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Lu CY, Penfold RB, Toh S, Sturtevant JL, Madden JM, Simon G, Ahmedani BK, Clarke G, Coleman KJ, Copeland LA, Daida YG, Davis RL, Hunkeler EM, Owen-Smith A, Raebel MA, Rossom R, Soumerai SB, Kulldorff M. Near Real-time Surveillance for Consequences of Health Policies Using Sequential Analysis. Med Care 2018; 56:365-372. [PMID: 29634627 PMCID: PMC5896783 DOI: 10.1097/mlr.0000000000000893] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND New health policies may have intended and unintended consequences. Active surveillance of population-level data may provide initial signals of policy effects for further rigorous evaluation soon after policy implementation. OBJECTIVE This study evaluated the utility of sequential analysis for prospectively assessing signals of health policy impacts. As a policy example, we studied the consequences of the widely publicized Food and Drug Administration's warnings cautioning that antidepressant use could increase suicidal risk in youth. METHOD This was a retrospective, longitudinal study, modeling prospective surveillance, using the maximized sequential probability ratio test. We used historical data (2000-2010) from 11 health systems in the US Mental Health Research Network. The study cohort included adolescents (ages 10-17 y) and young adults (ages 18-29 y), who were targeted by the warnings, and adults (ages 30-64 y) as a comparison group. Outcome measures were observed and expected events of 2 possible unintended policy outcomes: psychotropic drug poisonings (as a proxy for suicide attempts) and completed suicides. RESULTS We detected statistically significant (P<0.05) signals of excess risk for suicidal behavior in adolescents and young adults within 5-7 quarters of the warnings. The excess risk in psychotropic drug poisonings was consistent with results from a previous, more rigorous interrupted time series analysis but use of the maximized sequential probability ratio test method allows timely detection. While we also detected signals of increased risk of completed suicide in these younger age groups, on its own it should not be taken as conclusive evidence that the policy caused the signal. A statistical signal indicates the need for further scrutiny using rigorous quasi-experimental studies to investigate the possibility of a cause-and-effect relationship. CONCLUSIONS This was a proof-of-concept study. Prospective, periodic evaluation of administrative health care data using sequential analysis can provide timely population-based signals of effects of health policies. This method may be useful to use as new policies are introduced.
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Affiliation(s)
- Christine Y Lu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Robert B Penfold
- Department of Health Services Research, Kaiser Permanente Washington Health Research Institute, University of Washington, Seattle, WA
| | - Sengwee Toh
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Jessica L Sturtevant
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Jeanne M Madden
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
- School of Pharmacy, Northeastern University, Boston, MA
| | - Gregory Simon
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Brian K Ahmedani
- Center for Health Policy and Health Services Research and Behavioral Health Services, Henry Ford Health System, Detroit, MI
| | - Gregory Clarke
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Karen J Coleman
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Laurel A Copeland
- Center for Applied Health Research, Baylor Scott & White Health jointly with Central Texas Veterans Health Care System, Temple, TX
| | - Yihe G Daida
- Center for Health Research, Kaiser Permanente Hawaii, Honolulu, HI
| | - Robert L Davis
- Center for Biomedical Informatics, University of Tennessee Health Science Center, Memphis, TN
| | - Enid M Hunkeler
- Emeritus, Division of Research, Kaiser Permanente, Oakland, CA
| | - Ashli Owen-Smith
- Health Management & Policy, Georgia State University School of Public Health, Atlanta, GA
- Kaiser Permanente Georgia, The Center for Clinical and Outcomes Research, Atlanta, GA
| | - Marsha A Raebel
- Kaiser Permanente Colorado, Institute for Health Research, Denver, CO
| | | | - Stephen B Soumerai
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Martin Kulldorff
- Department of Medicine, Division of Pharmacoepidemiology and Pharmacoeconomics, Harvard Medical School and Brigham and Women's Hospital, Boston, MA
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Mayer F, Kirchmayer U, Coletta P, Agabiti N, Belleudi V, Cappai G, Di Martino M, Schneeweiss S, Davoli M, Patorno E. Safety and Effectiveness of Direct Oral Anticoagulants Versus Vitamin K Antagonists: Pilot Implementation of a Near-Real-Time Monitoring Program in Italy. J Am Heart Assoc 2018. [PMID: 29525786 PMCID: PMC5907561 DOI: 10.1161/jaha.117.008034] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Real‐time monitoring is used to the ends of postmarketing observational research on newly marketed drugs. We implemented a pilot near‐real‐time monitoring program on the test case of oral anticoagulants. Specifically, we evaluated the safety and effectiveness of direct oral anticoagulants compared to vitamin K antagonists in nonvalvular atrial fibrillation secondary prevention during 2013‐2015 in the Lazio Region, Italy. Methods and Results A cohort study was conducted using a sequential propensity‐score–matched new user parallel‐cohort design. Sequential analyses were performed using Cox models. Overall, 10 742 patients contributed to the analyses. Compared with vitamin K antagonists, direct oral anticoagulant use was associated with a reduction of all‐cause mortality (0.81; 95% confidence interval [CI] 0.66‐0.99), cardiovascular mortality (0.71; 95% CI 0.54‐0.93), myocardial infarction (0.67; 95% CI 0.43‐1.04), ischemic stroke (0.87; 95% CI 0.52‐1.45), hemorrhagic stroke (0.25; 95% CI 0.07‐0.88), and with a nonsignificant increase of gastrointestinal bleeding (1.26; 95% CI 0.69‐2.30). Conclusions The present pilot study is a cornerstone to develop real‐time monitoring for new drugs in our region.
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Affiliation(s)
- Flavia Mayer
- Department of Epidemiology, Local Health Authority Roma 1 Lazio Regional Health Service, Rome, Italy
| | - Ursula Kirchmayer
- Department of Epidemiology, Local Health Authority Roma 1 Lazio Regional Health Service, Rome, Italy
| | - Paola Coletta
- Centre for Oral Anticoagulant Therapy, Santo Spirito Hospital, Rome, Italy
| | - Nera Agabiti
- Department of Epidemiology, Local Health Authority Roma 1 Lazio Regional Health Service, Rome, Italy
| | - Valeria Belleudi
- Department of Epidemiology, Local Health Authority Roma 1 Lazio Regional Health Service, Rome, Italy
| | - Giovanna Cappai
- Department of Epidemiology, Local Health Authority Roma 1 Lazio Regional Health Service, Rome, Italy
| | - Mirko Di Martino
- Department of Epidemiology, Local Health Authority Roma 1 Lazio Regional Health Service, Rome, Italy
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Marina Davoli
- Department of Epidemiology, Local Health Authority Roma 1 Lazio Regional Health Service, Rome, Italy
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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Kulldorff M, Silva IR. Continuous Post-Market Sequential Safety Surveillance with Minimum Events to Signal. REVSTAT STATISTICAL JOURNAL 2017; 15:373-394. [PMID: 34393695 PMCID: PMC8363220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The CDC Vaccine Safety Datalink project has pioneered the use of near real-time post-market vaccine safety surveillance for the rapid detection of adverse events. Doing weekly analyses, continuous sequential methods are used, allowing investigators to evaluate the data near-continuously while still maintaining the correct overall alpha level. With continuous sequential monitoring, the null hypothesis may be rejected after only one or two adverse events are observed. In this paper, we explore continuous sequential monitoring when we do not allow the null to be rejected until a minimum number of observed events have occurred. We also evaluate continuous sequential analysis with a delayed start until a certain sample size has been attained. Tables with exact critical values, statistical power and the average times to signal are provided. We show that, with the first option, it is possible to both increase the power and reduce the expected time to signal, while keeping the alpha level the same. The second option is only useful if the start of the surveillance is delayed for logistical reasons, when there is a group of data available at the first analysis, followed by continuous or near-continuous monitoring thereafter.
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Affiliation(s)
- Martin Kulldorff
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, USA
| | - Ivair R. Silva
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, USA
- Department of Statistics, Universidad Federal de Ouro Preto, Ouro Preto, Brazil
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Meeker D, Jiang X, Matheny ME, Farcas C, D'Arcy M, Pearlman L, Nookala L, Day ME, Kim KK, Kim H, Boxwala A, El-Kareh R, Kuo GM, Resnic FS, Kesselman C, Ohno-Machado L. A system to build distributed multivariate models and manage disparate data sharing policies: implementation in the scalable national network for effectiveness research. J Am Med Inform Assoc 2015; 22:1187-95. [PMID: 26142423 PMCID: PMC4639714 DOI: 10.1093/jamia/ocv017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 02/18/2015] [Indexed: 11/29/2022] Open
Abstract
Background Centralized and federated models for sharing data in research networks currently exist. To build multivariate data analysis for centralized networks, transfer of patient-level data to a central computation resource is necessary. The authors implemented distributed multivariate models for federated networks in which patient-level data is kept at each site and data exchange policies are managed in a study-centric manner. Objective The objective was to implement infrastructure that supports the functionality of some existing research networks (e.g., cohort discovery, workflow management, and estimation of multivariate analytic models on centralized data) while adding additional important new features, such as algorithms for distributed iterative multivariate models, a graphical interface for multivariate model specification, synchronous and asynchronous response to network queries, investigator-initiated studies, and study-based control of staff, protocols, and data sharing policies. Materials and Methods Based on the requirements gathered from statisticians, administrators, and investigators from multiple institutions, the authors developed infrastructure and tools to support multisite comparative effectiveness studies using web services for multivariate statistical estimation in the SCANNER federated network. Results The authors implemented massively parallel (map-reduce) computation methods and a new policy management system to enable each study initiated by network participants to define the ways in which data may be processed, managed, queried, and shared. The authors illustrated the use of these systems among institutions with highly different policies and operating under different state laws. Discussion and Conclusion Federated research networks need not limit distributed query functionality to count queries, cohort discovery, or independently estimated analytic models. Multivariate analyses can be efficiently and securely conducted without patient-level data transport, allowing institutions with strict local data storage requirements to participate in sophisticated analyses based on federated research networks.
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Affiliation(s)
- Daniella Meeker
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA Information Sciences Institute, University of Southern California, Marina Del Rey, CA
| | - Xiaoqian Jiang
- Department of Biomedical Informatics, University of California San Diego, La Jolla, CA 92093
| | - Michael E Matheny
- Geriatrics Research, Education, and Clinical Care Service Department of Biomedical Informatics, Division of General Internal Medicine, Department of Biostatistics
| | - Claudiu Farcas
- Department of Biomedical Informatics, University of California San Diego, La Jolla, CA 92093
| | - Michel D'Arcy
- Information Sciences Institute, University of Southern California, Marina Del Rey, CA
| | - Laura Pearlman
- Information Sciences Institute, University of Southern California, Marina Del Rey, CA
| | | | - Michele E Day
- Department of Biomedical Informatics, University of California San Diego, La Jolla, CA 92093
| | - Katherine K Kim
- Department of Pathology and Laboratory Medicine and Department of Internal Medicine, University of California Davis, Sacramento, CA
| | - Hyeoneui Kim
- Department of Biomedical Informatics, University of California San Diego, La Jolla, CA 92093
| | - Aziz Boxwala
- Department of Biomedical Informatics, University of California San Diego, La Jolla, CA 92093
| | - Robert El-Kareh
- Department of Biomedical Informatics, University of California San Diego, La Jolla, CA 92093
| | - Grace M Kuo
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego
| | | | - Carl Kesselman
- Information Sciences Institute, University of Southern California, Marina Del Rey, CA
| | - Lucila Ohno-Machado
- Department of Biomedical Informatics, University of California San Diego, La Jolla, CA 92093
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Abstract
Adverse drug events (ADEs) are an important public health concern, accounting for 5% of all hospital admissions and two-thirds of all complications occurring shortly after hospital discharge. There are often long delays between when a drug is approved and when serious ADEs are identified. Recent and ongoing advances in drug safety surveillance include the establishment of government-sponsored networks of population databases, the use of data mining approaches, and the formal integration of diverse sources of drug safety information. These advances promise to reduce delays in identifying drug-related risks and in providing reassurance about the absence of such risks.
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Affiliation(s)
- Sean Hennessy
- Center for Pharmacoepidemiology Research and Training; Center for Clinical Epidemiology and Biostatistics; Department of Biostatistics and Epidemiology; and Department of Pharmacology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104;
| | - Brian L. Strom
- Rutgers the State University of New Jersey, Newark, New Jersey 07103, and Center for Pharmacoepidemiology Research and Training; Center for Clinical Epidemiology and Biostatistics; and Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104;
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6
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Franks R, Sandhu S, Avagyan A, Lu Y, Hong H, Garcia B, Worrall C, Kelman J, Ball R, MaCurdy T. Robustness properties of a sequential test for vaccine safety in the presence of misspecification. Stat Anal Data Min 2014. [DOI: 10.1002/sam.11234] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
| | | | | | - Yun Lu
- Food and Drug Administration (FDA); Silver Spring MD USA
| | - Han Hong
- Acumen, LLC; Burlingame CA 94010 USA
- Department of Economics; Stanford University; Palo Alto CA >USA
| | | | | | - Jeffrey Kelman
- Centers for Medicare and Medicaid Services (CMS); Baltimore MD USA
| | - Robert Ball
- Food and Drug Administration (FDA); Silver Spring MD USA
| | - Thomas MaCurdy
- Acumen, LLC; Burlingame CA 94010 USA
- Department of Economics; Stanford University; Palo Alto CA >USA
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7
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Abstract
BACKGROUND Postmarket surveillance of the comparative safety and efficacy of orphan therapeutics is challenging, particularly when multiple therapeutics are licensed for the same orphan indication. To make best use of product-specific registry data collected to fulfill regulatory requirements, we propose the creation of a distributed electronic health data network among registries. Such a network could support sequential statistical analyses designed to detect early warnings of excess risks. We use a simulated example to explore the circumstances under which a distributed network may prove advantageous. METHODS We perform sample size calculations for sequential and non-sequential statistical studies aimed at comparing the incidence of hepatotoxicity following initiation of two newly licensed therapies for homozygous familial hypercholesterolemia. We calculate the sample size savings ratio, or the proportion of sample size saved if one conducted a sequential study as compared to a non-sequential study. Then, using models to describe the adoption and utilization of these therapies, we simulate when these sample sizes are attainable in calendar years. We then calculate the analytic calendar time savings ratio, analogous to the sample size savings ratio. We repeat these analyses for numerous scenarios. KEY RESULTS Sequential analyses detect effect sizes earlier or at the same time as non-sequential analyses. The most substantial potential savings occur when the market share is more imbalanced (i.e., 90% for therapy A) and the effect size is closest to the null hypothesis. However, due to low exposure prevalence, these savings are difficult to realize within the 30-year time frame of this simulation for scenarios in which the outcome of interest occurs at or more frequently than one event/100 person-years. CONCLUSIONS We illustrate a process to assess whether sequential statistical analyses of registry data performed via distributed networks may prove a worthwhile infrastructure investment for pharmacovigilance.
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Affiliation(s)
- Judith C Maro
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 133 Brookline Avenue, 6th Floor, Boston, MA, 02215, USA,
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8
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Maro JC, Brown JS, Dal Pan GJ, Kulldorff M. Minimizing signal detection time in postmarket sequential analysis: balancing positive predictive value and sensitivity. Pharmacoepidemiol Drug Saf 2014; 23:839-48. [PMID: 24700557 DOI: 10.1002/pds.3618] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 02/28/2014] [Accepted: 02/28/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE Outcome misclassification in retrospective epidemiologic analyses has been well-studied, but little is known about such misclassification with respect to sequential statistical analysis during surveillance of medical product-associated risks, a planned capability of the US Food and Drug Administration's Sentinel System. METHODS Using a vaccine example, we model and simulate sequential database surveillance in an observational data network using a variety of outcome detection algorithms. We consider how these algorithms, as characterized by sensitivity and positive predictive value, impact the length of surveillance and timeliness of safety signal detection. We show investigators/users of these networks how they can perform preparatory study design calculations that consider outcome misclassification in sequential database surveillance. RESULTS Non-differential outcome misclassification generates longer surveillance times and less timely safety signal detection as compared with the case of no misclassification. Inclusive algorithms characterized by high sensitivity but low positive predictive value outperform more narrow algorithms when detecting rare outcomes. This decision calculus may change considerably if medical chart validation procedures were required. CONCLUSIONS These findings raise important questions regarding the design of observational data networks used for pharmacovigilance. Specifically, there are tradeoffs involved when choosing to populate such networks with component databases that are large as compared with smaller integrated delivery system databases that can more easily access laboratory or clinical data and perform medical chart validation.
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Affiliation(s)
- Judith C Maro
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
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