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Yang S, Starks MA, Hernandez AF, Turner EL, Califf RM, O'Connor CM, Mentz RJ, Roy Choudhury K. Impact of baseline covariate imbalance on bias in treatment effect estimation in cluster randomized trials: Race as an example. Contemp Clin Trials 2020; 88:105775. [PMID: 31228563 PMCID: PMC8337048 DOI: 10.1016/j.cct.2019.04.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 04/21/2019] [Accepted: 04/25/2019] [Indexed: 12/31/2022]
Abstract
Individual-level baseline covariate imbalance could happen more frequently in cluster randomized trials, and may influence the observed treatment effect. Using computer and real-data simulations, this paper quantifies the extent and impact of covariate imbalance on the estimated treatment effect for both continuous and binary outcomes, and relates it to the degree of imbalance for different numbers of clusters, cluster sizes, and covariate intraclass correlation coefficients. We focused on the impact of race as a covariate, given the emphasis of regulatory and funding bodies on understanding the influence of demographic characteristics on treatment effectiveness. We found that bias in the treatment effect is proportional to both the degree of baseline covariate imbalance and the covariate effect size. Larger numbers of clusters result in lower covariate imbalance, and increasing cluster size is less effective in reducing imbalance compared to increasing the number of clusters. Models adjusted for important baseline confounders are superior to unadjusted models for minimizing bias in both model-based simulations and an innovative simulation based on real clinical trial data. Higher outcome intraclass correlation coefficients did not affect bias but resulted in greater variance in treatment estimates.
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Affiliation(s)
- Siyun Yang
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, United States of America
| | - Monique Anderson Starks
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States of America.
| | - Adrian F Hernandez
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States of America
| | - Elizabeth L Turner
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, United States of America; Duke Global Health Institute, Duke University, Durham, NC, United States of America
| | - Robert M Califf
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States of America
| | | | - Robert J Mentz
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States of America
| | - Kingshuk Roy Choudhury
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, United States of America
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Luo N, Merrill P, Parikh KS, Whellan DJ, Piña IL, Fiuzat M, Kraus WE, Kitzman DW, Keteyian SJ, O'Connor CM, Mentz RJ. Exercise Training in Patients With Chronic Heart Failure and Atrial Fibrillation. J Am Coll Cardiol 2017; 69:1683-1691. [PMID: 28359513 DOI: 10.1016/j.jacc.2017.01.032] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Revised: 12/15/2016] [Accepted: 01/09/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND The safety and efficacy of aerobic exercise in heart failure (HF) patients with atrial fibrillation (AF) has not been well evaluated. OBJECTIVES This study examined whether outcomes with exercise training in HF vary according to AF status. METHODS HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) randomized 2,331 ambulatory HF patients with ejection fraction ≤35% to exercise training or usual care. We examined clinical characteristics and outcomes (mortality/hospitalization) by baseline AF status (past history of AF or AF on baseline electrocardiogram vs. no AF) using adjusted Cox models and explored an interaction with exercise training. We assessed post-randomization AF events diagnosed via hospitalizations for AF and reports of serious arrhythmia caused by AF. RESULTS Of 2,292 patients with baseline rhythm data, 382 (17%) had AF, 1,602 (70%) had sinus rhythm, and 308 (13%) had "other" rhythm. Patients with AF were older and had lower peak Vo2. Over a median follow-up of 2.6 years, AF was associated with a 24% per year higher rate of mortality/hospitalization (hazard ratio [HR]: 1.53; 95% confidence interval [CI]: 1.34 to 1.74; p < 0.001) in unadjusted analysis; this did not remain significant after adjustment (HR: 1.15; 95% CI: 0.98 to 1.35; p = 0.09). There was no significant difference in AF event rates by randomized treatment assignment in the overall population or by baseline AF status (all p > 0.10). There was no interaction between AF and exercise training on measures of functional status or clinical outcomes (all p > 0.10). CONCLUSIONS AF in patients with chronic HF was associated with older age, reduced exercise capacity at baseline, and a higher overall rate of clinical events, but not a differential response to exercise training for clinical outcomes or changes in exercise capacity. (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training [HF-ACTION]; NCT00047437).
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Affiliation(s)
- Nancy Luo
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
| | - Peter Merrill
- Duke Clinical Research Institute, Durham, North Carolina
| | - Kishan S Parikh
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | | | - Ileana L Piña
- Montefiore-Einstein Medical Center, New York, New York
| | - Mona Fiuzat
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - William E Kraus
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | | | | | - Christopher M O'Connor
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
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Cooper LB, Mentz RJ, Sun JL, Schulte PJ, Fleg JL, Cooper LS, Piña IL, Leifer ES, Kraus WE, Whellan DJ, Keteyian SJ, O'Connor CM. Psychosocial Factors, Exercise Adherence, and Outcomes in Heart Failure Patients: Insights From Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training (HF-ACTION). Circ Heart Fail 2016; 8:1044-51. [PMID: 26578668 DOI: 10.1161/circheartfailure.115.002327] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Psychosocial factors may influence adherence with exercise training for heart failure (HF) patients. We aimed to describe the association between social support and barriers to participation with exercise adherence and clinical outcomes. METHODS AND RESULTS Of patients enrolled in Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training (HF-ACTION), 2279 (97.8%) completed surveys to assess social support and barriers to exercise, resulting in the perceived social support score (PSSS) and barriers to exercise score (BTES). Higher PSSS indicated higher levels of social support, whereas higher BTES indicated more barriers to exercise. Exercise time at 3 and 12 months correlated with PSSS (r= 0.09 and r= 0.13, respectively) and BTES (r=-0.11 and r=-0.12, respectively), with higher exercise time associated with higher PSSS and lower BTES (All P<0.005). For cardiovascular death or HF hospitalization, there was a significant interaction between the randomization group and BTES (P=0.035), which corresponded to a borderline association between increasing BTES and cardiovascular death or HF hospitalization in the exercise group (hazard ratio 1.25, 95% confidence interval 0.99, 1.59), but no association in the usual care group (hazard ratio 0.83, 95% confidence interval 0.66, 1.06). CONCLUSIONS Poor social support and high barriers to exercise were associated with lower exercise time. PSSS did not impact the effect of exercise training on outcomes. However, for cardiovascular death or HF hospitalization, exercise training had a greater impact on patients with lower BTES. Given that exercise training improves outcomes in HF patients, assessment of perceived barriers may facilitate individualized approaches to implement exercise training therapy in clinical practice. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00047437.
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Affiliation(s)
- Lauren B Cooper
- From the Duke Clinical Research Institute (L.B.C., R.J.M., J.-L.S., P.J.S., C.M.O'C.), and Department of Medicine (L.B.C., R.J.M., W.E.K., C.M.O'C.), Duke University School of Medicine, Durham, NC; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F., L.S.C., E.S.L.); Division of Cardiology, Albert Einstein College of Medicine, Bronx, NY (I.L.P.); Division of Cardiology, Jefferson Medical College, Philadelphia, PA (D.J.W.); and Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (S.J.K.).
| | - Robert J Mentz
- From the Duke Clinical Research Institute (L.B.C., R.J.M., J.-L.S., P.J.S., C.M.O'C.), and Department of Medicine (L.B.C., R.J.M., W.E.K., C.M.O'C.), Duke University School of Medicine, Durham, NC; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F., L.S.C., E.S.L.); Division of Cardiology, Albert Einstein College of Medicine, Bronx, NY (I.L.P.); Division of Cardiology, Jefferson Medical College, Philadelphia, PA (D.J.W.); and Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (S.J.K.)
| | - Jie-Lena Sun
- From the Duke Clinical Research Institute (L.B.C., R.J.M., J.-L.S., P.J.S., C.M.O'C.), and Department of Medicine (L.B.C., R.J.M., W.E.K., C.M.O'C.), Duke University School of Medicine, Durham, NC; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F., L.S.C., E.S.L.); Division of Cardiology, Albert Einstein College of Medicine, Bronx, NY (I.L.P.); Division of Cardiology, Jefferson Medical College, Philadelphia, PA (D.J.W.); and Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (S.J.K.)
| | - Phillip J Schulte
- From the Duke Clinical Research Institute (L.B.C., R.J.M., J.-L.S., P.J.S., C.M.O'C.), and Department of Medicine (L.B.C., R.J.M., W.E.K., C.M.O'C.), Duke University School of Medicine, Durham, NC; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F., L.S.C., E.S.L.); Division of Cardiology, Albert Einstein College of Medicine, Bronx, NY (I.L.P.); Division of Cardiology, Jefferson Medical College, Philadelphia, PA (D.J.W.); and Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (S.J.K.)
| | - Jerome L Fleg
- From the Duke Clinical Research Institute (L.B.C., R.J.M., J.-L.S., P.J.S., C.M.O'C.), and Department of Medicine (L.B.C., R.J.M., W.E.K., C.M.O'C.), Duke University School of Medicine, Durham, NC; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F., L.S.C., E.S.L.); Division of Cardiology, Albert Einstein College of Medicine, Bronx, NY (I.L.P.); Division of Cardiology, Jefferson Medical College, Philadelphia, PA (D.J.W.); and Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (S.J.K.)
| | - Lawton S Cooper
- From the Duke Clinical Research Institute (L.B.C., R.J.M., J.-L.S., P.J.S., C.M.O'C.), and Department of Medicine (L.B.C., R.J.M., W.E.K., C.M.O'C.), Duke University School of Medicine, Durham, NC; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F., L.S.C., E.S.L.); Division of Cardiology, Albert Einstein College of Medicine, Bronx, NY (I.L.P.); Division of Cardiology, Jefferson Medical College, Philadelphia, PA (D.J.W.); and Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (S.J.K.)
| | - Ileana L Piña
- From the Duke Clinical Research Institute (L.B.C., R.J.M., J.-L.S., P.J.S., C.M.O'C.), and Department of Medicine (L.B.C., R.J.M., W.E.K., C.M.O'C.), Duke University School of Medicine, Durham, NC; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F., L.S.C., E.S.L.); Division of Cardiology, Albert Einstein College of Medicine, Bronx, NY (I.L.P.); Division of Cardiology, Jefferson Medical College, Philadelphia, PA (D.J.W.); and Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (S.J.K.)
| | - Eric S Leifer
- From the Duke Clinical Research Institute (L.B.C., R.J.M., J.-L.S., P.J.S., C.M.O'C.), and Department of Medicine (L.B.C., R.J.M., W.E.K., C.M.O'C.), Duke University School of Medicine, Durham, NC; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F., L.S.C., E.S.L.); Division of Cardiology, Albert Einstein College of Medicine, Bronx, NY (I.L.P.); Division of Cardiology, Jefferson Medical College, Philadelphia, PA (D.J.W.); and Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (S.J.K.)
| | - William E Kraus
- From the Duke Clinical Research Institute (L.B.C., R.J.M., J.-L.S., P.J.S., C.M.O'C.), and Department of Medicine (L.B.C., R.J.M., W.E.K., C.M.O'C.), Duke University School of Medicine, Durham, NC; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F., L.S.C., E.S.L.); Division of Cardiology, Albert Einstein College of Medicine, Bronx, NY (I.L.P.); Division of Cardiology, Jefferson Medical College, Philadelphia, PA (D.J.W.); and Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (S.J.K.)
| | - David J Whellan
- From the Duke Clinical Research Institute (L.B.C., R.J.M., J.-L.S., P.J.S., C.M.O'C.), and Department of Medicine (L.B.C., R.J.M., W.E.K., C.M.O'C.), Duke University School of Medicine, Durham, NC; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F., L.S.C., E.S.L.); Division of Cardiology, Albert Einstein College of Medicine, Bronx, NY (I.L.P.); Division of Cardiology, Jefferson Medical College, Philadelphia, PA (D.J.W.); and Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (S.J.K.)
| | - Steven J Keteyian
- From the Duke Clinical Research Institute (L.B.C., R.J.M., J.-L.S., P.J.S., C.M.O'C.), and Department of Medicine (L.B.C., R.J.M., W.E.K., C.M.O'C.), Duke University School of Medicine, Durham, NC; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F., L.S.C., E.S.L.); Division of Cardiology, Albert Einstein College of Medicine, Bronx, NY (I.L.P.); Division of Cardiology, Jefferson Medical College, Philadelphia, PA (D.J.W.); and Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (S.J.K.)
| | - Christopher M O'Connor
- From the Duke Clinical Research Institute (L.B.C., R.J.M., J.-L.S., P.J.S., C.M.O'C.), and Department of Medicine (L.B.C., R.J.M., W.E.K., C.M.O'C.), Duke University School of Medicine, Durham, NC; Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (J.L.F., L.S.C., E.S.L.); Division of Cardiology, Albert Einstein College of Medicine, Bronx, NY (I.L.P.); Division of Cardiology, Jefferson Medical College, Philadelphia, PA (D.J.W.); and Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (S.J.K.)
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Piña IL, Bittner V, Clare RM, Swank A, Kao A, Safford R, Nigam A, Barnard D, Walsh MN, Ellis SJ, Keteyian SJ. Effects of exercise training on outcomes in women with heart failure: analysis of HF-ACTION (Heart Failure-A Controlled Trial Investigating Outcomes of Exercise TraiNing) by sex. JACC-HEART FAILURE 2014; 2:180-6. [PMID: 24720927 DOI: 10.1016/j.jchf.2013.10.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 10/11/2013] [Accepted: 10/15/2013] [Indexed: 12/31/2022]
Abstract
OBJECTIVES The authors hypothesized that the women enrolled in the HF-ACTION (Heart Failure-A Controlled Trial Investigating Outcomes of Exercise TraiNing) trial and randomly assigned to exercise training (ET) would improve functional capacity as measured by peak oxygen uptake (VO2) compared with those in the usual care group. Furthermore, they hypothesized that the improvement in peak VO2 would correlate with prognosis. They explored whether exercise had a differential effect on outcomes in women versus men. BACKGROUND There is less evidence for the benefit of ET in women with heart failure (HF) compared with men because of the small numbers of women studied. METHODS HF-ACTION was a randomized trial of ET versus usual care in 2,331 patients with class II-IV HF and a left ventricular ejection fraction of ≤35%. Sex differences in the effects of randomized treatment on clinical outcomes were assessed through the use of a series of Cox proportional hazards models, controlling for covariates known to affect prognosis in HF-ACTION. RESULTS Women had lower baseline peak VO2 and 6-min walk distance than did men (median, 13.4 vs. 14.9 ml/min/kg and 353 vs. 378 m, respectively). An increase in peak VO2 at 3 months was present in women and men in the ET group (mean ± SD; median, 0.88 ± 2.2, 0.80 and 0.77 ± 2.7, 0.60, respectively, women vs. men; p = 0.42). Women randomly assigned to ET had a significant reduction in the primary endpoint, (hazard ratio: 0.74) compared with men (hazard ratio: 0.99) randomly assigned to ET, with a significant treatment-by-sex interaction (p = 0.027). CONCLUSIONS Although there is no significant difference between men and women in the effect of ET on peak VO2 change at 3 months, ET in women with HF is associated with a larger reduction in rate of the combined endpoint of all-cause mortality and hospital stay than in men.
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Affiliation(s)
- Ileana L Piña
- Division of Cardiology, Montefiore-Einstein Medical Center, Bronx, New York.
| | - Vera Bittner
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert M Clare
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Ann Swank
- University of Louisville, Louisville, Kentucky
| | - Andrew Kao
- University of Missouri-Kansas City, Kansas City, Missouri
| | - Robert Safford
- Mayo Clinic, Division of Cardiovascular Diseases, Jacksonville, Florida
| | - Anil Nigam
- Montreal Heart Institute/University of Montreal, Montreal, Quebec, Canada
| | - Denise Barnard
- University of California Health System, San Diego, California
| | - Mary N Walsh
- St. Vincent Heart Center of Indiana, Indianapolis, Indiana
| | - Stephen J Ellis
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
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