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Propensity Score
Propensity Score
Statistical techniques such as matching, stratification, and regression adjustment are commonly used to account for
differences in treatment groups but may be limited if using too few covariates in the adjustment process. The use of
propensity score techniques avoids this limitation because it can summarize more or all the covariate information into
a single score. So what is a propensity score? The propensity score is the conditional probability of being treated
based on individual covariates. Rosenbaum and Rubin demonstrated that propensity scores can account for
imbalances in treatment groups and reduce bias by resembling randomization of subjects into treatment groups.
By using propensity scores to balance groups, traditional adjustment methods can better estimate treatment effect on
outcomes while adjusting for covariates. One method professed by Ralph B. DAgostino, Jr. to adjust for the non
randomized treatment selection is to use a propensity score method in conjunction with traditional regression
techniques. This process is performed using two steps, the first of which calculates propensity scores as the
probability of patients being included in each treatment group based on pre-treatment observables. The aim of this
step is to create balance treatment groups and simulate random treatment allocation. The second step utilizes the
created propensity scores with ANCOVA to more accurately estimate outcomes and study the possible covariate
predictors.
P( X ) =
1
1 + e ( + iXi1)
Propensity scores are easily created using PROC LOGISTIC. In the cases described in this paper, the dependent
variable is treatment group (treatment for the patient) and the independent variables are patient and baseline
characteristics. In other cases the dependent variable may be any dichotomous outcome (treated or untreated,
disenrolled or not, visited specialist or not). The GENMOD procedure for generalized linear models may also create
propensity scores by using the OUTPUT statement and keyword PREDICTED.
Example of Creating Propensity Scores Using PROC LOGISTIC
The following example illustrates the use of PROC LOGISTIC to create propensity scores. A large pharmacy claims
database was used to identify 19,433 patients using oral antidiabetic therapy. Patients were categorized into two drug
treatment groups, A and B, with the main objective of comparing compliance and adherence rates. Compliance was
measured as the proportion of days a medication was supplied over a 180 day period. Adherent patients were
identified as those reaching a threshold of 80% compliance. Selection bias is believed to be a factor as the two drug
treatment groups differ in patient tolerance, adverse events, and side effects which possibly influence drug choice and
compliance to each drug. Other variables controlled for in the analyses include demographic variables (age, gender)
and previous medication use/patterns measured in a 6 month baseline period prior to treatment. Previous medication
use was recorded by the use of specific cardiovascular, asthma, and antidepressant medications and previous
medication pattern use was measured by refill patterns of maintenance type medications.
PROC LOGISTIC calculates propensity scores as the conditional probability of each patient receiving a particular
treatment based on pre-treatment variables and can output the propensity score to a data set. In this example,
propensity scores were calculated based on the covariates listed in Table 1 below. The objective was to balance the
treatment groups so to reduce bias of treatment selection and obtain better idea of treatment effect on the outcome of
compliance. The logit function is specified in the LINK option to fit the binary logit model and the RSQUARE option
assesses the amount of variation explained by the independent variables. The propensity score is output to data set
named psdataset. The predicted probabilities are output to a variable named ps.
proc logistic data = wuss;
class naive0;
model tx (event=Drug A) = age female b_hmo pre_drug_cnt_subset naive0
pre_refill_pct copay_idxdrug pre_sulf pre_htn pre_asthma pre_pain pre_lipo
pre_depress
/link=logit rsquare;
output out=psdataset pred=ps;
run;
Where,
tx = treatment selection indicator, age = age of patient at date of treatment initiation (index date),
female = indicator variable, b_hmo= HMO insurance, copay_idxdrug = patient co-payment for initial prescription
All variables with the prefix pre_ describe utilization in the baseline period.
pre_drug_cnt = number of medications (generic) utilized excluding medications for the categories below
pre_sulf = sulfonylurea use
pre_htn = hypertension use
pre_asthma = asthma use
pre_pain = pain medication use
pre_lipo = lipotropic use
pre_depress = antidepressant use
pre_refill_pct = refill percentage for maintenance medications
After creating the propensity scores, an evaluation of the distributions can check comparability of the treatment
groups. Sizeable overlaps among the groups illustrate satisfactory overlap in covariate distributions and indicate that
the groups are comparable.
14
12
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10
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14
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P
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0. 35
0. 37
0. 39
0. 41
0. 43
0. 45
0. 47
0. 49
0. 51
0. 53
0. 55
0. 57
0. 59
0. 61
0. 63
Est i m
at ed Pr obabi l i t y
Tables 1 and 2 demonstrate how propensity scoring can balance the groups. Table 1 contains the unadjusted values
(before propensity scores) for the two treatment groups. Descriptors include demographic variables (age, gender),
type of health plan insurance, and medication use in a 6 month period prior to treatment (baseline period). Age was
the age of the patient at date of treatment initiation (index date). Type of insurance was categorized by health
maintenance organization (HMO), Medicare, Medicaid, or self-insured. Prior medication use was measured for
sulfonylureas, antihypertensives, lipid lowering agents as well as asthma and antidepressant medications. Refill
patterns of medications for chronic diseases, or maintenance medications, were used to estimate patients behavior
to following prescribed dosing. The TABULATE procedure was used to create the table below and PROC TTEST
and PROC FREQ was used to test for differences between groups. Those observables that differed significantly in
the two groups of patients include type of insurance (proportion of patients enrolled in an HMO), oral antidiabetic,
sulfonylurea, and pain medication use.
Table 1. Unadjusted Demographic and Baseline Measures
UNADJUSTED VALUES
Drug A
Member Count
9,129
Age
Mean 57.7
SD
10.5
Female
%
43.1%
HMO *
%
73.3%
# of Drugs Utilized
Mean 4.9
Drug B
10,304
57.5
10.7
43.4%
75.3%
5.0
p-value
0.3786
0.7115
0.0018
0.0841
UNADJUSTED VALUES
Maintenance Medication Refill *
Prior Oral Antidiabetic Use *
Sulfonylurea *
Hypertension
Lipid Irregularity
Pain Management *
Antidepressant
Asthma
* p < .05
SD
%
%
%
%
%
%
%
%
Drug A
3.0
59.6%
77.5
55.3%
79.1%
68.3%
23.6%
19.5%
9.3%
Drug B
3.1
60.5%
80.4
51.3%
78.4%
68.5%
24.9%
18.4%
9.9%
p-value
0.0492
<.0001
<.0001
0.2381
0.7509
0.0357
0.0575
0.1967
Table 2 contains the adjusted values (after propensity scores) for the two treatment groups. PROC GLM was used to
compare groups while adjusting for the propensity score. Differences between groups were minimized when using
the propensity score method.
Table 2. Propensity Score Adjusted Demographic and Baseline Measures
WITH PROPENSTIY SCORING
Drug A
Drug B
Member Count
9,129
10,304
Age
Mean 57.4
57.4
SD
10.5
10.7
Female
%
42.9%
42.8%
HMO
%
75.2%
75.1%
# of Drugs Utilized
Mean 4.9
4.9
SD
3.0
3.0
Maintenance Medication Refill
%
60.3
60.3
Prior Oral Antidiabetic Use
%
80.2%
80.7%
Sulfonylurea
%
53.2%
53.6%
Hypertension
%
78.6%
78.7%
Lipid Irregularity
%
68.7%
68.8%
Pain Management
%
24.0%
23.9%
Antidepressant
%
18.8%
18.8%
Asthma
%
9.5%
9.5%
p-value
0.9329
0.9062
0.8922
0.9390
0.0687
0.3088
0.5204
0.8674
0.9303
0.8380
0.9112
0.9407
Stratification
Stratification, subclassification or binning using propensity scores involves grouping subjects into classes or strata
based on the subjects observed characteristics. Once the propensity scores are calculated, subjects are placed into
strata (Cochran states that 5 strata can remove 90% of the bias) with the idea that subjects in the same stratum are
similar in the characteristics used in the propensity score development process. The tutorial by DAgostino details how
to perform this technique. Briefly, quintiles are used to group subjects into five strata after making sure that there is
adequate propensity score overlap between treatment groups. To prove that the propensity scores removed any bias
due to differences in covariates between treatment groups, t-tests or chi-square tests are conducted before and after
propensity score creation. Finally, outcomes and treatment effects can be assessed using models while adjusting for
the propensity scores. Continuing with the example and code above, subjects are divided into 5 classes based on the
common propensity score overlap using the RANK procedure. Checking for difference between treatment group
before and after stratifying subjects by propensity scores can be done using PROC FREQ, PROC TTEST and PROC
GLM.
proc rank data= psdataset groups=5 out = r;
ranks rnks + 1;
var ps;
run;
data quintile;
set r;
quintile = rnks + 1;
run;
/*check for differences in groups before propensity score*/
proc freq data=quintile;
tables tx*(female b_hmo naive0 pre_sulf pre_htn pre_asthma pre_pain pre_lipo
pre_depress)/chisq;run;
Conservative N (%)
17,735
68.213.0
10,914 (61.5)
15,002 (88.4)
4,441 (25.0)
5,382 (30.3)
p-value
Conservative N (%)
2,036
61.713.3
1,445 (71.0)
1,858 (91.3)
381 (18.7)
491 (24.1)
p-value
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
0.5405
0.8087
0.6952
0.7189
0.9124
socioeconomic status, and education level. This limitation is modified if unobserved covariates are correlated to
observed factors. Analyses also need large samples sizes in order to establish adequate variance in covariate
distributions.
CONCLUSION
This tutorial introduces potential selection bias in observational studies and describes how propensity score
methodology can control for overt bias when estimating treatment effectiveness. Propensity scoring methodology
attempts to balance groups before comparing outcomes between treatment groups. Commonly used techniques via
propensity scores include matching, stratification, and regression adjustment using the inverse of the propensity
score. Each method can be used in conjunction with traditional risk adjustment techniques to reduce bias and better
describe the effect of treatment on outcomes.
REFERENCES
DAgostino R.B. Sr, Kwan H. 1995. Measuring Effectiveness: What to Expect Without a Randomized Control Group.
Medical Care. 195:33 (4 suppl): AS95-AS105.
DAgostino R.B., Jr, DAgostino R.B., Sr. 2007. Estimating Treatment Effects Using Observational Data. JAMA. 297
(3). 314-316
Rosenbaum P.R. and Rubin D.B. 1983. The Central Role of the Propensity Score in Observational Studies for
Causal Effects, Biometrika, 70, 41-55.
DAgostino, R.B. 1998. Tutorial on Biostatistics: Propensity Score Methods for Bias Reduction in the comparison of a
treatment to a non-randomized control group. Statistics in Medicine 17, 2265-2281.
Hogan, J.W., Lancaster, T. 2004. Instrumental variable and propensity weighting for causal inference from
longitudinal observational studies. Statistical Methods in Medical Research 13: 17-48.
Obenchain, R.L., Melfi, C.A., Propensity Score and Heckman Adjustments for Treatment Selection Bias in Database
Studies.
Pasta, David J. 2000. Using Propensity Scores to Adjust for Group Differences: Examples Comparing Alternative
Surgical Methods. Proceedings of the Twenty-Fifth Annual SAS Users Group International Conference, Indianapolis,
IN, 261-25.
Parsons, Lori. 2000. Using SAS Software to Perform a Case Control Match on Propensity Score in an
Observational Study. Proceedings of the Twenty-Fifth Annual SAS Users Group International Conference,
Indianapolis, IN, 214-26.
SAS Institute Inc. 2004. SAS Procedures: The LOGISTIC Procedure. SAS OnlineDoc 9.1.3. Cary, NC: SAS
Institute Inc.
http://support.sas.com/documentation/onlinedoc/91pdf/sasdoc_91/stat_ug_7313.pdf
CONTACT INFORMATION
Your comments and questions are valued and encouraged. Contact the author at:
R. Scott Leslie
MedImpact Healthcare Systems, Inc.
10680 Treena Street
San Diego, CA 92131
Work Phone: 858-790-6685
Fax: 858-689-1799
Email: scott.leslie@medimpact.com
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