A drug classification pipeline for Medicaid claims using RxNorm

Objective: Freely preprocess drug codes recorded in electronic health records and insurance claims to drug classes that may then be used in biomedical research. Materials and Methods: We developed a drug classification pipeline for linking National Drug Codes to the World Health Organization Anatomical Therapeutic Chemical classification. To implement our solution, we created an R package interface to the National Library of Medicine's RxNorm API. Results: Using the classification pipeline, 59.4% of all unique NDC were linked to an ATC, resulting in 95.5% of all claims being successfully linked to a drug classification. We identified 12,004 unique NDC codes that were classified as being an opioid or non-opioid prescription for treating pain. Discussion: Our proposed pipeline performed similarly well to other NDC classification routines using commercial databases. A check of a small, random sample of non-active NDC found the pipeline to be accurate for classifying these codes. Conclusion: The RxNorm NDC classification pipeline is a practical and reliable tool for categorizing drugs in large-scale administrative claims data

Using Sensitivity Analyses for Unobserved Confounding to Address Covariate Measurement Error in Propensity Score Methods

Propensity score methods are a popular tool to control for confounding in observational data, but their bias-reduction properties are threatened by covariate measurement error. There are few easy-to-implement methods to correct for such bias. We describe and demonstrate how existing sensitivity analyses for unobserved confounding---propensity score calibration, Vanderweele and Arah\u27s bias formulas, and Rosenbaum\u27s sensitivity analysis---can be adapted to address this problem. In a simulation study, we examined the extent to which these sensitivity analyses can correct for several measurement error structures: classical, systematic differential, and heteroscedastic covariate measurement error. We then apply these approaches to address covariate measurement error in estimating the association between depression and weight gain in a cohort of adults in Baltimore City. We recommend the use of Vanderweele and Arah\u27s bias formulas and propensity score calibration (assuming it is adapted appropriately for the measurement error structure), as both approaches perform well for a variety of propensity score estimators and measurement error structures

Robust and Flexible Estimation of Stochastic Mediation Effects: A Proposed Method and Example in a Randomized Trial Setting

Causal mediation analysis can improve understanding of the mechanisms underlying epidemiologic associations. However, the utility of natural direct and indirect effect estimation has been limited by the assumption of no confounder of the mediator-outcome relationship that is affected by prior exposure---an assumption frequently violated in practice. We build on recent work that identified alternative estimands that do not require this assumption and propose a flexible and double robust semiparametric targeted minimum loss-based estimator for data-dependent stochastic direct and indirect effects. The proposed method treats the intermediate confounder affected by prior exposure as a time-varying confounder and intervenes stochastically on the mediator using a distribution which conditions on baseline covariates and marginalizes over the intermediate confounder. In addition, we assume the stochastic intervention is given, conditional on observed data, which results in a simpler estimator and weaker identification assumptions. We demonstrate the estimator's finite sample and robustness properties in a simple simulation study. We apply the method to an example from the Moving to Opportunity experiment. In this application, randomization to receive a housing voucher is the treatment/instrument that influenced moving to a low-poverty neighborhood, which is the intermediate confounder. We estimate the data-dependent stochastic direct effect of randomization to the voucher group on adolescent marijuana use not mediated by change in school district and the stochastic indirect effect mediated by change in school district. We find no evidence of mediation. Our estimator is easy to implement in standard statistical software, and we provide annotated R code to further lower implementation barriers.Comment: 24 pages, 2 tables, 2 figure

Transporting treatment effects from difference-in-differences studies

Difference-in-differences (DID) is a popular approach to identify the causal effects of treatments and policies in the presence of unmeasured confounding. DID identifies the sample average treatment effect in the treated (SATT). However, a goal of such research is often to inform decision-making in target populations outside the treated sample. Transportability methods have been developed to extend inferences from study samples to external target populations; these methods have primarily been developed and applied in settings where identification is based on conditional independence between the treatment and potential outcomes, such as in a randomized trial. This paper develops identification and estimators for effects in a target population, based on DID conducted in a study sample that differs from the target population. We present a range of assumptions under which one may identify causal effects in the target population and employ causal diagrams to illustrate these assumptions. In most realistic settings, results depend critically on the assumption that any unmeasured confounders are not effect measure modifiers on the scale of the effect of interest. We develop several estimators of transported effects, including a doubly robust estimator based on the efficient influence function. Simulation results support theoretical properties of the proposed estimators. We discuss the potential application of our approach to a study of the effects of a US federal smoke-free housing policy, where the original study was conducted in New York City alone and the goal is extend inferences to other US cities

Estimating population treatment effects from a survey sub-sample

We consider the problem of estimating an average treatment effect for a target population from a survey sub-sample. Our motivating example is generalizing a treatment effect estimated in a sub-sample of the National Comorbidity Survey Replication Adolescent Supplement to the population of U.S. adolescents. To address this problem, we evaluate easy-to-implement methods that account for both non-random treatment assignment and a non-random two-stage selection mechanism. We compare the performance of a Horvitz-Thompson estimator using inverse probability weighting (IPW) and two double robust estimators in a variety of scenarios. We demonstrate that the two double robust estimators generally outperform IPW in terms of mean-squared error even under misspecification of one of the treatment, selection, or outcome models. Moreover, the double robust estimators are easy to implement, providing an attractive alternative to IPW for applied epidemiologic researchers. We demonstrate how to apply these estimators to our motivating example

Introducing longitudinal modified treatment policies: a unified framework for studying complex exposures

This tutorial discusses a recently developed methodology for causal inference based on longitudinal modified treatment policies (LMTPs). LMTPs generalize many commonly used parameters for causal inference including average treatment effects, and facilitate the mathematical formalization, identification, and estimation of many novel parameters. LMTPs apply to a wide variety of exposures, including binary, multivariate, and continuous, as well as interventions that result in violations of the positivity assumption. LMTPs can accommodate time-varying treatments and confounders, competing risks, loss-to-follow-up, as well as survival, binary, or continuous outcomes. This tutorial aims to illustrate several practical uses of the LMTP framework, including describing different estimation strategies and their corresponding advantages and disadvantages. We provide numerous examples of types of research questions which can be answered within the proposed framework. We go into more depth with one of these examples -- specifically, estimating the effect of delaying intubation on critically ill COVID-19 patients' mortality. We demonstrate the use of the open source R package lmtp to estimate the effects, and we provide code on https://github.com/kathoffman/lmtp-tutorial