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Pitfalls and perils of survival analysis under incorrect assumptions: the case of COVID-19 data. BIOMEDICA 2021; 41:21-28. [PMID: 34669275 PMCID: PMC8582431 DOI: 10.7705/biomedica.5987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Indexed: 12/15/2022]
Abstract
Non-parametric survival analysis has become a very popular statistical method in current medical research. However, resorting to survival analysis when its fundamental assumptions are not fulfilled can severely bias the results. Currently, hundreds of clinical studies are using survival methods to investigate factors potentially associated with the prognosis of coronavirus disease 2019 (COVID-19) and test new preventive and therapeutic strategies. In the pandemic era, it is more critical than ever to base decision-making on evidence and rely on solid statistical methods, but this is not always the case. Serious methodological errors have been identified in recent seminal studies about COVID-19: One reporting outcomes of patients treated with remdesivir and another one on the epidemiology, clinical course, and outcomes of critically ill patients. High-quality evidence is essential to inform clinicians about optimal COVID-19 therapies and policymakers about the true effect of preventive measures aiming to tackle the pandemic. Though timely evidence is needed, we should encourage the appropriate application of survival analysis methods and careful peer-review to avoid publishing flawed results, which could affect decision-making. In this paper, we recapitulate the basic assumptions underlying non-parametric survival analysis and frequent errors in its application and discuss how to handle data on COVID-19.
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Gunasekeran DV, Tseng RMWW, Tham YC, Wong TY. Applications of digital health for public health responses to COVID-19: a systematic scoping review of artificial intelligence, telehealth and related technologies. NPJ Digit Med 2021; 4:40. [PMID: 33637833 PMCID: PMC7910557 DOI: 10.1038/s41746-021-00412-9] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 01/15/2021] [Indexed: 12/29/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has overwhelmed healthcare services, faced with the twin challenges in acutely meeting the medical needs of patients with COVID-19 while continuing essential services for non-COVID-19 illnesses. The need to re-invent, re-organize and transform healthcare and co-ordinate clinical services at a population level is urgent as countries that controlled initial outbreaks start to experience resurgences. A wide range of digital health solutions have been proposed, although the extent of successful real-world applications of these technologies is unclear. This study aims to review applications of artificial intelligence (AI), telehealth, and other relevant digital health solutions for public health responses in the healthcare operating environment amidst the COVID-19 pandemic. A systematic scoping review was performed to identify potentially relevant reports. Key findings include a large body of evidence for various clinical and operational applications of telehealth (40.1%, n = 99/247). Although a large quantity of reports investigated applications of artificial intelligence (AI) (44.9%, n = 111/247) and big data analytics (36.0%, n = 89/247), weaknesses in study design limit generalizability and translation, highlighting the need for more pragmatic real-world investigations. There were also few descriptions of applications for the internet of things (IoT) (2.0%, n = 5/247), digital platforms for communication (DC) (10.9%, 27/247), digital solutions for data management (DM) (1.6%, n = 4/247), and digital structural screening (DS) (8.9%, n = 22/247); representing gaps and opportunities for digital public health. Finally, the performance of digital health technology for operational applications related to population surveillance and points of entry have not been adequately evaluated.
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Affiliation(s)
- Dinesh Visva Gunasekeran
- Singapore Eye Research Institute (SERI), Singapore National Eye Center (SNEC), Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore
| | | | - Yih-Chung Tham
- Singapore Eye Research Institute (SERI), Singapore National Eye Center (SNEC), Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore
| | - Tien Yin Wong
- Singapore Eye Research Institute (SERI), Singapore National Eye Center (SNEC), Singapore, Singapore. .,Yong Loo Lin School of Medicine, National University of Singapore (NUS), Singapore, Singapore. .,Duke-NUS Medical School, Singapore, Singapore.
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Janiaud P, Axfors C, van't Hooft J, Saccilotto R, Agarwal A, Appenzeller-Herzog C, Contopoulos-Ioannidis DG, Danchev V, Dirnagl U, Ewald H, Gartlehner G, Goodman SN, Haber NA, Ioannidis AD, Ioannidis JPA, Lythgoe MP, Ma W, Macleod M, Malički M, Meerpohl JJ, Min Y, Moher D, Nagavci B, Naudet F, Pauli-Magnus C, O'Sullivan JW, Riedel N, Roth JA, Sauermann M, Schandelmaier S, Schmitt AM, Speich B, Williamson PR, Hemkens LG. The worldwide clinical trial research response to the COVID-19 pandemic - the first 100 days. F1000Res 2020; 9:1193. [PMID: 33082937 PMCID: PMC7539080 DOI: 10.12688/f1000research.26707.2] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2020] [Indexed: 12/13/2022] Open
Abstract
Background: Never before have clinical trials drawn as much public attention as those testing interventions for COVID-19. We aimed to describe the worldwide COVID-19 clinical research response and its evolution over the first 100 days of the pandemic. Methods: Descriptive analysis of planned, ongoing or completed trials by April 9, 2020 testing any intervention to treat or prevent COVID-19, systematically identified in trial registries, preprint servers, and literature databases. A survey was conducted of all trials to assess their recruitment status up to July 6, 2020. Results: Most of the 689 trials (overall target sample size 396,366) were small (median sample size 120; interquartile range [IQR] 60-300) but randomized (75.8%; n=522) and were often conducted in China (51.1%; n=352) or the USA (11%; n=76). 525 trials (76.2%) planned to include 155,571 hospitalized patients, and 25 (3.6%) planned to include 96,821 health-care workers. Treatments were evaluated in 607 trials (88.1%), frequently antivirals (n=144) or antimalarials (n=112); 78 trials (11.3%) focused on prevention, including 14 vaccine trials. No trial investigated social distancing. Interventions tested in 11 trials with >5,000 participants were also tested in 169 smaller trials (median sample size 273; IQR 90-700). Hydroxychloroquine alone was investigated in 110 trials. While 414 trials (60.0%) expected completion in 2020, only 35 trials (4.1%; 3,071 participants) were completed by July 6. Of 112 trials with detailed recruitment information, 55 had recruited <20% of the targeted sample; 27 between 20-50%; and 30 over 50% (median 14.8% [IQR 2.0-62.0%]). Conclusions: The size and speed of the COVID-19 clinical trials agenda is unprecedented. However, most trials were small investigating a small fraction of treatment options. The feasibility of this research agenda is questionable, and many trials may end in futility, wasting research resources. Much better coordination is needed to respond to global health threats.
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Affiliation(s)
- Perrine Janiaud
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University,, Stanford, California, USA
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Cathrine Axfors
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University,, Stanford, California, USA
- Department for Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Janneke van't Hooft
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University,, Stanford, California, USA
- Amsterdam University Medical Center, Amsterdam University, Amsterdam, The Netherlands
| | - Ramon Saccilotto
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University,, Stanford, California, USA
| | - Arnav Agarwal
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Valentin Danchev
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University,, Stanford, California, USA
- Stanford Prevention Research Center, Department of Medicine,, Stanford University School of Medicine, Stanford, California, USA
| | - Ulrich Dirnagl
- QUEST Center for Transforming Biomedical Research, Berlin Institute of Health, Berlin, Germany
| | - Hannah Ewald
- University Medical Library, University of Basel, Basel, Switzerland
| | - Gerald Gartlehner
- Department for Evidence-based Medicine and Evaluation, Danube University Krems, Krems, Austria
- RTI International, Research Triangle Park Laboratories, Raleigh, North Carolina, USA
| | - Steven N. Goodman
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University,, Stanford, California, USA
- Stanford University School of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - Noah A. Haber
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University,, Stanford, California, USA
| | - Angeliki Diotima Ioannidis
- Molecular Toxicology Interdepartmental Program, University of California, Los Angeles, Los Angeles, California, USA
| | - John P. A. Ioannidis
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University,, Stanford, California, USA
- Stanford Prevention Research Center, Department of Medicine,, Stanford University School of Medicine, Stanford, California, USA
- Stanford University School of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, USA
- Meta-Research Innovation Center Berlin (METRIC-B), Berlin Institute of Health, Berlin, Germany
| | - Mark P. Lythgoe
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - Wenyan Ma
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Malcolm Macleod
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Mario Malički
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University,, Stanford, California, USA
| | - Joerg J. Meerpohl
- Institute for Evidence in Medicine, Medical Center and Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Yan Min
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University,, Stanford, California, USA
- Stanford University School of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - David Moher
- Centre for Journalology, Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa, Canada
| | - Blin Nagavci
- Institute for Evidence in Medicine, Medical Center and Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Florian Naudet
- CHU Rennes, Inserm, CIC 1414 [(Centre d’Investigation Clinique de Rennes)],, University of Rennes 1, Rennes, France
| | | | - Jack W. O'Sullivan
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University,, Stanford, California, USA
- Division of Cardiology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Nico Riedel
- QUEST Center for Transforming Biomedical Research, Berlin Institute of Health, Berlin, Germany
| | - Jan A. Roth
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Mandy Sauermann
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Stefan Schandelmaier
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Andreas M. Schmitt
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Deparment of Medical Oncology, University Hospital Basel, Basel, Switzerland
| | - Benjamin Speich
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Paula R. Williamson
- MRC/NIHR Trials Methodology Research Partnership, University of Liverpool, Liverpool, UK
| | - Lars G. Hemkens
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University,, Stanford, California, USA
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Meta-Research Innovation Center Berlin (METRIC-B), Berlin Institute of Health, Berlin, Germany
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Janiaud P, Axfors C, van't Hooft J, Saccilotto R, Agarwal A, Appenzeller-Herzog C, Contopoulos-Ioannidis DG, Danchev V, Dirnagl U, Ewald H, Gartlehner G, Goodman SN, Haber NA, Ioannidis AD, Ioannidis JPA, Lythgoe MP, Ma W, Macleod M, Malički M, Meerpohl JJ, Min Y, Moher D, Nagavci B, Naudet F, Pauli-Magnus C, O'Sullivan JW, Riedel N, Roth JA, Sauermann M, Schandelmaier S, Schmitt AM, Speich B, Williamson PR, Hemkens LG. The worldwide clinical trial research response to the COVID-19 pandemic - the first 100 days. F1000Res 2020; 9:1193. [PMID: 33082937 PMCID: PMC7539080 DOI: 10.12688/f1000research.26707.1] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2020] [Indexed: 12/13/2022] Open
Abstract
Background: Never before have clinical trials drawn as much public attention as those testing interventions for COVID-19. We aimed to describe the worldwide COVID-19 clinical research response and its evolution over the first 100 days of the pandemic. Methods: Descriptive analysis of planned, ongoing or completed trials by April 9, 2020 testing any intervention to treat or prevent COVID-19, systematically identified in trial registries, preprint servers, and literature databases. A survey was conducted of all trials to assess their recruitment status up to July 6, 2020. Results: Most of the 689 trials (overall target sample size 396,366) were small (median sample size 120; interquartile range [IQR] 60-300) but randomized (75.8%; n=522) and were often conducted in China (51.1%; n=352) or the USA (11%; n=76). 525 trials (76.2%) planned to include 155,571 hospitalized patients, and 25 (3.6%) planned to include 96,821 health-care workers. Treatments were evaluated in 607 trials (88.1%), frequently antivirals (n=144) or antimalarials (n=112); 78 trials (11.3%) focused on prevention, including 14 vaccine trials. No trial investigated social distancing. Interventions tested in 11 trials with >5,000 participants were also tested in 169 smaller trials (median sample size 273; IQR 90-700). Hydroxychloroquine alone was investigated in 110 trials. While 414 trials (60.0%) expected completion in 2020, only 35 trials (4.1%; 3,071 participants) were completed by July 6. Of 112 trials with detailed recruitment information, 55 had recruited <20% of the targeted sample; 27 between 20-50%; and 30 over 50% (median 14.8% [IQR 2.0-62.0%]). Conclusions: The size and speed of the COVID-19 clinical trials agenda is unprecedented. However, most trials were small investigating a small fraction of treatment options. The feasibility of this research agenda is questionable, and many trials may end in futility, wasting research resources. Much better coordination is needed to respond to global health threats.
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Affiliation(s)
- Perrine Janiaud
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University,, Stanford, California, USA
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Cathrine Axfors
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University,, Stanford, California, USA
- Department for Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Janneke van't Hooft
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University,, Stanford, California, USA
- Amsterdam University Medical Center, Amsterdam University, Amsterdam, The Netherlands
| | - Ramon Saccilotto
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University,, Stanford, California, USA
| | - Arnav Agarwal
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Valentin Danchev
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University,, Stanford, California, USA
- Stanford Prevention Research Center, Department of Medicine,, Stanford University School of Medicine, Stanford, California, USA
| | - Ulrich Dirnagl
- QUEST Center for Transforming Biomedical Research, Berlin Institute of Health, Berlin, Germany
| | - Hannah Ewald
- University Medical Library, University of Basel, Basel, Switzerland
| | - Gerald Gartlehner
- Department for Evidence-based Medicine and Evaluation, Danube University Krems, Krems, Austria
- RTI International, Research Triangle Park Laboratories, Raleigh, North Carolina, USA
| | - Steven N. Goodman
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University,, Stanford, California, USA
- Stanford University School of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - Noah A. Haber
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University,, Stanford, California, USA
| | - Angeliki Diotima Ioannidis
- Molecular Toxicology Interdepartmental Program, University of California, Los Angeles, Los Angeles, California, USA
| | - John P. A. Ioannidis
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University,, Stanford, California, USA
- Stanford Prevention Research Center, Department of Medicine,, Stanford University School of Medicine, Stanford, California, USA
- Stanford University School of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, USA
- Meta-Research Innovation Center Berlin (METRIC-B), Berlin Institute of Health, Berlin, Germany
| | - Mark P. Lythgoe
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - Wenyan Ma
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Malcolm Macleod
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Mario Malički
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University,, Stanford, California, USA
| | - Joerg J. Meerpohl
- Institute for Evidence in Medicine, Medical Center and Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Yan Min
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University,, Stanford, California, USA
- Stanford University School of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - David Moher
- Centre for Journalology, Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa, Canada
| | - Blin Nagavci
- Institute for Evidence in Medicine, Medical Center and Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Florian Naudet
- CHU Rennes, Inserm, CIC 1414 [(Centre d’Investigation Clinique de Rennes)],, University of Rennes 1, Rennes, France
| | | | - Jack W. O'Sullivan
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University,, Stanford, California, USA
- Division of Cardiology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Nico Riedel
- QUEST Center for Transforming Biomedical Research, Berlin Institute of Health, Berlin, Germany
| | - Jan A. Roth
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Mandy Sauermann
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Stefan Schandelmaier
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Andreas M. Schmitt
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Deparment of Medical Oncology, University Hospital Basel, Basel, Switzerland
| | - Benjamin Speich
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Paula R. Williamson
- MRC/NIHR Trials Methodology Research Partnership, University of Liverpool, Liverpool, UK
| | - Lars G. Hemkens
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University,, Stanford, California, USA
- Department of Clinical Research, University of Basel, Basel, Switzerland
- Meta-Research Innovation Center Berlin (METRIC-B), Berlin Institute of Health, Berlin, Germany
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