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Causal Directed Acyclic Graphs

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME

The design and interpretation of clinical studies requires consideration of variables beyond the exposure or treatment of interest and patient outcomes, including decisions about which variables to capture and, of those, which to control for in statistical analyses to minimize bias in estimating treatment effects. Causal directed acyclic graphs (DAGs) are a useful tool for communicating researchers’ understanding of the potential interplay among variables and are commonly used for mediation analysis.1,2 Assumptions are presented visually in a causal DAG and, based on this visual representation, researchers can deduce which variables require control to minimize bias and which variables could introduce bias if controlled in the analysis.35

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: Ari M. Lipsky, MD, PhD, Department of Emergency Medicine, HaEmek Medical Center, Yitshak Rabin Blvd 21, Afula 1834111, Israel (aril@alum.mit.edu).

Published Online: February 28, 2022. doi:10.1001/jama.2022.1816

Conflict of Interest Disclosures: None reported.

References
1.
Lee  H , Herbert  RD , McAuley  JH .  Mediation analysis.   JAMA. 2019;321(7):697-698. doi:10.1001/jama.2018.21973PubMedGoogle ScholarCrossref
2.
Lee  H , Cashin  AG , Lamb  SE ,  et al.  A guideline for reporting mediation analyses of randomized trials and observational studies: the AGReMA Statement.   JAMA. 2021;326(11):1045-1056. doi:10.1001/jama.2021.14075PubMedGoogle ScholarCrossref
3.
Greenland  S , Pearl  J , Robins  JM .  Causal diagrams for epidemiologic research.   Epidemiology. 1999;10(1):37-48. doi:10.1097/00001648-199901000-00008PubMedGoogle ScholarCrossref
4.
Glymour  MM , Greenland  S . Causal diagrams. In: Rothman  KJ , Greenland  S , Lash  TL , eds.  Modern Epidemiology. 3rd ed. Lippincott Williams & Wilkins; 2008:183-212.
5.
Greenland  S , Pearl  J.  Causal diagrams. In: Lovric  M , ed.  International Encyclopedia of Statistical Science. Vol 3. Springer; 2011:208-216. doi:10.1007/978-3-642-04898-2_162
6.
Ramirez  FD , Chen  S , Langan  SM ,  et al.  Association of atopic dermatitis with sleep quality in children.   JAMA Pediatr. 2019;173(5):e190025. doi:10.1001/jamapediatrics.2019.0025PubMedGoogle Scholar
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