Modeling Longitudinal Outcomes in a Small Matched-Pair Sample Motivated by Cardiovascular Data: A Simulation Study

Introduction: In cardiovascular research, matched pairs with longitudinal outcomes are used to assess time and treatment effects on relevant cardiovascular parameters of interest. Generalized estimating equations (GEE) with independent working correlation are commonly employed for unbiased estimation, but their consistency depends on large sample properties. This study investigates the validity of independent GEE for small sample matched pair data under various working correlations, comparing the results with quasi-least squares (QLS) estimates through simulation. Methods: We simulate a hospital cohort with longitudinal outcomes for two exposure groups and individual random effects. After obtaining the propensity score-matched sample, we performed different simulation scenarios across various mortality rates and the random effect. We compare results from GEE and QLS methods under independence, exchangeable, and AR1 working correlation structures. Results: The independence structure often yields a wider range of relative biases and higher standard errors when there is considerable drop-out. Conversely, the exchangeable structure appears as the true correlation structure, providing more accurate and reliable estimates. No significant discrepancies are observed between the results generated by GEE and QLS methods in this study, and the performance of both approaches is significantly influenced by mortality rates and the standard deviation of the random intercept. Conclusion: Our findings suggest that GEE with an independent working correlation structure is misspecified due to incorrect correlation assumptions and is less efficient. Therefore, correctly specifying the working correlation structure is important for small sample data.