# How to determine the age cut-off to be used in prediction model by the restricted cubic spline?

I not so fimiliar with this as I used to adopt age as a single continous variable all the time. I am trying to figure out the appropriate knot number and cut-off of age to be used in my model for 6 months mortality. By the default rcs function, here I tried with knot 3, 4, 5. I am not sure should I use 3 or 4 as the knot or should I just input the age as continous factor like before.

And as shown below, the default cut-off age are not the ones we commonly applied. Should I mannually set the age cut-off close to the knot ones? Such as for with 3 knots, I should set perhaps 30, 65 and 85; and for with 4 knots, I should set perhaps 20, 55, 70, 90? Because I saw people using the restricted cubic spline and their cut-off value for the age are quite â€ścleanâ€ť.

And a minor issue is that I cannot find a way to plot the x-axis in smaller increment, the age here starts from 16 year old.

And I can only upload one picture now, I uploaded the one with 4 knots. The picture with 3 knots is quite linear.

(picture with 3 knots, quite linear, cannot upload picture now)
Blockquote

Assumption Parameters d.f.
Age rcspline 27 63 87 2

Assumption Parameters d.f.
Age rcspline 22 55 71 89 3

(picture with 5 knots, quite a strange shape, cannot upload now)

Assumption Parameters d.f.
Age rcspline 22 49 63 76 89 4

I asked the same question in cross validated where three picture can be seen

The default is to get predictions for the 10th smallest to the 10th largest age. You can say `Predict(fit, age=....)` to take control over the range of age plotted.

To your main question, it is not a good idea to â€śplayâ€ť with the knots as then the confidence intervals no longer apply. And these are not â€ścutoffsâ€ť but are points at which the 3rd derivative of the curve is allowed to abruptly change. Use default knot placement and select 3, 4, or 5 knots depending on your effective sample size. Model as flexibly as the sample size will allow but pre-specify the number of knots. The RMS book and course notes goes more into knot specification.

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Thank you Professor Harrell, I have been reading your course notes extensively in recent months and found how naive I was in developing prediction model.

I also used rcspline.plot function to look at the GCS (Glasgow Coma Scale) with the mortality for the patients. After looking at the results, should I applied it as a continous variable for prediction. I am not so sure and cannot find a example for interpretation of the results, does the linearity wald test for a p>0.05, indicates the rejection of the H0 hypothesis: the relationship of GCS and logit mortality is not linear?

rcspline.plot(data\$EDGCS, as.numeric(data\$M6MLog)-1, model=â€ślogisticâ€ť, nk = 5, showknots=TRUE,
noprint=FALSE, show=â€śxbetaâ€ť, m=140)

And is there a way to take control over the range of GCS and increment being plotted in rcspline.plot function as well?

I have also tried with Predict(fit, age=â€¦) by the code for the age:

fit <- lrm(M6MLog ~ rcs(age, 5), data = data, x = T, y = T)
plot(Predict(fit, age=seq(16, 104, by=5)))

But the graph stays the pretty much the same and the increment of the x-axis wonâ€™t change.

You should have seen the whole range on the x-axis. If not you might play with the `ylim` argument to the `plot` method. Also note there is a `ggplot` method and a `plotly` method, called `plotp` for interactive graphics. And use `rcs` instead of `rcspline.plot`.

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Thank you so much Professor Harrell, and do you think I should use the GCS as a continous variable here for my prediction model? Because some clinicians suggest to use them as mild (GCS 13-15), moderate (9-12) and severe (GCS 3-8) instead.

Never create an interval that contains multiple values. It is easy to see that throws way information. I would use it as a quadratic polynomial.

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Get it. Thank you for your suggestion:)
And just to make sure I get it right here, use it as a quadratic polynomial means to use it with the rcs function with 3 knot?

No, I meant a regular quadratic. In the R `rms` package this is `pol(glasgowComaScore, 2)`. The reason Iâ€™d use a quadratic for a scale that is fairly discrete is that itâ€™s too hard to pick knot locations with a lot of ties in the data.

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Thank you, I guess my main problem is with the transformation of continous and scale in my model and how to explain the coefficients of them. I am also using lasso as a comparative methods with the traditional backward stepwise.

Variable selection, whether by `lasso` or traditional methods, is unreliable and results in invalid standard errors in many cases.

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