Ignoring competing events in the analysis of survival data may lead to biased results: a nonmathematical illustration of competing risk analysis

Schuster, Noah A.; Hoogendijk, Emiel O.; Kok, A.; Twisk, Jos W. R.; Heymans, Martijn W.

doi:10.1016/j.jclinepi.2020.03.004

Cited by 109 publications

(106 citation statements)

References 30 publications

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“…We considered statistically significant difference if p value is equal or less than 0.050. Then, assuming that death has to be considered an event that precludes the occurrence of our event of interest, that is diagnosis of dementia, we performed competing risk models, with death as a competitive event [ 17 – 19 ]. Considering the prediction nature of our main research aim, we fitted univariable Fine and Gray’s semiparametric proportional sub-distribution hazards models to obtain sub-hazard ratios (SHRs), with 95% CI, representing the effect of each risk factor on the cumulative incidence function (CIF) of dementia and death in a competing risk situation [ 20 – 22 ].…”

Section: Methodsmentioning

confidence: 99%

Estimating the potential for dementia prevention through modifiable risk factors elimination in the real-world setting: a population-based study

et al. 2020

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Background: Preventing dementia onset is one of the global public health priorities: around 35% of dementia cases could be attributable to modifiable risk factors. These estimates relied on secondary data and did not consider the concurrent effect of non-modifiable factors and death. Here, we aimed to estimate the potential reduction of dementia incidence due to modifiable risk factors elimination, controlling for non-modifiable risk factors and for the competing risk of death. Methods: Participants from the InveCe.Ab population-based prospective cohort (Abbiategrasso, Italy) without a baseline dementia diagnosis and attending at least one follow-up visit were included (N = 1100). Participants underwent multidimensional assessment at baseline and after 2, 4, and 8 years, from November 2009 to January 2019. Modifiable risk factors were low education, obesity, hypertension, diabetes, depression, smoking, physical inactivity, hearing loss, loneliness, heart disease, stroke, head injury, and delirium. Non-modifiable risk factors were age, sex, and APOE ε4 genotype. The primary endpoint was dementia diagnosis within the follow-up period (DSM-IV criteria). We performed competing risk regression models to obtain sub-hazard ratio (SHR) for each exposure, with death as competing risk. The exposures associated with dementia were included in a multivariable model to estimate their independent influence on dementia and the corresponding population attributable fraction (PAF). Results: Within the study period (mean follow-up, 82.3 months), 111 participants developed dementia (10.1%). In the multivariable model, APOE ε4 (SHR = 1.89, 95% CI 1.22-2.92, p = 0.005), diabetes (SHR = 1.56, 95% CI 1.00-2.39, p = 0.043), heart disease (SHR = 1.56, 95% CI 1.03-2.36, p = 0.037), stroke (SHR = 2.31, 95% CI 1.35-3.95, p = 0.002), and delirium (SHR = 8.70, 95% CI 3.26-23.24, p < 0.001) were independently associated with increased dementia risk. In the present cohort, around 40% of dementia cases could be attributable to preventable comorbid diseases.

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Section: Methodsmentioning

confidence: 99%

Estimating the potential for dementia prevention through modifiable risk factors elimination in the real-world setting: a population-based study

et al. 2020

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“…At the end of followup, 13 patients (19.4%) were alive and disease-free, 20 patients (29.9%) were alive with a new RCC recurrence, 23 patients (34.3%) died of disease, and 11 patients (16.4%) died of other causes. Because the absolute percentage of deaths from other causes was in excess of 10%, the adoption of a competing risk model was justified (20).…”

Section: Recurrence and Survival Analysismentioning

confidence: 99%

Long-term Outcomes After Surgical Resection of Pancreatic Metastases from Renal Clear-Cell Carcinoma

et al. 2021

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Background Pancreatic metastases (PM) from renal cell carcinoma (RCC) are uncommon. We herein describe the long-term outcomes associated with pancreatectomy at two academic institutions, with a specific focus on 10-year survival. Methods This investigation was limited to patients undergoing pancreatectomy for PM between 2000 and 2008 at the University of Verona and Memorial Sloan Kettering Cancer Center, allowing a potential for 10 years of surveillance. The probabilities of further RCC recurrence and RCC-related death were estimated using a competing risk analysis (method of Fine and Gray) to account for patients who died of other causes during follow-up. Results The study population consisted of 69 patients, mostly with isolated metachronous PM (77%). The median interval from nephrectomy to pancreatic metastasectomy was 109 months, whereas the median post-pancreatectomy follow-up was 141 months. The 10-year cumulative incidence of new RCC recurrence was 62.7%. In the adjusted analysis, the relative risk of repeated recurrence was significantly higher in PM synchronous to the primary RCC (sHR = 1.27) and in patients receiving extended pancreatectomy (sHR = 3.05). The 10-year cumulative incidence of disease-specific death was 25.5%. The only variable with an influence on disease-specific death was the recurrence-free interval following metastasectomy (sHR = 0.98). In patients with repeated recurrence, the 10-year cumulative incidence of RCC-related death was 35.4%. Conclusion In a selected group of patients followed for a median of 141 months and mostly with isolated metachronous PM, resection was associated with a high possibility of long-term disease control in surgically fit patients with metastases confined to the pancreas.

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“…The subdistribution hazard ratio (SHR) for assessing the risk of developing dementia for an individual factor was calculated using the cmprsk library in the R package, which allows adjustment for socio-demographic and clinical variables. The SHR is a way of expressing the instantaneous risk of developing a given event in an individual who has not yet experienced such an event (at risk), when taking into account a competing risk, such as death [40]. A higher SHR would mean a higher risk of developing AD for this factor, taking into account death as a competing risk.…”

Section: Discussionmentioning

confidence: 99%

A Novel Score for Predicting Alzheimer’s Disease Risk from Late Life Psychopathological and Health Risk Factors

Santabárbara

Lipnicki

Cámara

et al. 2021

IJERPH

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With the increasing size of the aging population, dementia risk reduction has become a main public health concern. Dementia risk models or indices may help to identify individuals in the community at high risk to develop dementia. We have aimed to develop a novel dementia risk index focused on the late-life (65 years or more) population, that addresses risk factors for Alzheimer’s disease (AD) easily identifiable at primary care settings. These risk factors include some shown to be associated with the risk of AD but not featured in existing indices, such as hearing loss and anxiety. Our index is also the first to account for the competing risk of death. The Zaragoza Dementia and Depression Project (ZARADEMP) Alzheimer Dementia Risk Score predicts an individual´s risk of developing AD within 5 years. The probability of late onset AD significantly increases in those with risk scores between 21 and 28 and, furthermore, is almost 4-fold higher for those with risk scores of 29 or higher. Our index may provide a practical instrument to identify subjects at high risk of AD and to design preventive strategies targeting the contributing risk factors.

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Ignoring competing events in the analysis of survival data may lead to biased results: a nonmathematical illustration of competing risk analysis

Cited by 109 publications

References 30 publications

Estimating the potential for dementia prevention through modifiable risk factors elimination in the real-world setting: a population-based study

Estimating the potential for dementia prevention through modifiable risk factors elimination in the real-world setting: a population-based study

Long-term Outcomes After Surgical Resection of Pancreatic Metastases from Renal Clear-Cell Carcinoma

A Novel Score for Predicting Alzheimer’s Disease Risk from Late Life Psychopathological and Health Risk Factors

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