John B. Carlin

Observational studies examining causal effects rely on unverifiable assumptions, the violation of which can induce multiple biases. Quantitative bias analysis (QBA) methods examine the sensitivity of findings to such violations, generally, by producing estimates under alternative assumptions, incorporating additional information. Although substantial guidance exists for implementing QBA, there is limited guidance on how to systematically determine the assumptions underlying a primary causal analysis and the potential violations that should guide bias analysis. Consequently, many assumptions remain implicit, leading to selective and therefore misleading QBA. To address this gap, we propose a roadmap for systematically identifying and analyzing multiple biases. Briefly, this consists of (1) articulating the assumptions underlying the primary analysis through specification of the “ideal trial” that defines the causal estimand and the assumptions required by its (possibly implicit) emulation, depicting these assumptions using a causal diagram; (2) extending the diagram to depict alternative assumptions, under which biases may arise; (3) obtaining a single estimate that simultaneously corrects for all potential biases. We illustrate the roadmap using an investigation of the effect of breastfeeding on the risk of childhood asthma and, through simulations, demonstrate the need for analyzing multiple biases jointly rather than one at a time.

Regression methods dominate the practice of biostatistical analysis, but biostatistical training emphasizes the details of regression models and methods ahead of the purposes for which such modeling might be useful. More broadly, statistics is widely understood to provide a body of techniques for “modeling data,” underpinned by what we describe as the “true model myth”: that the task of the statistician/data analyst is to build a model that closely approximates the true data generating process. By way of our own historical examples and a brief review of mainstream clinical research journals, we describe how this perspective has led to a range of problems in the application of regression methods, including misguided “adjustment” for covariates, misinterpretation of regression coefficients and the widespread fitting of regression models without a clear purpose. We then outline a new approach to the teaching and application of biostatistical methods, which situates them within a framework that first requires clear definition of the substantive research question at hand, within one of three categories: descriptive, predictive, or causal. Within this approach, the development and application of (multivariable) regression models, as well as other advanced biostatistical methods, should proceed differently according to the type of question. Regression methods will no doubt remain central to statistical practice as they provide a powerful tool for representing variation in a response or outcome variable as a function of “input” variables, but their conceptualization and usage should follow from the purpose at hand.

Longitudinal studies are frequently used in medical research and involve collecting repeated measures on individuals over time. Observations from the same individual are invariably correlated and thus an analytic approach that accounts for this clustering by individual is required. While almost all research suffers from missing data, this can be particularly problematic in longitudinal studies as participation often becomes harder to maintain over time. Multiple imputation (MI) is widely used to handle missing data in such studies. When using MI, it is important that the imputation model is compatible with the proposed analysis model. In a longitudinal analysis, this implies that the clustering considered in the analysis model should be reflected in the imputation process. Several MI approaches have been proposed to impute incomplete longitudinal data, such as treating repeated measurements of the same variable as distinct variables or using generalized linear mixed imputation models. However, the uptake of these methods has been limited, as they require additional data manipulation and use of advanced imputation procedures. In this tutorial, we review the available MI approaches that can be used for handling incomplete longitudinal data, including where individuals are clustered within higher‐level clusters. We illustrate implementation with replicable R and Stata code using a case study from the Childhood to Adolescence Transition Study.

In the context of missing data, the identifiability or “recoverability” of the average causal effect (ACE) depends not only on the usual causal assumptions but also on missingness assumptions that can be depicted by adding variable‐specific missingness indicators to causal diagrams, creating missingness directed acyclic graphs (m‐DAGs). Previous research described canonical m‐DAGs, representing typical multivariable missingness mechanisms in epidemiological studies, and examined mathematically the recoverability of the ACE in each case. However, this work assumed no effect modification and did not investigate methods for estimation across such scenarios. Here, we extend this research by determining the recoverability of the ACE in settings with effect modification and conducting a simulation study to evaluate the performance of widely used missing data methods when estimating the ACE using correctly specified g‐computation. Methods assessed were complete case analysis (CCA) and various implementations of multiple imputation (MI) with varying degrees of compatibility with the outcome model used in g‐computation. Simulations were based on an example from the Victorian Adolescent Health Cohort Study (VAHCS), where interest was in estimating the ACE of adolescent cannabis use on mental health in young adulthood. We found that the ACE is recoverable when no incomplete variable (exposure, outcome, or confounder) causes its own missingness, and nonrecoverable otherwise, in simplified versions of 10 canonical m‐DAGs that excluded unmeasured common causes of missingness indicators. Despite this nonrecoverability, simulations showed that MI approaches that are compatible with the outcome model in g‐computation may enable approximately unbiased estimation across all canonical m‐DAGs considered, except when the outcome causes its own missingness or causes the missingness of a variable that causes its own missingness. In the latter settings, researchers may need to consider sensitivity analysis methods incorporating external information (e.g., delta‐adjustment methods). The VAHCS case study illustrates the practical implications of these findings.

Targeted maximum likelihood estimation (TMLE) is increasingly used for doubly robust causal inference, but how missing data should be handled when using TMLE with data-adaptive approaches is unclear. Based on data (1992-1998) from the Victorian Adolescent Health Cohort Study, we conducted a simulation study to evaluate 8 missing-data methods in this context: complete-case analysis, extended TMLE incorporating an outcome-missingness model, the missing covariate missing indicator method, and 5 multiple imputation (MI) approaches using parametric or machine-learning models. We considered 6 scenarios that varied in terms of exposure/outcome generation models (presence of confounder-confounder interactions) and missingness mechanisms (whether outcome influenced missingness in other variables and presence of interaction/nonlinear terms in missingness models). Complete-case analysis and extended TMLE had small biases when outcome did not influence missingness in other variables. Parametric MI without interactions had large bias when exposure/outcome generation models included interactions. Parametric MI including interactions performed best in bias and variance reduction across all settings, except when missingness models included a nonlinear term. When choosing a method for handling missing data in the context of TMLE, researchers must consider the missingness mechanism and, for MI, compatibility with the analysis method. In many settings, a parametric MI approach that incorporates interactions and nonlinearities is expected to perform well.

Multiple imputation (MI) is a popular method for handling missing data. Auxiliary variables can be added to the imputation model(s) to improve MI estimates. However, the choice of which auxiliary variables to include is not always straightforward. Several data‐driven auxiliary variable selection strategies have been proposed, but there has been limited evaluation of their performance. Using a simulation study we evaluated the performance of eight auxiliary variable selection strategies: (1, 2) two versions of selection based on correlations in the observed data; (3) selection using hypothesis tests of the “missing completely at random” assumption; (4) replacing auxiliary variables with their principal components; (5, 6) forward and forward stepwise selection; (7) forward selection based on the estimated fraction of missing information; and (8) selection via the least absolute shrinkage and selection operator (LASSO). A complete case analysis and an MI analysis using all auxiliary variables (the “full model”) were included for comparison. We also applied all strategies to a motivating case study. The full model outperformed all auxiliary variable selection strategies in the simulation study, with the LASSO strategy the best performing auxiliary variable selection strategy overall. All MI analysis strategies that we were able to apply to the case study led to similar estimates, although computational time was substantially reduced when variable selection was employed. This study provides further support for adopting an inclusive auxiliary variable strategy where possible. Auxiliary variable selection using the LASSO may be a promising alternative when the full model fails or is too burdensome.

To 1) describe primary health care utilization and 2) estimate the effect of primary care early follow-up, continuity, regularity, frequency, and long consultations on asthma hospital readmission, ...

To (a) identify rates of hospital readmission and emergency department (ED) re-presentation for asthma within a 12-month period, (b) estimate the effects of modifiable hospital, general practitione...