On the relevance of prognostic information for clinical trials: A theoretical quantification

Digital twins and Bayesian dynamic borrowing: Two recent approaches for incorporating historical control data

Recent years have seen an increasing interest in incorporating external control data for designing and evaluating randomized clinical trials (RCT). This may decrease costs and shorten inclusion times by reducing sample sizes. For small populations, with limited recruitment, this can be especially important. Bayesian dynamic borrowing (BDB) has been a popular choice as it claims to protect against potential prior data conflict. Digital twins (DT) has recently been proposed as another method to utilize historical data. DT, also known as PROCOVA™, is based on constructing a prognostic score from historical control data, typically using machine learning. This score is included in a pre-specified ANCOVA as the primary analysis of the RCT. The promise of this idea is power increase while guaranteeing strong type 1 error control. In this paper, we apply analytic derivations and simulations to analyze and discuss examples of these two approaches. We conclude that BDB and DT, although similar in scope, have fundamental differences which need be considered in the specific application. The inflation of the type 1 error is a serious issue for BDB, while more evidence is needed of a tangible value of DT for real RCTs.

The analysis of continuous data from n-of-1 trials using paired cycles: a simple tutorial

N-of-1 trials are defined and the popular paired cycle design is introduced, together with an explanation as to how suitable sequences may be constructed.Various approaches to analysing such trials are explained and illustrated using a simulated data set. It is explained how choosing an appropriate analysis depends on the question one wishes to answer. It is also shown that for a given question, various equivalent approaches to analysis can be found, a fact which may be exploited to expand the possible software routines that may be used.Sets of N-of-1 trials are analogous to sets of parallel group trials. This means that software for carrying out meta-analysis can be used to combine results from N-of-1 trials. In doing so, it is necessary to make one important change, however. Because degrees of freedom for estimating variances for individual subjects will be scarce, it is advisable to estimate local standard errors using pooled variances. How this may be done is explained and fixed and random effect approaches to combining results are illustrated.

"Super-covariates": Using predicted control group outcome as a covariate in randomized clinical trials

The power of randomized controlled clinical trials to demonstrate the efficacy of a drug compared with a control group depends not just on how efficacious the drug is, but also on the variation in patients' outcomes. Adjusting for prognostic covariates during trial analysis can reduce this variation. For this reason, the primary statistical analysis of a clinical trial is often based on regression models that besides terms for treatment and some further terms (e.g., stratification factors used in the randomization scheme of the trial) also includes a baseline (pre-treatment) assessment of the primary outcome. We suggest to include a "super-covariate"-that is, a patient-specific prediction of the control group outcome-as a further covariate (but not as an offset). We train a prognostic model or ensembles of such models on the individual patient (or aggregate) data of other studies in similar patients, but not the new trial under analysis. This has the potential to use historical data to increase the power of clinical trials and avoids the concern of type I error inflation with Bayesian approaches, but in contrast to them has a greater benefit for larger sample sizes. It is important for prognostic models behind "super-covariates" to generalize well across different patient populations in order to similarly reduce unexplained variability whether the trial(s) to develop the model are identical to the new trial or not. In an example in neovascular age-related macular degeneration we saw efficiency gains from the use of a "super-covariate".