Prognostic Models With Competing Risks: Methods and Application to Coronary Risk Prediction

Clinical decision-making often relies on a subject's absolute risk of a disease event of interest. However, in a frail population, competing risk events may preclude the occurrence of the event of interest. We review competing-risk regression models with a view toward predictive modeling. We show how measures of prognostic performance (such as calibration and discrimination) can be adapted to the competing-risks setting. An example of coronary heart disease (CHD) prediction in women aged 55–90 years in the Rotterdam study is used to illustrate the proposed methods, and to compare the Fine and Gray regression model to 2 alternative approaches: (1) a standard Cox survival model, which ignores the competing risk of non-CHD death, and (2) a cause-specific hazards model, which combines proportional hazards models for the event of interest and the competing event. The Fine and Gray model and the cause-specific hazards model perform similarly. However, the standard Cox model substantially overestimates 10-year risk of CHD; it classifies 18% of the individuals as high risk (>20%), compared with only 8% according to the Fine and Gray model. We conclude that competing risks have to be considered explicitly in frail populations such as the elderly.