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  • Developing Methods to Assess Health Outcomes in the Presence of Competing Risks for Effectiveness Research

Research Report - Final – Feb. 11, 2010

Developing Methods to Assess Health Outcomes in the Presence of Competing Risks for Effectiveness Research

Findings from this study were published in the following journal articles.

1. Weiss CO, Segal JB, Varadhan R. Assessing the applicability of trial evidence to a target sample in the presence of heterogeneity of treatment effect. Pharmacoepidemiol Drug Saf 2012 May;21(Suppl 2):121-9. PMID: 22552987. Exit Disclaimer



To propose methods for the quantitative assessment of the applicability of evidence from a trial to a target sample using individual data. Methods Demonstration was with a trial of drug therapy to prevent mortality and an accompanying registry of people with heart failure. Principal components analysis with biplots did not identify measurement discrepancies. Multiple imputation with chained equations addressed missing predictor values. A proportional hazards model with interaction term, including graphical interpretation and a multivariate interaction test, identified heterogeneity of treatment effect. An interval of homogeneity of treatment effect was the interval of the baseline risk of outcome in which no two treatment effects were statistically significantly different. Absolute risk reduction for individuals was estimated for both benefit and harm outcomes and presented in a bivariate treatment effects scatterplot.


Overall, the trial evidence applied to most of the registry according to overlapping distributions of estimated benefit and harm. However, 52% of trial and 33% of registry participants were estimated to have net benefit, and 14% of trial and 36% of registry participants were estimated to have strong net harmful treatment effect, that is, the individual estimate of harm was more than twice the estimate of benefit. Conclusions The proposed methods provide quantitative assessment of the applicability of trial evidence to a target sample. They combine the strengths of different study designs, namely, unbiased effects estimation from trials and representation in observational studies, while addressing the practical challenges of combining information, namely, measurement discrepancies and missing data. Copyright © 2012 John Wiley & Sons, Ltd.

2. Varadhan R, Weiss CO, Segal JB, et al. Evaluating health outcomes in the presence of competing risks: a review of statistical methods and clinical applications. Med Care 2010 Jun;48(6 Suppl):S96-105. PMID: 20473207. Exit Disclaimer



An evaluation of the effect of a healthcare intervention (or an exposure) must consider multiple possible outcomes, including the primary outcome of interest and other outcomes such as adverse events or mortality. The determination of the likelihood of benefit from an intervention, in the presence of other competing outcomes, is a competing risks problem. Although statistical methods exist for quantifying the probability of benefit from an intervention while accounting for competing events, these methods have not been widely adopted by clinical researchers.


  1. To demonstrate the importance of considering competing risks in the evaluation of treatment effectiveness, and
  2. to review appropriate statistical methods, and recommend how they might be applied.

Research Design and Methods

We reviewed 3 statistical approaches for analyzing the competing risks problem: (a) cause-specific hazard (CSH), (b) cumulative incidence function (CIF), and (c) event-free survival (EFS). We compare these methods using a simulation study and a reanalysis of a randomized clinical trial.


Simulation studies evaluating the statistical power to detect the effect of intervention under different scenarios showed that: (1) CSH approach is best for detecting the effect of an intervention if the intervention only affects either the primary outcome or the competing event; (2) EFS approach is best only when the intervention affects bot