Multivariate Joint Models for Multiple Longitudinal Outcomes and a Time-to-Event

A new, development version, of package JMbayes has been rolled-out on the dedicated GitHub repo. The major addition in this version is a set of new functions that can fit multivariate joint models for multiple longitudinal outcomes and a time-to-event. As with other GitHub packages, it can be easily installed using the install_github() function from package devtools. The new function that fits multivariate joint models is called mvJointModelBayes() and has a very similar syntax as the jointModelBayes() function described in a previous post. However, contrary to jointModelBayes() that is entirely written in R, the main bulk of computations of mvJointModelBayes() are based on C++ code building upon the excellent Rcpp and RcppArmadillo packages.

To make the connection between the two functions from a practical viewpoint more clear, let's fit first a univariate joint model using mvJointModelBayes(). As for jointModelBayes(), we first need to separately fit a mixed-effects model for the longitudinal outcome, and a Cox model for the survival outcome. However, contrary to jointModelBayes(), which required the mixed model to be fitted with function lme() from the nlme package, for mvJointModelBayes() the mixed model needs to be fitted with the new function mvlgmer(). This follows the syntax of lmer() from package lme4. For example, the code below fits a linear mixed model for the longitudinal biomarker serum bilirubin from the Mayo Clinic PBC data set:



The main arguments of this function are: formulas a list of lme4-like formulas (a formula per outcome), data a data.frame that contains all the variables specified in formulas (NAs allowed), and families a list of family objects specifying the type of each outcome (currently the gaussian, binomial and poisson families are allowed). Following, we fit a Cox model using function coxph() from the survival package; argument model of coxph() needs to be set to TRUE:


Then the univariate joint model is fitted by the following simple call to mvJointModelBayes():


To fit a multivariate joint model for multiple longitudinal outcomes, the only thing that needs to be adapted from the procedure described above, is the call to mvglmer(). For example, to fit a bivariate joint model for serum bilirubin and presence of spiders, we use the syntax:


In addition, similarly to jointModelBayes(), mvJointModelBayes() allows to specify different functional forms for the longitudinal outcomes that are included in the Cox model.  As an example, we extend model JMFit2 by including the value and slope term for bilirubin, and the area term for spiders (in the log-odds scale). To include these terms into the model we specify the Formulas argument. This is specified in a similar manner as the derivForms argument of jointModelBayes(). In particular, it should be a list of lists. Each component of the outer list should have as name the name of the corresponding outcome variable. Then in the inner list we need to specify four components, namely, the fixed & random R formulas specifying the fixed and random effects part of the term to be included, and indFixed & indRandom integer indices specifying which of the original fixed and random effects are involved in the calculation of the new term. In the inner list you can also optionally specify a name for the term you want to include. A couple of notes:

1. For terms not specified in the Formulas list, the default value functional form is used.
2. If for a particular outcome you want to include both the value functional form and an extra term, then you need to specify that in the Formulas using two entries. To include the value functional form you only need to set the corresponding to "value", and for the second term to specify the inner list. See example below on how to include the value and slope for serum bilirubin (for example, if the list below the entry "log(serBilir)" = "value" was not given, then only the slope term would have been included in the survival submodel).

We further extend the previous model by including the interactions terms between the terms specified in Formulas and the randomized treatment indicator drug. The names specified in the list that defined the interaction factors should match with the names of the output from JMFit3. Because of the many association parameters we have, we place a shrinkage prior on the association coefficients 'alpha'. In particular, if we have K association parameters, we assume that alpha_k ~ N(0, tau * phi_k), k = 1, ..., K. The precision parameters tau and phi_k are given Gamma priors. Parameter tau is global shrinkage parameter, and phi_k a specific shrinkage parameter per alpha coefficient:



Future updates of the package will include additional features, including among others

• a method for the generic functions survfitJM() and predict() to compute dynamic predictions for multivariate longitudinal data setting for both the longitudinal and survival outcomes.
• allow for competing risks.
• make the C++ code (even) faster.

An Integrated Shiny App for a Course on Repeated Measurements Analysis (completed)

Repeated Measurements Analysis

Repeated measurements analysis, and in particular longitudinal data analysis, is one of the two most frequently used types of analysis in my field (Biostatistics) - the other being survival analysis. Starting from this year I will be teaching in my university a new course on regression model for repeated measurements data that is primarily focused on applied statisticians, epidemiologists and clinicians. In general, this type of audience often finds this topic quite difficult, mainly due to the fact that one has to carefully consider the two levels of such data, namely, how to model longitudinal evolutions, and how to model correlations. On top of that, many of the researchers following this course have been primarily exposed to SPSS, making the transition to R that I will be using in the course somewhat more demanding.

Shiny app

Based on the considerations mentioned above, when I was developing the course I was thinking of ways to facilitate both the understanding of the key concepts of repeated measurements analysis, and how to effectively explain the use of R to analyze such data. The answer to both questions was to utilize the great capabilities of shiny. I have created an app the replays all analyses done in the course - a snapshot shown below.

The students can select a chapter and a section, see the code used in that section in the 'Code' tab, and examine the output in the 'Output' tab. The slides of the course are also integrated in the app, and can been seen in the 'Slides' tab. The 'Help' tab explains the basic usage of the main functions used in the selected chapter. To further enhance understanding of some key concepts, such as how random effects capture correlations and how longitudinal evolutions are affected by the levels of baseline covariates, the app allows to interactively change values for some parameters that control these features. The app also includes four practicals aimed at Chapter 2 that introduces marginal models for continuous data, Chapter 3 that explains linear mixed effects models, Chapter 4 the presents the framework of generalized estimating equations, and Chapter 5 the presents generalized linear mixed effects models, respectively. Chapter 6 focuses on explaining the issues with incomplete data in longitudinal studies. For each practical the students may reveal the answer to specific questions they have trouble solving, or download a whole R markdown report with a detailed explanation of the solutions.

The app is based on some popular packages for repeated measurements analysis (nlme, lme4, MCMCglmm, geepack), and some additional utilities packages (lattice, MASS, corrplot).

The app is available in my dedicated GitHub repository for this course, and can be invoked using the command (assuming that you have the aforementioned packages installed):

shiny::runGitHub("Repeated_Measurements", "drizopoulos")

Dynamic Predictions using Joint Models

What are Dynamic Predictions

In this post we will explain the concept of dynamic predictions and illustrate how these can be computed using the framework of joint models for longitudinal and survival data, and the R package JMbayes. The type of dynamic predictions we will discuss here are calculated in follow-up studies in which some sample units (e.g., patients) who are followed-up in time provide a set of longitudinal measurements. These longitudinal measurements are expected to be associated to events that the sample units may experience during follow-up (e.g., death, onset of disease, getting a child, dropout from the study, etc.). In this context, we would like to utilize the longitudinal information we have available up to  particular time point t to predict the risk of an event after t. For example, for a particular patient we would like to use his available blood values up to year 5 to predict the chance that he will develop a disease before year 7 (i.e., within two years from his last available measurement). The dynamic nature of these predictions stems from the fact that each time we obtain a new a longitudinal measurement we can update the prediction we have previously calculated.

Joint models for longitudinal and survival data have been shown to be a valuable tool for obtaining such predictions. They allow to investigate which features of the longitudinal profiles are most predictive, while appropriately accounting for the complex correlations in the longitudinal measurements.

Fit a Joint Model

For this illustration we will be using the Primary Biliary Cirrhosis (PBC) data set collected by the Mayo Clinic from 1974 to 1984. For our analysis we will consider 312 patients who have been randomized to D-penicillamine and placebo. During follow-up several biomarkers associated with PBC have been collected for these patients. Here we focus on serum bilirubin levels, which is considered one of the most important ones associated with disease progression. In package JMbayes the PBC data are available in the data frames pbc2 and pbc2.id containing the longitudinal and survival information, respectively (i.e., the former is in the long format while the latter contains a single row per patient).

We start by fitting a joint model to the PBC data set. For the log-transformed serum bilirubin we use a linear mixed effects models with natural cubic splines in the fixed and random effects for time, and also correct in the fixed part for age and sex. For the time-to-death we use a Cox model with baseline covariates age, sex and their interaction and the underlying level of serum bilirubin as estimated from the mixed model. This joint model is fitted using the following piece of code:

Calculate Dynamic Predictions

In package JMbayes these subject-specific predictions are calculated using function survfitJM(), respectively. As an illustration, we show how this function can be utilized to derive predictions for Patient 2 from the PBC data set using our fitted joint model jointFit. We first extract the data of this patient in a separate data frame and then we call survfitJM()

The last available measurement of this patient was in year 8.83, and survfitJM() will by default produce estimates of event-free probabilities starting from this last time point to the end of the follow-up. The calculation of these probabilities is based on a Monte Carlo procedure, and in the output we obtain as estimates the mean and median over the Monte Carlo samples along with the 95% pointwise credible intervals. Hence, the probability that this patient will survive up to year 11.2 is 60%. A plot of these probabilities can be obtained using the plot() method for objects returned by survfitJM()

Shiny app for Dynamic Predictions

To facilitate the use of dynamic predictions in practice, a web interface has been written using package shiny. This is available in the demo folder of the package and can be invoked with a call to the runDynPred() function. With this interface users may load an R workspace with the fitted joint model(s), load the data of the new subject, and subsequently obtain dynamic estimates of survival probabilities and future longitudinal measurements (i.e., an estimate after each longitudinal measurement). Several additional options are provided to calculate predictions based on different joint models (if the R workspace contains more than one model), to obtain estimates at specific horizon times, and to extract the data set with the estimated conditional survival probabilities. A detailed description of the options of this app is provided in the 'Help' tab within the app.