Bias through selective inclusion and attrition: Representativeness when comparing provider performance with routine outcome monitoring data

Background: Observational research based on routine outcome monitoring is prone to missing data, and outcomes can be biased due to selective inclusion at baseline or selective attrition at posttest. As patients with complete data may not be representative of all patients of a provider, missing data may bias results, especially when missingness is not random but systematic. Methods: The present study establishes clinical and demographic patient variables relevant for representativeness of the outcome information. It applies strategies to estimate sample selection bias (weighting by inclusion propensity) and selective attrition bias (multiple imputation based on multilevel regression analysis) and estimates the extent of their impact on an index of provider performance. The association between estimated bias and response rate is also investigated. Results: Provider-based analyses showed that in current practice, the effect of selective inclusion was minimal, but attrition had a more substantial effect, biasing results in both directions: overstating and understating performance. For 22% of the providers, attrition bias was estimated to be in excess of 0.05 ES. Bias was associated with overall response rate (r =.50). When selective inclusion and attrition bring providers' response below 50%, it is more likely that selection bias increased beyond a critical level, and conclusions on the comparative performance of such providers may be misleading. Conclusions: Estimates of provider performance were biased by selection, especially by missing data at posttest. Results on the extent and direction of bias and minimal requirements for response rates to arrive at unbiased performance indicators are discussed.