Count data are generated by processes yielding nonnegative integers exclusively. In simpler terms, this data type encompasses only nonnegative and integer values (e.g., 0,1,2,…). Counts denote the frequency of event occurrences within fixed time intervals, exemplified by weekly cholera counts reported per locality, emergencies in referral or secondary care hospitals, and antenatal care (ANC) visits.
While the Poisson model is conventionally used for count data analysis, it is considered constrained by the requirement for mean and variance equality. In medical research, count outcomes with equal mean and variance are rare. The negative binomial model, an alternative to the Poisson, accommodates overdispersion (variance exceeding the mean). When overdispersion involves zeros, models like the generalized Poisson (GP), hurdle, and zeroinflated models are recommended.1,2 Overdispersion attributed to zeros is tackled using mixture models and twopart models such as hurdle and zeroinflated models.3,4 The GP model can substitute a mixture model and two partpart models for overdispersed count responses due to zeros. The GP model based on maximum likelihood estimation, is versatile for both overdispersed and underdispersed data.5,6
Ordinal variables in medical research often express patient characteristics, attitudes, behavior, or status. These variables have natural ordering among their levels like cancer stages (I, II, III, IV), pain levels (0–10 Likert scale), satisfaction levels (very dissatisfied, dissatisfied, neutral, satisfied, very satisfied), and Likert scales measurements in questionnaire surveys (strongly disagree, disagree, agree, strongly agree) among others. A major assumption for ordinal data is the constant effect of an independent variable on the response variable with a unit increase in the independent variable’s level. Essentially, the values are presumed equally distanced and ordered.
Ordinal outcomes are analyzed using ordinal logistic regression (OLR) when specific conditions are met.7,8 When the interest lies in ordinal outcomes that adhere to the proportionality assumption, and the independent variables are categorical, ordinal, or continuous, analysis options include Poisson, zeroinflated Poisson (ZIP), hurdle Poisson, negative binomial models, and proportional odds (PO) models.9 However, studies reveal that medical research often fails to present or analyze statistical data, especially ordinal data, according to the structure of the data.10–12
Many types of ordinal models have been developed, with the most common being the PO and the continuation ratio models. In this paper, we focus solely on the PO model.13 Both models employ maximum likelihood techniques to estimate odds ratios (ORs) but differ in their dichotomizations, referred to as ῾cutpoints’. While both models assume homogeneity across cutpoints and calculate a single OR, the PO model extends binary logistic regression for binary outcomes to handle ordinal outcomes.13,14 It is also named as cumulative logit model, built on the assumption of identical log ORs across cutpoints. At each cutpoint, for example, the level of severity is categorized as case and noncase. The OR of an exposure variable (level of severity) for any of these comparisons will be equal irrespective of cutpoint is made. In other words, OR is invariant to the dichotomization of the outcome. The PO model assumes that in the hypothetical population from which this sample was drawn, the ORs from each of the two possible dichotomies are the same.
In cases of ordinal responses where the absence of symptoms or disease activity leads to a substantial proportion of zeros, resulting in skewed outcomes, traditional statistical techniques can yield biased findings. In such scenarios, count models prove to be more appropriate.
The GP model serves as a replacement for the mixture model and two partpart models for overdispersed count responses involving zeros. The GP model, based on maximum likelihood estimation, is suitable for both overdispersed and underdispersed data.5,6 In a study by Yusuf and Ugalahi,6 Poisson, negative binomial, and GP were compared to find the best fit for overdispersed ANC visit counts that involve zeros. Among the three models, GP exhibited the lowest fit statistics values, including loglikelihood, Akaike Information Criteria (AIC), and Bayesian Schwartz Information Criteria (BIC), indicating its suitability for identifying parameters related to ANC visits.
Yadav et al,15 compared GP, mixture Poisson, mixture negative binomial, and ZIP models in terms of fit statistics such as bias, mean square error (MSE), AIC, and BIC, using both realtime and simulated data. This study showed that GP provides lower values of all fit statistics and identifies as a better model. Hence, the goal of this study was to ascertain whether the GP model was a better alternative to the OLR model in zeroinflated outcomes, using both simulated and realtime data.
Methods
The Poisson model has been widely employed for count data analysis. The probability mass function of the Poisson model is given by:
The Poisson model is characterized by a single parameter distribution. Its mean and variance are equal. In the Poisson regression model, the focus is on modeling the conditional mean E (θx). The expected outcome in terms of the log function is expressed as θ = exp (xβ), where θ is mean, x is independent variables, and β stands for the regression parameters.16
For overdispersed or underdispersed count data, the GP regression model may prove beneficial. It assumes that the outcome variable Yi follows a probability mass function:
Where θi > 0 and max (−1,− θi /4) < δ < 1. The mean and variance of the GP model are defined as:
Mean(ųi) = E(yi) =

θi

(1δ)

Where φ = 1/(1 − δ)2 is a dispersion factor. When δ = 0, the model becomes equidispersed, reducing to the Poisson model with parameter θi. For δ > 0, overdispersion is present, and for δ < 0, underdispersion is observed.17
In practice, the oftenused OLR model is the PO model, also referred to as the cumulative logit model. The PO model is invariant to collapsing categories, a technique often used to summarize results.18 For instance, for an outcome variable with four categories, assuming three ways to divide these categories into two collapsed categories while maintaining the natural order, merging groups 0 and 3 for comparison with groups 1 and 2 is not valid, as it disrupts the inherent order. If an ordinal response variable D has G levels (D = 0, 1, 2. . ., G1), there are G 1 ways to dichotomize the response outcome (e.g., D ≥ 1 vs. D < 1; D ≥ 2 vs. D < 2, ..., D ≥ G1 vs. D < G1). The odds that D ≥ g are defined as:
Here, g = 1, 2, 3. . . G1. An essential assumption of this model is that the OR remains constant when calculated across different cut points. For example, OR (D ≥ 1) = OR (D ≥ 3).19
For model evaluation, AIC and BIC are used [Box 1]. Both models are based on the maximum likelihood estimates, with lower values indicating better model fit. The AIC is defined as:
Box 1: Model preference in terms of AIC and BIC.
> 0.1–≤ 2.5

No difference in model

> 2.5–≤ 6.0

Choose model A if n > 256

> 6.0–≤ 9.0

Choose model A if n > 64

> 9

Choose model A

0–2

Weak

2–6

Positive

6–10

Strong

AIC: Akaike Information Criteria; BIC: Bayesian Schwartz Information Criteria.
AIC = 2L + 2k
Where L is loglikelihood and k is number of parameters in the model (including variables and intercept).
Similarly, BIC is given by: BIC = 2L + k log (n)
Where L is loglikelihood, k is number of parameters (including intercept), and n is number of rating classes or number of model observations.20
The commonest criterion for evaluating a statistical model’s performance is based on its accuracy in fitting the data. The MSE is a widely used measure of accuracy, where a smaller value indicates a more accurate and reliable model.
Where n represents the sample size.
For the initial simulation study, we assessed the models under varying sample sizes. To assess how well the GP model and ordinal model fit data exhibiting varying degrees of zero inflation (10%, 20%, 30%, 40%, and 50%), we generated five simulated datasets with varying sample sizes (100, 250, 500, 750, and 1000) while maintaining fixed regression estimates (intercept = 0.5 and slope = 1). The independent variable x was generated from binomial distribution with n observations. Additionally, an error was generated with a mean of zero and a variance of 0.03. Using this independent variable x and the error term, the dependent variable was generated as a linear combination with fixed regression estimates (intercept = 0.5 and slope = 1). This resultant mean was considered as the population mean. The antilog of the predicted estimate from the regression equation represented the mean. Using this mean, the dependent variable (y) was generated using the package ZIP (gamlss.dist) in R software. Subsequently, the dependent variable (y) and independent variable (x) were combined. The GP model and OLR model were then compared across varying proportions of zeros and different sample sizes. This entire process was repeated 1000 times, and the median values of fit statistics were reported in the Simulation Table 1. Model comparison was based on bias, MSE, AIC, and BIC, where the better model exhibited smaller AIC, BIC, Bias, and MSE values.
Table 1: Simulation based on zeroinflated Poisson.

10% zeros

100

2.42E09

2.87

365

373

1.86

6.86

368

393

250

1.49E09

2.94

908

919

2.03

7.50

911

949

500

1.08E09

2.96

1813

1826

2.09

7.72

1817

1864

750

7.85E10

2.97

2714

2727

2.11

7.85

2718

2772

1000

8.37E10

2.97

3621

3635

2.10

7.84

3623

3682


20% zeros

100

7.23E09

3.15

363

371

2.01

7.43

364

388

250

2.08E09

3.26

903

914

2.05

7.60

901

938

500

1.35E09

3.27

1805

1817

2.08

7.69

1794

1841

750

7.09E09

3.28

2703

2717

2.08

7.69

2686

2740

1000

7.71E10

3.28

3607

3622

2.08

7.70

3582

3641


30% zeros

100

3.68E09

3.32

351

360

2.01

7.46

350

374

250

2.47E09

3.42

876

887

2.06

7.68

867

903

500

1.55E09

3.42

1749

1761

2.06

7.66

1726

1772

750

1.32E09

3.44

2621

2635

1.96

7.44

2586

2640

1000

1.21E09

3.43

3493

3508

1.95

7.44

3443

3500


40% zeros

100

4.08E09

3.33

332

339

2.36

8.90

328

351

250

2.63E09

3.44

826

836

2.48

10.00

812

848

500

1.87E09

3.42

1647

1660

2.50

10.17

1615

1662

750

1.43E09

3.44

2464

2469

2.49

10.22

2415

2478

1000

1.10E09

3.44

3288

3302

2.50

10.25

3218

3276


50% zeros

100

3.48E09

3.21

303

311

2.20

8.37

297

320

250

2.49E09

3.29

754

764

2.25

8.67

736

771

500

1.75E09

3.28

1515

1510

2.25

8.69

1464

1510

750

1.48E09

3.29

2246

2242

2.25

8.68

2190

2260

MSE: mean square error; AIC: Akaike Information Criteria; BIC: Bayesian Schwartz Information Criteria.
Three realtime studies were used including: 1) Fir, 2) decayed, missing, and filled teeth (DMF), and 3) acute diarrheal disease (ADD). Multiple datasets were chosen to apply GP and OLR models to scenarios ranging from small to large numbers of observations.
The "Fir" dataset was sourced from R’s ‘boot package’ and contained 50 observations. This study aimed to tally the number of balsamfir seedlings within all quadrants of grid of a 50 fivefoot square grid.21 The DMF study constituted a crosssectional analysis of 440 children’s caries. Its objective was to elucidate the oral health status and preventive dental habits of children across different age groups. The DMF count distribution was skewed positively due to the high incidence of zero counts among children without caries experience.22 The ADD dataset, comprising 3720 cases, was reported from Chennai’s communicable disease hospital from 2008 to 2010. This data was extracted from patients’ case histories across 155 wards in Chennai.
Results
The simulation results presented in Table 1 indicate the performance of the GP and OLR models across varying sample sizes and proportions of zeros. The following observations were made based on these results.
Sample size 100: The GP model generally exhibited lower bias, MSE, and BIC estimates than the OLR model. AIC values were slightly lower at the 30%, 40%, and 50% of the zeros in the OLR model, but not significantly. The details of the preference of a better model based on AIC value were presented in the methods.
Sample size 250: Similar to the sample size 100, the GP model yielded lower values for bias, MSE, and BIC, with slightly lower AIC values in the OLR model.
Sample size 500 and 750: The bias, MSE, and BIC estimates were lower in the GP model, while the AIC values were either lower or not significantly different in the OLR model.
Sample size 1000: The GP model consistently showed lower bias, MSE, and BIC estimates compared to the OLR model. However, the AIC values were lower in the OLR model for this sample size.
The GP model consistently provided lower bias and MSE values compared to the OLR model across various sample sizes and proportions of zeros. The BIC estimates were generally lower in the GP model, except for specific cases in the sample size 1000 and zeros at 30% and 40%. The AIC values were mostly slightly lower in the OLR model or nearly equal in both models. Figures 1 and 2 visually represent the variation of BIC and MSE with different sample sizes and proportions of zeros. The AIC values were slightly lower in OLR or almost equal in both models.
GP: generalized Poisson, OLR: ordinal logistic regression
Figure 1: Bayesian Schwartz Information Criteria (BIC) with varying sample sizes and varying proportions of zeros.
GP: generalized Poisson, OLR: ordinal logistic regression.
Figure 2: Mean square error (MSE) with varying sample sizes and varying proportions of zeros.
The results from three realtime studies are shown in Table 2. The mean (variance) of the studies fir, DMF and ADD were 2.1 (2.4), 3.4 (25.9) and 1.7 (19.5), respectively. The proportion of observed zeros of the outcome was 14%, 45.5% and 60% in the fir, DMF and ADD studies, respectively. The outcome of studies were overdispersed and inflated by zeros according to Poisson model.
Table 2: Results from three realtime data.
Fir

50

 0.021

0.073

184

190

 0.130

0.183

188

201

DMF

440

 0.052

0.123

1937

2009

 0.083

0.174

1997

2031

SE: standard error; AIC: Akaike Information Criteria; BIC: Bayesian Schwartz Information Criteria; DMF: decayed, missing, and filled teeth; ADD: acute diarrheal disease.
Fir data: The Fir dataset (50 observations) demonstrated lower regression coefficients, standard errors (SE), AIC, and BIC values in the GP model compared to the OLR model.
DMF data: In the DMF dataset (440 observations), the GP model showed lower regression coefficients and SE for the gender variable, along with lower AIC and BIC values.
ADD data: The ADD dataset (3720 observations) also displayed lower regression coefficients and SE for the gender variable in the GP model, alongside lower AIC and BIC estimates.
Across all three realtime datasets, the GP model consistently yielded lower SE, suggesting better precision than the OLR model. The OLR model tended to overestimate regression estimates compared to the GP model. Furthermore, the AIC and BIC values consistently favored the GP model over the OLR model, indicating a better model fit in terms of these criteria.
Discussion
Researchers commonly use OLR for outcomes that are count variables. In nature, the count outcome is ordinal in structure.9 In such situations, it is ideal to fit models that are suitable for ordinal data with or without zeros. While there are many models available for count data analysis, it is important to find which model fits the data well in terms of AIC, BIC, and other goodness of fit statistics.
Ordinal regression models have a longstanding history in statistics, offering flexibility in modeling ordinal count outcomes and in aiding model selection.23,24 We have suggested a new statistical GP model tailored for overdispersed count responses inflated by zeros.
Manuguerra and Heller applied ordinal regression to continuous outcomes derived from visual analog scales used in pain assessment.25 A common method for analyzing visual analog scales responses involves grouping and treating them as discrete ordinal responses. This study also assessed the healthrelated quality of life in breast cancer patients after chemotherapy, utilizing Linear Analog SelfAssessment scales. Pain assessment outcomes were analyzed in two ways: ordinal responses using an ordinal model, and continuous responses employing a parametric g function. Similarly, the quality of life outcome was compared between parametric and nonparametric g functions. The GP model emerges as a suitable alternative for such response types.
Kelley and Anderson introduced a mixture model for zeroinflated ordinal outcomes resulting from “never” responses.18 They compared the effectiveness of different models, including PO, partial PO, and ZIPO, using realtime alcohol consumption data. The AIC value was slightly lower in the ZIPO model. In our earlier work on simulation and realtime studies, GP was a better model for zeroinflated outcome compared with mixture Poisson, mixture negative binomial, and ZIP in terms of fit statistics.15 However, this study compared the performance of GP with OLR, and it has shown that the GP model is better as compared to the OLR model.
Our objective was to present a suitable method that enables researchers to more accurately analyze ordinal response outcomes using the GP model. GP could be a better alternative to the ordinal model. Limited studies have explored the application of ordinal models to count data. Our research consistently demonstrates the GP model's superiority to the OLR model, across both real and simulated data.
Our study acknowledges certain limitations, such as the absence of integration of the GP regression method into standard software like SPSS, which may require researchers to use R or Python. Furthermore, the reasons behind divergent findings in cases involving 1000 observations with outcome proportions of 30% and 40% remain unexplained. The scarcity of comparable studies also poses a limitation.
Conclusion
The GP model consistently outperforms the OLR model in terms of bias, MSE, and BIC estimates. The AIC estimates were almost similar or slightly lower in the OLR model. Despite the ease of use of the OLR model, the proposed GP model is recommended due to its better modeling accuracy and interpretation. Our study suggests that the GP model is a superior choice for analyzing ordinal count data compared to the OLR model, offering improved accuracy and ease of interpretation.
Disclosure
The authors declared no conflicts of interest. No funding was received for this study.
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