A free-knot spline modeling framework for piecewise linear logistic regression in complex samples with body mass...

This paper details the design, evaluation, and implementation of a framework for detecting and modeling nonlinearity between a binary outcome and a continuous predictor variable adjusted for covariates in complex samples. The framework provides familiar-looking parameterizations of output in terms of linear slope coefficients and odds ratios. Estimation methods focus on maximum likelihood optimization of piecewise linear free-knot splines formulated as B-splines. Correctly specifying the optimal number and positions of the knots improves the model, but is marked by computational intensity and numerical instability. Our inference methods utilize both parametric and nonparametric bootstrapping. Unlike other nonlinear modeling packages, this framework is designed to incorporate multistage survey sample designs common to nationally representative datasets. We illustrate the approach and evaluate its performance in specifying the correct number of knots under various conditions with an example using body mass index (BMI; kg/m²) and the complex multi-stage sampling design from the Third National Health and Nutrition Examination Survey to simulate binary mortality outcomes data having realistic nonlinear sample-weighted risk associations with BMI. BMI and mortality data provide a particularly apt example and area of application since BMI is commonly recorded in large health surveys with complex designs, often categorized for modeling, and nonlinearly related to mortality. When complex sample design considerations were ignored, our method was generally similar to or more accurate than two common model selection procedures, Schwarz's Bayesian Information Criterion (BIC) and Akaike's Information Criterion (AIC), in terms of correctly selecting the correct number of knots. Our approach provided accurate knot selections when complex sampling weights were incorporated, while AIC and BIC were not effective under these conditions.