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Challenges in risk estimation using routinely collected clinical data: The example of estimating cervical cancer risks from electronic health-records. Prev Med 2018 Jun;111:429-435 PMID: 29222045 PMCID: PMC5930038

Pubmed ID



Electronic health-records (EHR) are increasingly used by epidemiologists studying disease following surveillance testing to provide evidence for screening intervals and referral guidelines. Although cost-effective, undiagnosed prevalent disease and interval censoring (in which asymptomatic disease is only observed at the time of testing) raise substantial analytic issues when estimating risk that cannot be addressed using Kaplan-Meier methods. Based on our experience analysing EHR from cervical cancer screening, we previously proposed the logistic-Weibull model to address these issues. Here we demonstrate how the choice of statistical method can impact risk estimates. We use observed data on 41,067 women in the cervical cancer screening program at Kaiser Permanente Northern California, 2003-2013, as well as simulations to evaluate the ability of different methods (Kaplan-Meier, Turnbull, Weibull and logistic-Weibull) to accurately estimate risk within a screening program. Cumulative risk estimates from the statistical methods varied considerably, with the largest differences occurring for prevalent disease risk when baseline disease ascertainment was random but incomplete. Kaplan-Meier underestimated risk at earlier times and overestimated risk at later times in the presence of interval censoring or undiagnosed prevalent disease. Turnbull performed well, though was inefficient and not smooth. The logistic-Weibull model performed well, except when event times didn't follow a Weibull distribution. We have demonstrated that methods for right-censored data, such as Kaplan-Meier, result in biased estimates of disease risks when applied to interval-censored data, such as screening programs using EHR data. The logistic-Weibull model is attractive, but the model fit must be checked against Turnbull non-parametric risk estimates.

Author List

Landy R, Cheung LC, Schiffman M, Gage JC, Hyun N, Wentzensen N, Kinney WK, Castle PE, Fetterman B, Poitras NE, Lorey T, Sasieni PD, Katki HA


Noorie Hyun PhD Assistant Professor in the Institute for Health and Equity department at Medical College of Wisconsin

jenkins-FCD Prod-300 626508253d14e4184314fb9f66322a03a5906796