method study investigating family and professional perspectives on home adaptations for disabled children. The methods were an online survey of staff involved in adaptations processes (n =39), semi-structured interviews with families with disabled children (n = 48) and an online survey for families (n = 16). One of the wider study’s recommendations was that families need to be enabled to engage with processes proactively. This article focuses on families’ experiences of the meaning attributed to adapting the home and highlights that, although satisfied with the completed adaptation, families were dissatisfied with the process they had been through. Thus, despite the need for the meaning of home being central to the adaptation process, families felt excluded from the process as it progressed. This had a negative impact on the continuing use of the adaptation and affected the meaning of home for families with a disabled child.