Reducing bias through directed acyclic graphs

Shrier, Ian; Platt, Robert W.

doi:10.1186/1471-2288-8-70

Cited by 1,158 publications

(898 citation statements)

References 28 publications

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“…Subsequently, CRP, TAS-20, and BDI-II scores were entered into the same model in succession. Variables to be entered as potential confounders into the final model were selected from those that exhibited a significant correlation with perceived pain and any of the TAS-20, BDI-II, or CRP scores (31).…”

Section: Significance and Innovationsmentioning

confidence: 99%

Alexithymia, Depression, Inflammation, and Pain in Patients With Rheumatoid Arthritis

Kojima

Suzuki

et al. 2014

Arthritis Care & Research

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Objective. We previously reported that depression and inflammation have independent effects on pain severity in patients with rheumatoid arthritis (RA). Alexithymia is a personality trait characterized by deficits in cognitive processing and regulation of emotions. A broad association between alexithymia and various health problems has been suggested, including depression, inflammation, and pain. The objective of this study was to examine the independent influence of alexithymia on pain perception and its relationship to depression and inflammation. Methods. We evaluated 213 RA outpatients who completed self-administered questionnaires, including the Beck Depression Inventory-II (BDI-II) to measure depression severity, the 20-item Toronto Alexithymia Scale (TAS-20) to measure degree of alexithymia, and a visual analog scale to quantify perceived pain. Serum C-reactive protein (CRP) levels were measured to quantify inflammation severity.Results. An initial significant positive association between the TAS-20 score and pain severity (P ‫؍‬ 0.01) lost significance after controlling for BDI-II score and CRP level using regression analysis. An interaction was observed among alexithymia, depression, and inflammation with regard to perceived pain. Among those without alexithymia, pain severity increased linearly with the CRP tertile levels regardless of the presence of depression (P < 0.001 for trend). No linear association between pain severity and CRP level was observed among those with alexithymia. Moreover, depressed patients with alexithymia (BDI-II score >14 and TAS-20 score >61) reported severe pain even at low CRP levels. Conclusion. Alexithymia might have a substantial role in pain perception as well as depression in patients with RA. A biopsychosocial approach is essential to achieve better pain control. INTRODUCTIONRheumatoid arthritis (RA) is a chronic disease in which an autoimmune disorder causes inflammation of the joints and surrounding tissues. Patients with RA experience persistent pain, arising from inflammation. This pain is also known to possess a strong emotional component and is affected by mood and psychosocial factors (1). We previously reported the independent influences of depression severity and inflammation on perceived pain in patients with RA (2). Both the depression score and the serum levels of C-reactive protein (CRP), a biomarker of inflammation, were significantly associated with pain, even after controlling for each other and for clinical covariates by regression analysis. Alexithymia is defined as a personality construct with difficulties in affective self-regulation (3). It has been proposed to be a cluster of cognitive and affective characteristics that are commonly observed among classic psychosomatic patients for whom therapy has been unsuccessful (4). Individuals with alexithymia tend to experience difficulties in identifying and describing their inner feelings and have a limited imaginary capacity and a preference for externally oriented thinking rather than introspection (3)....

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Section: Significance and Innovationsmentioning

confidence: 99%

Alexithymia, Depression, Inflammation, and Pain in Patients With Rheumatoid Arthritis

Kojima

Suzuki

et al. 2014

Arthritis Care & Research

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“…We identified potential confounders using a 166 directed acyclic graph (Shrier and Platt 2008): maternal age at delivery, pre-pregnancy body 167 weight, gestational weight gain, parity, socioeconomic status measured using the Hollingshead 168…”

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confidence: 99%

Prenatal and early-life polychlorinated biphenyl (PCB) levels and behavior in Inuit preschoolers

Verner

Plusquellec

Desjardins³

et al. 2015

Environment International

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Methods: Prenatal exposure to PCBs was informed by cord plasma PCB-153 levels. We used a 43 validated pharmacokinetic model to estimate monthly infants' levels across the first year of life. 44Child inattention and activity were assessed by coding of video recordings of children undergoing 45 fine motor testing. We used multivariable linear regression to evaluate the association between 46 prenatal and postnatal PCB-153 levels and inattention (n=97) and activity (n=98) at 5 years of 47 age. 48Results: Cord plasma PCB-153 was not associated with inattention and activity. Each 49 interquartile range (IQR) increase in estimated infant PCB-153 levels at 2 months was associated 50 with a 1.02% increase in the duration of inattention (95% CI: 0.04, 2.00). Statistical adjustment 51 for the duration of breastfeeding slightly increased regression coefficients for postnatal level 52 estimates, some of which became statistically significant for inattention (months: 2-4) and 53 activity (months: 2-5). 54Conclusions: Our study adds to the growing evidence of postnatal windows of development 55 during which children are more susceptible to neurotoxicants like PCBs. 56 57

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“…For comparisons with the literature, we nevertheless report the main findings in terms of prevalence rate ratios in Online Appendix C. All models were fitted in Stata 13 using the -gsem-suite of commands 54 as well as the user-written routine -gllamm-. 55,56 To guide model building and classification of covariates' likely role as confounders or mediators of neighborhood SES association with access to care, we constructed a simple directed acyclic graph (DAG) 57,58 of the potential causal structure underlying this association (Fig. 1).…”

Section: Discussionmentioning

confidence: 99%

Neighborhood Socioeconomic Status and Primary Health Care: Usual Points of Access and Temporal Trends in a Major US Urban Area

2016

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Neighborhood socioeconomic status (SES), an overall marker of neighborhood conditions, may determine residents' access to health care, independently of their own individual characteristics. It remains unclear, however, how the distinct settings where individuals seek care vary by neighborhood SES, particularly in US urban areas. With existing literature being relatively old, revealing how these associations might have changed in recent years is also timely in this US health care reform era. Using data on the Philadelphia region from 2002 to 2012, we performed multilevel analysis to examine the associations of neighborhood SES (measured as census tract median household income) with access to usual sources of primary care (physician offices, community health centers, and hospital outpatient clinics). We found no evidence that residence in a low-income (versus high-income) neighborhood was associated with poorer overall access. However, low-income neighborhood residence was associated with less reliance on physician offices [−4.40 percentage points; 95 % confidence intervals (CI) −5.80, −3.00] and greater reliance on the safety net provided by health centers [2.08; 95 % CI 1.42, 2.75] and outpatient clinics [1.61; 95 % CI 0.97, 2.26]. These patterns largely persisted over the 10 years investigated. These findings suggest that safety-net providers have continued to play an important role in ensuring access to primary care in urban, low-income communities, further underscoring the importance of supporting a strong safety net to ensure equitable access to care regardless of place of residence.

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Reducing bias through directed acyclic graphs

Cited by 1,158 publications

References 28 publications

Alexithymia, Depression, Inflammation, and Pain in Patients With Rheumatoid Arthritis

Alexithymia, Depression, Inflammation, and Pain in Patients With Rheumatoid Arthritis

Prenatal and early-life polychlorinated biphenyl (PCB) levels and behavior in Inuit preschoolers

Neighborhood Socioeconomic Status and Primary Health Care: Usual Points of Access and Temporal Trends in a Major US Urban Area

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