title: Instrumental variable meta-analysis of individual patient data: application to adjust for treatment non-compliance.
abstract: BACKGROUND
  Intention-to-treat (ITT) is the standard data analysis method which includes all patients regardless of receiving treatment. Although the aim of ITT analysis is to prevent bias due to prognostic dissimilarity, it is also a counter-intuitive type of analysis as it counts patients who did not receive treatment, and may lead to "bias toward the null." As treated (AT) method analyzes patients according to the treatment actually received rather than intended, but is affected by the selection bias. Both ITT and AT analyses can produce biased estimates of treatment effect, so instrumental variable (IV) analysis has been proposed as a technique to control for bias when using AT data. Our objective is to correct for bias in non-experimental data from previously published individual patient data meta-analysis by applying IV methods
  
  
  METHODS
  Center prescribing preference was used as an IV to assess the effects of methotrexate (MTX) in preventing debilitating complications of chronic graft-versus-host-disease (cGVHD) in patients who received peripheral blood stem cell (PBSCT) or bone marrow transplant (BMT) in nine randomized controlled trials (1107 patients). IV methods are applied using 2-stage logistic, 2-stage probit and generalized method of moments models.
  
  
  RESULTS
  ITT analysis showed a statistically significant detrimental effect with the use of day 11 MTX, resulting in cGVHD odds ratio (OR) of 1.34 (95% CI 1.02-1.76). AT results showed no difference in the odds of cGVHD with the use of MTX [OR 1.31 (95%CI 0.99-1.73)]. IV analysis further corrected the results toward no difference in the odds of cGVHD between PBSCT vs. BMT, allowing for a possibility of beneficial effects of MTX in preventing cGVHD in PBSCT recipients (OR 1.14; 95%CI 0.83-1.56).
  
  
  CONCLUSIONS
  All instrumental variable models produce similar results. IV estimates correct for bias and do not exclude the possibility that MTX may be beneficial, contradicting the ITT analysis.
authors.affiliation: Center for Evidence Based Medicine and Health Outcomes Research, University of South Florida, Tampa, FL, USA. bmiladin@health.usf.edu
authors.forename: Branko
authors.initials: B
authors.lastname: Miladinovic
authors.forename: Ambuj
authors.initials: A
authors.lastname: Kumar
authors.forename: Iztok
authors.initials: I
authors.lastname: Hozo
authors.forename: Benjamin
authors.initials: B
authors.lastname: Djulbegovic
mesh_terms: D015982:Bias; D016026:Bone Marrow Transplantation / Q000706:statistics & numerical data; D003627:Data Interpretation, Statistical; D006086:Graft vs Host Disease / Q000517:prevention & control*; D006801:Humans; D057194:Intention to Treat Analysis; D008727:Methotrexate / Q000627:therapeutic use*; D010349:Patient Compliance; D012107:Research Design; D015983:Selection Bias; D033581:Stem Cell Transplantation / Q000706:statistics & numerical data; D016896:Treatment Outcome
chemical_list: D008727:Methotrexate