# Quantifying Potential Immortal Time Bias in Observational Studies in Acute Severe Infection

## TL;DR

This paper introduces a tool to quantify how observational studies might overstate treatment benefits due to a bias called immortal time bias, particularly in severe infections.

## Contribution

The novel contribution is the development of IMMORTOOL, an R package and web tool to estimate the potential for immortal time bias in observational studies.

## Key findings

- IMMORTOOL estimates the potential for immortal time bias using time-to-intervention and time-to-event data.
- Published estimates of IVIG benefits in STSS may be partly explained by immortal time bias.
- The tool does not account for other selection biases beyond misallocated person-time.

## Abstract

Immortal time bias is a spurious or exaggerated protective association that commonly arises in naive analyses of observational data. It occurs when people receive the intervention because they survive, rather than survive because they received the intervention. Studies in conditions with substantial early mortality, such as acute severe infections, are particularly vulnerable.

We developed IMMORTOOL, an R package accessible via a user-friendly web interface (https://petedodd.github.io/IMMORTOOL-live/). This tool will estimate the potential for immortal time bias using empiric or assumed data on the distributions of time to intervention and time to event. Assumptions are that no other biases are present and that the intervention does not affect the outcome. The tool was benchmarked using studies presenting both naive analyses and analyses with the intervention fit as a time-varying exposure. We applied IMMORTOOL to a set of influential observational studies that used naive analyses when estimating the impact of polyclonal intravenous immunoglobulin (IVIG) on survival in streptococcal toxic shock syndrome (STSS).

IMMORTOOL demonstrated that published estimates suggesting a survival advantage from giving IVIG in STSS are explained, at least in part, by immortal time bias.

IMMORTOOL can quantify the potential for immortal time bias in observational analyses. Importantly, it simulates only bias resulting from misallocation of person-time, not other related selection biases. The tool may help readers interrogate published studies. We do not advocate IMMORTOOL being used to justify naive analyses where robust analyses are possible. To what extent giving IVIG in STSS improves survival remains uncertain.

Immortal time bias exaggerates estimates of treatment efficacy in naive analyses of observational data. We developed a tool to estimate the extent of this bias. The benefits of giving intravenous immunoglobulin in streptococcal toxic shock syndrome have likely been overstated.