Principal stratification with recurrent events truncated by a terminal event: A nested Bayesian nonparametric approach

Abstract: Recurrent events often serve as key endpoints in clinical studies but may be prematurely truncated by terminal events such as death, creating selection bias and complicating causal inference. To address this challenge, we propose novel causal estimands within the principal stratification framework, introducing a refined ``always-survivor'' stratum that defines survival until the final recurrent event rather than a fixed time point, yielding more stable and interpretable causal contrasts. We develop a flexible Bayesian nonparametric prior -- the enriched dependent Dirichlet process -- specifically designed for joint modeling of recurrent and terminal events, addressing a critical limitation where standard Dirichlet process priors create random partitions dominated by recurrent events, yielding poor predictive performance for terminal events. Our nested structure separates within-arm and cross-arm dependence through a dual-frailty framework, enabling transparent sensitivity analysis for non-identifiable parameters. Simulations are carried out to show that our method has superior performance compared to existing methods. We also illustrate the proposed Bayesian methods to infer the causal effect of intensive blood pressure control on recurrent cardiovascular events in a cardiovascular clinical trial.