Development and validation of an index score to adjust for healthy user bias in observational studies

Eurich, Dean T.; Achtymichuk, Karly A; Johnson, Jeffrey; Minhas-Sandhu, Jashu K; Lin, Min

doi:10.22374/1710-6222.24.3.6

Cited by 5 publications

(4 citation statements)

References 40 publications

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“…First, although we adjusted for participant sociodemographic and clinical characteristics as covariates, there may be unmeasured confounders. In particular, healthy adherer bias is a typical concern in the adherence literature [60-63]; participants adherent to PAP therapy may also be more likely to adhere to other medical care (e.g., medication use or receiving preventative therapy) or healthy lifestyle behaviors (e.g., diet and exercise). However, our assessment of medication adherence at baseline as well as six-month healthcare costs prior to randomization were similar across PAP adherence groups.…”

Section: Discussionmentioning

confidence: 99%

Association between Positive Airway Pressure Adherence and Healthcare Costs

Glick

Sawyer

et al. 2021

Preprint

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Background: The impact of positive airway pressure (PAP) therapy for obstructive sleep apnea (OSA) on healthcare costs is uncertain. Research Question: Are three-year healthcare costs associated with PAP adherence in participants from the Tele-OSA clinical trial? Study Design and Methods: Participants with OSA and prescribed PAP in the Tele-OSA study were stratified into three PAP adherence groups based on usage patterns over three years: (a) high (consistently ≥4 hours/night); (b) moderate (2-3.9 hours/night or inconsistently ≥4 hours/night); (c) low (<2 hours/night). Using data from three months of the Tele-OSA trial and 33 months of post-trial follow-up, average healthcare costs (2020 US dollars) in six-month intervals were derived from electronic health records and analyzed using multivariable generalized linear models. Results: Of 543 participants, 25% were categorized as having high adherence, 22% moderate adherence, and 52% low adherence to PAP therapy. Average (standard deviation) PAP use was 6.5 (1.0) hours, 3.7 (1.2) hours, and 0.5 (0.5) hours for the high, moderate, and low adherence groups, respectively. The high adherence group had the lowest average [standard error] covariate-adjusted six-month healthcare costs ($3,162 [$240]) compared with the moderate ($3,658 [$369]) and low ($4,016 [$315]) adherence groups. Significant cost savings were observed between the high and low adherence groups ($854 [95% CI $158, $1,551]); savings between moderate and low adherence were non-significant ($359 [95% CI -$459, $1,176]). Interpretation: In participants with OSA, better PAP adherence was associated with significantly lower healthcare costs over three years. Findings support the importance of strategies to enhance long-term PAP adherence.

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Section: Discussionmentioning

confidence: 99%

Association between Positive Airway Pressure Adherence and Healthcare Costs

Glick

Sawyer

et al. 2021

Preprint

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“…Preventive health care, especially well visits and cancer screenings (e.g. colonoscopy), are common indicators that we used to measure and control for healthy patient bias ( Wiemken et al, 2021 , Eurich et al, 2017 ). As shown in Table 1 , Elixhauser comorbidities include 26 physical conditions and 4 psychiatric disorders, and these were measured in the 2-years prior to index.…”

Section: Methodsmentioning

confidence: 99%

Lower risk for COVID-19 hospitalization among patients in the United States with past vaccinations for herpes zoster and tetanus, diphtheria and pertussis

Salas

Morley

Hoft

et al. 2023

Preventive Medicine Reports

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“…In older populations, they are a marker of frailty and were selected as an NCO in the two aforementioned studies 20,21 to detect uncontrolled confounding by this mechanism. Receipt of influenza vaccination can be considered a proxy for higher healthcare engagement and use of preventive services; it was chosen as an NCO by both studies to capture the potential for confounding by health‐seeking behaviors 27 . Figure 2 illustrates the potential for bias due to an unmeasured confounder (functional impairment), even after controlling for a measured confounder (age).…”

Section: Practical Considerations For Nco Studiesmentioning

confidence: 99%

“…Receipt of influenza vaccination can be considered a proxy for higher healthcare engagement and use of preventive services; it was chosen as an NCO by both studies to capture the potential for confounding by health-seeking behaviors. 27…”

Section: Outcomes Of Interestmentioning

confidence: 99%

Pragmatic considerations for negative control outcome studies to guide non‐randomized comparative analyses: A narrative review

Levintow

Nielson

Hernandez

et al. 2023

Pharmacoepidemiology and Drug

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Purpose: This narrative review describes the application of negative control outcome (NCO) methods to assess potential bias due to unmeasured or mismeasured confounders in non-randomized comparisons of drug effectiveness and safety. An NCO is assumed to have no causal relationship with a treatment under study while subject to the same confounding structure as the treatment and outcome of interest; an association between treatment and NCO then reflects the potential for uncontrolled confounding between treatment and outcome. Methods:We focus on two recently completed NCO studies that assessed the comparability of outcome risk for patients initiating different osteoporosis medications and lipid-lowering therapies, illustrating several ways in which confounding may result. In these studies, NCO methods were implemented in claims-based data sources, with the results used to guide the decision to proceed with comparative effectiveness or safety analyses.Results: Based on this research, we provide recommendations for future NCO studies, including considerations for the identification of confounding mechanisms in the target patient population, the selection of NCOs expected to satisfy required assumptions, the interpretation of NCO effect estimates, and the mitigation of uncontrolled confounding detected in NCO analyses. We propose the use of NCO studies prior to initiating comparative effectiveness or safety research, providing information on the potential presence of uncontrolled confounding in those comparative analyses.Conclusions: Given the increasing use of non-randomized designs for regulatory decision-making, the application of NCO methods will strengthen study design, analysis, and interpretation of real-world data and the credibility of the resulting realworld evidence.

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Development and validation of an index score to adjust for healthy user bias in observational studies

Cited by 5 publications

References 40 publications

Association between Positive Airway Pressure Adherence and Healthcare Costs

Association between Positive Airway Pressure Adherence and Healthcare Costs

Lower risk for COVID-19 hospitalization among patients in the United States with past vaccinations for herpes zoster and tetanus, diphtheria and pertussis

Pragmatic considerations for negative control outcome studies to guide non‐randomized comparative analyses: A narrative review

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