# Non-compliance and missing data in health economic evaluation

## TL;DR

This paper discusses the challenges of non-compliance and missing data in health economic evaluations, illustrating appropriate statistical methods and emphasizing the need for sensitivity analyses and advanced techniques.

## Contribution

It provides an overview of methods for handling non-compliance and missing data in health economics, with practical guidance and an application to RCT data.

## Key findings

- Instrumental variable methods can estimate causal effects despite non-compliance.
- Multiple imputation and inverse probability weighting are recommended for missing data.
- Sensitivity analyses are crucial for addressing data missing not at random.

## Abstract

Health economic evaluations face the issues of non-compliance and missing data. Here, non-compliance is defined as non-adherence to a specific treatment, and occurs within randomised controlled trials (RCTs) when participants depart from their random assignment. Missing data arises if, for example, there is loss to follow-up, survey non-response, or the information available from routine data sources is incomplete. Appropriate statistical methods for handling non-compliance and missing data have been developed, but they have rarely been applied in health economics studies. Here, we illustrate the issues and outline some of the appropriate methods to handle these with an application to a health economic evaluation that uses data from an RCT. In an RCT the random assignment can be used as an instrument for treatment receipt, to obtain consistent estimates of the complier average causal effect, provided the underlying assumptions are met. Instrumental variable methods can accommodate essential features of the health economic context such as the correlation between individuals' costs and outcomes in cost-effectiveness studies. Methodological guidance for handling missing data encourages approaches such as multiple imputation or inverse probability weighting, that assume the data are Missing At Random, but also sensitivity analyses that recognise the data may be missing according to the true, unobserved values, that is, Missing Not at Random. Future studies should subject the assumptions behind methods for handling non-compliance and missing data to thorough sensitivity analyses. Modern machine learning methods can help reduce reliance on correct model specification. Further research is required to develop flexible methods for handling more complex forms of non-compliance and missing data.