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Lm sng thng k
Chn bin trong phn tch hi qui logistic:
mt sai lm ph bin

Nguyn Vn Tun

Hi: Trong mt bi vit trc y, Thy vit rng cch chn bin cho mt m
hnh hi qui logistic a bin t cc phn tch n bin l sai lm. Xin Thy gii thch
thm ti sao?

Mt nghin cu y hc tiu biu thng o lng nhiu yu t lm sng nhm
tin lng mt bin c no , chng hn nh t vong, gy xng, i tho ng, v.v...
Ly v d mt nghin cu v nguy c t vong, nh nghin cu c th thu thp cc thng
tin nh tui, chiu cao, cn nng, tin s bnh tt, li sng, hay c th o lng cc
hormone, cc ch s sinh ha, v.v (s gt tt l bin hay variable) v cu hi t ra l
trong nhng bin ny, bin no c lin quan n t vong. y l mt vn khng n
gin, v cu tr li thng phi da vo kt qu phn tch thng k v kin thc sinh hc.
Mt m hnh c th tin on rt chnh xc, nhng hon ton v dng v khng c
ngha lm sng hay sinh hc; ngc li, mt m hnh c ngha lm sng nhng khng
ph hp vi cc gi nh thng k cng ch l mt tr chi con s!

Mt trong nhng kh khn v c th ni l vn nan gii trong cc nghin cu
a bin l cc bin tin lng (predictor variables) thng c mi lin quan sinh hc vi
nhau. Chng hn nh chiu cao v cn nng c lin quan vi nhau, hay cc ch s sinh
ha bin chuyn theo tng tui. V, nhng mi tng quan ny lm cho vn chn
m hnh thm rc ri, nht l trong iu kin nghin cu da vo mt mu.

Vn chn m hnh

bn c hiu r vn , ti s ly mt v d n gin: mt nghin cu lm
sng nhm mc ch pht trin mt m hnh tin lng nguy c t vong (hay kh
nng sng st cho tch cc hn) cc bnh nhn cp cu (ICU) da vo cc ch s
lm sng thu thp c t lc bnh nhn nhp vin. Tiu ch lm sng l t l bnh nhn
sng st sau 30 ngy xut vin (v tit kim ch ngha, gi bin ny l Y). Cc bin
thu thp lc nhp vin gm tui, cn nng, v khong 8 ch s sinh ha khc (gi tt l
x
1
, x
2
, x
3
, ., x
10
). tin lng kh nng sng st chng ta c rt nhiu m hnh kh d,
chng hn nh:

Y = b
0
+ b
1
x
1
+ e
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Y = b
0
+ b
1
x
1
+ b
2
x
2
+ e
Y = b
0
+ b
1
x
1
+ b
2
x
2
+ b
3
x
3
+ e
Y = b
0
+ b
1
x
1
+ b
2
x
2
+ b
6
x
6
+ e
v.v

trong , b
0
, b
1
, b
3
, v.v l nhng thng s lin quan n tng bin cn c tnh, v e
l phn ngu nhin ca m hnh. Tht ra, cc m hnh trn y cn n gin, v chng ta
cha xem xt n cc nh hng tng tc, nh hng phi tuyn tnh, v.v C th ni
khng ngoa rng, vi 10 bin s, con s m hnh kh d c th ln n hng trm ngn,
thm ch bt tn. Nhng trong nhng m hnh ny, m hnh no c th tin lng
chnh xc nht v n gin nht?

y l mt cu hi lm tn bit bao cng sc ca nhiu nh khoa hc thng
k, nh ton hc v bit bao giy mc tr li, nhng cho n nay vn vn cha ng
ng. Rt nhiu phng php c pht trin, nhng cha c mt phng php no
hon chnh. Rt nhiu nh thng k hc v ton hc mun gii quyt vn , v i khi
h cng pht trin mt vi phng php, nhng rt tic l cc phng php ny khi p
dng vo mi trng y hc th rt v ngha, v duyn, v khng th s dng c. Ti s
khng bn chi tit ti sao vn vn cha ng ng (ti s quay li ch ny trong mt
bi vit khc), m ch nhn c hi ny bn v mt sai lm ph bin trong vic i tm
mt m hnh tin lng.

Mt sai lm ph bin

c mt bi bo khoa hc trn mt tp san y hc trong nc trc y, ti cc
thy tc gi vit: Cc bin c lin quan vi t vong trong phn tch n bin vi mc
ngha p<0.05 s c a vo phn tch hi qui a bin logistic. Ni cch khc, cc tc
gi tin hnh phn tch hai giai on:
Giai on 1, phn tch tng bin mt v lu cc bin c ngha thng k (tc p
< 0.05);
Giai on 2, cho tt c cc bin c ngha thng k trong giai on 1 vo mt m
hnh a bin.

y l mt sai lm rt v t v kh ph bin trong y vn, khng ch nc ta
m cn rt ph bin cc nc Ty phng. Thm ch, theo kinh nghim ca ngi vit
bi ny, cc nh thng k chuyn nghip cng sai! Sai lm ny khng hn l do tc gi
c , nhng do hiu lm (hay cha thng hiu) c ch ca cc m hnh thng k.

Vn chnh ca cch chn m hnh theo hai giai an trn l khi phn tch tng
bin mt (giai on 1), m hnh hi qui logistic khng xem xt n nh hng ca cc
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bin khc cng mt lc. Chng hn nh nu bin x
1
v x
2
c tng quan vi nhau, th
phn tch giai on 1 c th chn c hai bin, nhng trong m hnh a bin (giai on 2),
c th ch c x
1
c ngha thng k, cn x
2
th khng (hay ngc li), bi v thng tin
ca bin ny hm cha trong thng tin ca bin kia (do hai bin c lin quan nhau).

Mt vn khc, tinh vi hn v t nh hn, l nh hng ca mt bin trung
gian, rt kh hay khng th kim sot trong giai on 1. (Ti s bn qua v vn nh
hng ca bin trung gian trong mt bi khc). Trong trng hp ny, c th hai bin c
th hai bin x
1
v

x
5
(chng hn) trong thc t u c nh hng n Y, nhng nh hng
ny ch tn ti khi chng xut hin bn nhau (cng hng); do , khi phn tch ring l,
chng ta khng pht hin c nh hng ca chng, v do phn tch n gin trong
giai on 1 c th b qua c hai bin!

V d 1: Gii, th dc, v t vong. Mt nghin cu (m phng) mt thi im
(cross-sectional study) nhm nh gi mi lin h ca gii v nguy c t vong v bnh
nhi mu c tim. Cc nh nghin cu cn thu thp thng tin lin quan n thi quen tp
th dc v vn ng c th tng i tng. Kt qu nghin cu c th tm lc nh
sau:

Bng 1. S i tng t vong v cn sng chia theo gii v thi quen tp th dc

Bin T vong Sng Odds ratio v tr s P
Gii
N
Nam

113
94

2000
2000

OR = 1.21
p = 0.176
Tp th dc
Khng
C

164
43

2000
2000

OR = 4.06
p = 0.0001

Trong nghin cu trn, nu chng ta p dng phng php phn tch hi qui logistic cho
tng bin ring l, chng ta s c:

OR (odds ratio) cho n l 1.21 vi tr s p = 0.176, tc khng c ngha thng
k.

OR cho nhm khng thng xuyn tp th dc l 4.06 vi p = 0.0001, tc c
ngha thng k.

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Nh vy, nu da vo phn tch ny, chng ta ch chn bin tp th dc vo m hnh a
bin. Nhng kt qu ny c th sai. Quay li vi s liu ca nghin cu trn, chng ta
th xc nh tn s t vong v sng st theo c hai bin cng mt lc nh sau:

Bng 2. S i tng t vong v cn sng chia theo thi quen tp th dc cng vi
gii

Tp th dc v gii T vong Sng OR v tr s P
Khng tp th dc
N
Nam

80
84

800
1200

OR = 1.43
p = 0.028
Tp th dc
N
Nam

33
10

1200
800

OR = 2.20
p = 0.026

Kt qu phn tch, nh trnh by trong ct s 3 ca bng trn, rt khc vi kt qu
phn tch trong bng 1. y, chng ta thy, gii c nh hng n nguy c t vong
trong c hai nhm khng tp th dc v tp th dc thng xuyn. Trong nhm khng
tp th dc thng xuyn, OR t vong n l 1.43 vi p = 0.028; trong nhm tp th dc
thng xuyn, OR l 2.20 vi p = 0.026.

Do , phng php phn tch ng cho trng hp ny l chng ta phi xem xt
n nh hng ca hai bin cng mt lc trong m hnh a bin. M hnh ny c th vit
nh sau:

Y = b
0
+ b
1
x
1
+ b
2
x
2
+ e [1]

Trong , Y l log ca odd t vong, x
1
l gii, x
2
l tp th dc, v b
0
, b
1
, v b
2
l cc
thng s cn c tnh. c s ca m hnh ny c th tm lc nh sau:

Bin H s ca phng trnh hi
qui logistic
OR v tr s P
Gii (N) b
1
= 0.434 OR = 1.54, p = 0.003
Tp th dc (Khng) b
2
= 1.425 OR = 4.16, p < 0.0001

Kt qu phn tch a bin trn cho chng ta mt bc tranh rt khc vi phn
tch n bin trong bng 1. n y, chng ta c th kt lun rng nh hng ca c hai
bin (gii v tp th dc) u c ngha thng k, nhng nh hng ca tp th dc c
v cao hn nh hng ca gii.

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Mt s nh nghin cu cho rng cch truy tm bin c ngha thng k cho phn
tch a bin c th da vo kt qu ca phn tch n bin bng cch nng tr s p ln
0.15 (thay v 0.05). Ni cch khc, thay v lu gi nhng bin c tr s p < 0.05 trong
giai on 1, c th nng cao tiu chun ny thnh p < 0.15 lu gi nhng bin c th
b st v tiu chun p < 0.05. Tuy nhin, phng php ny cng sai nt! chng
minh cho sai lm ny, ti s ly mt v d di y.

V d 2: Vn vi ch ca v d 1, nhng ln ny, ti thay i vi s liu
chng minh khim khuyt va nu nh sau:

Bng 3. S i tng t vong v cn sng chia theo thi quen tp th dc cng vi
gii

Bin T vong Sng Odds ratio v tr s P
Gii
N
Nam

107
91

1935
1935

OR = 1.18
p = 0.267
Tp th dc
Khng
C

107
91

1984
1886

OR = 3.71
p = 0.0001

Trong nghin cu trn, nu phn tch tng bin ring l, mt ln na, nh hng ca yu
t gii khng c ngha thng k (p = 0.267). Do , nu da vo tiu chun p < 0.15,
chng ta phi loi b yu t gii trong phn tch a bin. Tuy nhin, bng s liu di
y (Bng 4) cho thy nu phn tch nh hng ca gii trong tng nhm tp th dc,
chng ta thy nh hng ca gii c ngha thng k.

Bng 4. S lng i tng t vong v cn sng chia theo thi quen tp th dc
cng vi gii

Tp th dc v gii T vong Sng OR v tr s P
Khng tp th dc
N
Nam

75
81

774
1161

OR = 1.39
p = 0.048
Tp th dc
N
Nam

32
10

1161
774

OR = 2.13
p = 0.034

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By gi, chng ta xem xt m hnh [1] (tc c tnh nh hng ca hai bin s cng
mt lc trong mt m hnh a bin) cho s liu trong Bng 4, kt qu cho thy c hai bin
u c ngha thng k:

Bin H s ca phng trnh hi
qui logistic
OR v tr s P
Gii (N) b
1
= 0.4077 OR = 1.50, p = 0.0064
Tp th dc (Khng) b
2
= 1.3938 OR = 4.03, p < 0.0001


Tm tt

Xy dng mt m hnh hi qui logistic a bin l mt vn khng n gin,
nht l trong trng hp cc bin tin lng c tng quan vi nhau. Cc v d trn y
cho thy phng php truy tm bin c ngha thng k trong m hnh a bin da vo
phn tch n bin c th dn n sai lm quan trng. Ngay c nng cao tr s p ln 0.15
cng vn c th phm sai lm.

Hin nay, cc phn mm thng k c sn mt s thut ton (algorithm) truy
tm bin c lp cho m hnh a bin, nh thut ton stepwise, backward, v forward.
Nhng ngay c cc thut ton ny, nht l thut ton stepwise v forward, vn c nhiu
khim khuyt v cho ra nhng kt qu dng tnh gi, tc l nhng bin chng c lin
quan g n bin ph thuc. Rt nhiu ngi khng hiu cc thut ton ny nn vn p
dng chng mt cch v ti v v h qu l c rt nhiu nghin cu vi nhng kt qu sai
trong y vn.

Xy dng mt m hnh a bin l mt khoa hc, nhng cng l mt ngh thut.
Khoa hc tnh lin quan n cc tiu chun nh lng v thut ton thch hp. Ngh
thut tnh lin quan n nhng yu t c th ni l ch quan, i hi nh nghin cu phi
vn dng kin thc chuyn ngnh i n mt m hnh c ngha lm sng. M m
hnh a bin nu ch tha mn cc tiu chun khoa hc vn cha th l mt m hnh c
ch. Mt m hnh c ngha lm sng nhng khng p ng cc tiu chun khoa hc
khng th l mt m hnh c tin cy cao. Do , phn tch a bin, d l m hnh
logistic hay hi qui tuyn tnh, l mt phng php phc tp, i hi nhiu thi gian
suy ngh v tnh ton. Khng th v khng nn cho my tnh suy ngh dm cho chng
ta.

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Ch thch k thut:

Phn di y l cc m R s dng cho cc c tnh trnh by trong bi vit.

# Phn tch s liu v d 1
# phn tch nh hng ca gii
sex <- c("Nu", "Nam")
ntotal <- c(2000, 2000)
ndeaths <- c(113, 94)
pdeath <- ndeaths/ntotal
logistic <- glm(pdeath ~ sex, binomial, weight=ntotal)
logistic.display(logistic)

# phn tch nh hng ca tp th dc
pa <- c("No", "Yes")
ntotal <- c(2000, 2000)
ndeaths <- c(164, 43)
pdeath <- ndeaths/ntotal
logistic <- glm(pdeath ~ pa, binomial, weight=ntotal)
logistic.display(logistic)

# phn tch nh hng ca tp th dc v gii cng mt lc, m hnh [1]
pa <- c("No", No, "Yes", Yes)
sex <- c(Nu, Nam, Nu, Nam)
ntotal <- c(880, 1284, 1233, 810)
ndeaths <- c(80, 84, 33, 10)
pdeath <- ndeaths/ntotal
logistic <- glm(pdeath ~ pa + sex, binomial, weight=ntotal)
summary(logistic)


# V d 2: phn tch a bin - s liu bng 4
pa <- c("No", "No", "Yes", "Yes")
sex <- c("Nu", "Nam", "Nu", "Nam")
ntotal <- c(849, 1242, 1193, 784)
ndeaths <- c(75, 81, 32, 10)
pdeath <- ndeaths/ntotal
logistic <- glm(pdeath ~ pa + sex, binomial, weight=ntotal)
summary(logistic)