Widding-Havneraas, Chaulagain, Lyhmann, Zachrisson, Elwert, Markussen, McDaid & Mykletun (2021): Preference-based instrumental variables in health research rely on important and underreported assumptions: a systematic review

I: Journal of Clinical Epidemiology. Online first. Open Access

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Tarjei Widding-Havneraas, Ashmita Chaulagain, Ingvild Lyhmann, Henrik Daae Zachrisson, Felix Elwert, Simen Markussen, David McDaid og Arnstein Mykletun



Preference-based instrumental variables (PP IV) designs can identify causal effects when patients receive treatment due to variation in providers’ treatment preference. We offer a systematic review and methodological assessment of PP IV applications in health research.

Study Design and Setting

We included studies that applied PP IV for evaluation of any treatment in any population in health research (PROSPERO: CRD42020165014). We searched within four databases (Medline, Web of Science, ScienceDirect, SpringerLink) and four journals (including full-text and title and abstract sources) between January 1, 1998, and March 5, 2020. We extracted data on areas of applications and methodology, including assumptions using Swanson and Hernan's (2013) guideline.


We included 185 of 1087 identified studies. The use of PP IV has increased, being predominantly used for treatment effects in cancer, cardiovascular disease, and mental health. The most common PP IV was treatment variation at the facility-level, followed by physician- and regional-level. Only 12 percent of applications report the four main assumptions for PP IV. Selection on treatment may be a potential issue in 46 percent of studies.


The assumptions of PP IV are not sufficiently reported in existing work. PP IV-studies should use reporting guidelines.

Publisert 29. juni 2021 15:21 - Sist endret 29. juni 2021 15:21