title: [Time-dependent confounding in the estimation of treatment effects in randomised trials with multimodal therapies--an illustration of the problem of time-dependent confounding by causal graphs].
abstract: Biased effect estimates induced by unconsidered confounding variables are a known problem in observational studies. Selection bias, resulting from non-random sampling of study participants, is widely recognised as a problem in case-control and cross-sectional studies. In contrast, possible bias in randomised controlled trials (RCTs) is mostly ignored. This paper illustrates, by applying directed acyclic graphs (DAGs), possible bias in the effect estimates of first-line therapy, caused by subsequent changes in therapy (time-dependent confounding). Possible selection bias, induced by not only random loss to follow-up, will be explained as well using DAGs. Underlying assumptions of standard methods usually used to analyse RCTs (like intention-to-treat, per-protocol) are shown and it is explained why effect estimates may be biased in RCTs, if only these conventional methods are used. Adequate statistical methods (causal inference models as marginal structural models and structural nested models) exist. Higher documentary efforts, however, are necessary, because any changes in medication, loss to follow-up as well as reasons for such changes need to be documented in detail as required by these advanced statistical methods. Nevertheless, causal inference models should become standard along side the currently applied standard methods, especially in studies with high non-compliance due to changes in therapy and substantial loss to follow-up. Possible bias cannot be excluded if similar results are obtained from both methods. However, study results should be interpreted with caution if they differ between both approaches.
authors.affiliation: Institut für Schlaganfallforschung und Demenzforschung, Ludwig-Maximilians-Universität München.
authors.forename: V D
authors.initials: VD
authors.lastname: Zietemann
authors.affiliation: Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada.
authors.forename: T
authors.initials: T
authors.lastname: Schuster
authors.affiliation: Pneumologische Onkologie, Asklepios Lungenfachkliniken München-Gauting, Gauting.
authors.forename: T H G
authors.initials: TH
authors.lastname: Duell
mesh_terms: D003131:Combined Modality Therapy / Q000706:statistics & numerical data*; D003198:Computer Simulation; D015986:Confounding Factors, Epidemiologic; D003627:Data Interpretation, Statistical; D006801:Humans; D015233:Models, Statistical; D017063:Outcome Assessment, Health Care / Q000379:methods* / Q000706:statistics & numerical data; D016032:Randomized Controlled Trials as Topic / Q000706:statistics & numerical data*; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D013997:Time Factors