title: Competing events influence estimated survival probability: when is Kaplan-Meier analysis appropriate?
abstract: The Kaplan-Meier estimator is the current method for estimating the probability of an event to occur with time in orthopaedics. However, the Kaplan-Meier estimator was designed to estimate the probability of an event that eventually will occur for all patients, ie, death, and this does not hold for other outcomes. For example, not all patients will experience hip arthroplasty loosening because some may die first, and some may have their implant removed to treat infection or recurrent hip dislocation. Such events that preclude the observation of the event of interest are called competing events. We suggest the Kaplan-Meier estimator is inappropriate in the presence of competing events and show that it overestimates the probability of the event of interest to occur with time. The cumulative incidence estimator is an alternative approach to Kaplan-Meier in situations where competing risks are likely. Three common situations include revision for implant loosening in the long-term followup of arthroplasties or implant failure in the context of limb-salvage surgery or femoral neck fracture.
authors.affiliation: Département de Biostatistique et Informatique Médicale, Unité INSERM 717, Hôpital Saint Louis, Paris, France. djmbiau@yahoo.fr
authors.forename: David Jean
authors.initials: DJ
authors.lastname: Biau
authors.forename: Aurélien
authors.initials: A
authors.lastname: Latouche
authors.forename: Raphaël
authors.initials: R
authors.lastname: Porcher
mesh_terms: D019643:Arthroplasty, Replacement / Q000401:mortality; D001847:Bone Diseases / Q000401:mortality*; D015897:Comorbidity; D003627:Data Interpretation, Statistical; D005264:Femoral Fractures / Q000401:mortality / Q000601:surgery; D005272:Femur Neck / Q000293:injuries; D005500:Follow-Up Studies; D006801:Humans; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage / Q000401:mortality; D011183:Postoperative Complications / Q000401:mortality*; D011336:Probability; D011475:Prosthesis Failure; D012086:Reoperation / Q000401:mortality; D012306:Risk; D013514:Surgical Procedures, Operative / Q000401:mortality*; D015996:Survival Rate