Survivor Treatment Selection Bias and Outcomes Research: A Case Study of Surgery in Infective Endocarditis
Abstract
Background— Recent studies in infective endocarditis have suggested an association between surgery and reduced mortality. However, these studies did not account for survivor treatment selection bias, which is an underrecognized source of error in observational studies. Therefore, we sought to evaluate the effects of survivor bias on surgical outcomes in infective endocarditis. Methods and Results— We studied 223 patients admitted with left-sided infective endocarditis between 1996 and 2006 and compared all-cause mortality between surgically treated and medically treated patients using Cox regression analysis. Propensity scores were used to account for selection bias, and time-dependent analyses were performed to account for survivor bias. Compared with medical patients (n=161), surgical patients (n=62) had lower mortality during a median follow-up of 5.2 years (32% versus 51%; P =0.02) with an unadjusted hazard ratio of 0.54 (95% CI, 0.33 to 0.88, P =0.01). After adjustment for baseline differences in propensity for surgery and risk of mortality, there remained a significant benefit for surgery (hazard ratio, 0.50; 95% CI, 0.28 to 0.88; P =0.02). However, this was diminished after time-dependent analysis (hazard ratio, 0.77; 95% CI, 0.42 to 1.40; P =0.39). Conditional Kaplan–Meier analyses confirmed the effect of survivor bias because the apparent benefit of surgery was primarily attributable to excess mortality in the medical group during early hospitalization when surgery was not frequently performed. Conclusions— Survivor bias significantly affects the evaluation of surgical outcomes in infective endocarditis, and it should be considered in other areas of outcomes research where randomized controlled trials are not feasible. Survivor bias is not corrected by propensity analysis alone but may be reduced by time-dependent survival analysis.
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Since 2007, at least 3 studies have documented the effect of survivor bias on the association between surgery and mortality in infective endocarditis patients.
“Since 2007, at least 3 studies 15,16,258 have documented the effect of survivor bias on the association between surgery and mortality in IE patients.”
When adjusted for survivor bias, analyses have shown either a statistical loss of benefit of early surgery or findings indicating that the surgical intervention may actually result in harm.
“When adjusted for survivor bias, analyses have shown either a statistical loss of benefit of early surgery or findings indicating that the surgical intervention may actually result in harm.”
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Gros, A., Séguy, B., Bonnet, G., Guettard, Y.-O., Pillois, X., Prével, R., Orieux, A., Ternacle, J., Préau, S., Lavie-Badie, Y., et al. (2024) · Figshare · doi:10.6084/m9.figshare.26676272
Gros, A., Séguy, B., Bonnet, G., Guettard, Y.-O., Pillois, X., Prével, R., Orieux, A., Ternacle, J., Préau, S., Lavie-Badie, Y., et al. (2024) · Figshare · doi:10.6084/m9.figshare.26676281
Gros, A., Séguy, B., Bonnet, G., Guettard, Y.-O., Pillois, X., Prével, R., Orieux, A., Ternacle, J., Préau, S., Lavie-Badie, Y., et al. (2024) · Figshare · doi:10.6084/m9.figshare.26676275
Adeyemi, O., Kewalramani, D., Choron, R. L., Teichman, A. L., Englert, Z. P., Kyaw, C. A., Cai, J., Goswami, J., Güven, H., Bharvad, D., et al. (2026) · Surgery · doi:10.1016/j.surg.2026.110249
Not All Strokes Are Equal: Phenotype‐Dependent Surgical Timing in Infective Endocarditis
Kubi, B., Homaei, A., Keshwani, A., Bajaj, R., Odekunle, E., Walker, R., Bloom, J. P., Osho, A. A., Michel, E., Jassar, A. S., et al. (2026) · Journal of the American Heart Association · doi:10.1161/jaha.126.052918
- Authors
- Sy, R. W., Bannon, P. G., Bayfield, M. S., Brown, C., & Kritharides, L.
- Affiliations
- Sydney South West Area Health Service (AU)
- Venue
- Circulation: Cardiovascular Quality and Outcomes
- Published
- 2009-09
- Volume
- 2
- Issue
- 5
- Pages
- 469-474
- ISSN
- 1941-7705 (ISSN-L)
- 1941-7713
- OpenAlex
- W2889166221
- Semantic Scholar
- 18173e53c9ef7b9ce52bad2775f711edde6b53f3
- Cited by
- 71
- References
- 22
- Citations by year
- 2026: 2 · 2025: 6 · 2024: 8 · 2023: 5 · 2022: 3 · 2021: 7 · 2020: 2 · 2019: 2 · 2018: 3 · 2017: 6 · 2016: 3 · 2015: 5 · 2014: 1 · 2013: 2 · 2012: 6
- FWCI
- 3.56
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Circulation Cardiovascular Quality and Outcomes (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Epidemiology › Infective Endocarditis Diagnosis and Management
- Physical Sciences › Mathematics › Statistics and Probability › Advanced Causal Inference Techniques
- Physical Sciences › Mathematics › Statistics and Probability › Statistical Methods in Epidemiology
- Keywords
- survivorship bias, treatment selection bias, infective endocarditis, cardiac surgery, left-sided endocarditis, all-cause mortality, surgical versus medical treatment, propensity score analysis, bias in observational studies
- MeSH terms
- Adult, Aged, Endocarditis, Female, Follow-Up Studies, Humans, Male, Middle Aged, Retrospective Studies, Risk Factors, Selection Bias, Multivariate Analysis, Logistic Models, Proportional Hazards Models, Hospital Mortality, Outcome Assessment, Health Care, Survivors, Kaplan-Meier Estimate
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