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Selker HP, Cohen T, D'Agostino RB, Dere WH, Ghaemi SN, Honig PK, Kaitin KI, Kaplan HC, Kravitz RL, Larholt K, McElwee NE, Oye KA, Palm ME, Perfetto E, Ramanathan C, Schmid CH, Seyfert-Margolis V, Trusheim M, Eichler HG. A Useful and Sustainable Role for N-of-1 Trials in the Healthcare Ecosystem. Clin Pharmacol Ther 2021; 112:224-232. [PMID: 34551122 PMCID: PMC9022728 DOI: 10.1002/cpt.2425] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 09/05/2021] [Indexed: 11/29/2022]
Abstract
Clinicians and patients often try a treatment for an initial period to inform longer‐term therapeutic decisions. A more rigorous approach involves N‐of‐1 trials. In these single‐patient crossover trials, typically conducted in patients with chronic conditions, individual patients are given candidate treatments in a double‐blinded, random sequence of alternating periods to determine the most effective treatment for that patient. However, to date, these trials are rarely done outside of research settings and have not been integrated into general care where they could offer substantial benefit. Designating this classical, N‐of‐1 trial design as type 1, there also are new and evolving uses of N‐of‐1 trials that we designate as type 2. In these, rather than focusing on optimizing treatment for chronic diseases when multiple approved choices are available, as is typical of type 1, a type 2 N‐of‐1 trial tests treatments designed specifically for a patient with a rare disease, to facilitate personalized medicine. While the aims differ, both types face the challenge of collecting individual‐patient evidence using standard, trusted, widely accepted methods. To fulfill their potential for producing both clinical and research benefits, and to be available for wide use, N‐of‐1 trials will have to fit into the current healthcare ecosystem. This will require generalizable and accepted processes, platforms, methods, and standards. This also will require sustainable value‐based arrangements among key stakeholders. In this article, we review opportunities, stakeholders, issues, and possible approaches that could support general use of N‐of‐1 trials and deliver benefit to patients and the healthcare enterprise. To assess and expand the benefits of N‐of‐1 trials, we propose multistakeholder meetings, workshops, and the generation of methods, standards, and platforms that would support wider availability and the value of N‐of‐1 trials.
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Affiliation(s)
- Harry P Selker
- Tufts Medical Center, Tufts Clinical and Translational Science Institute, Boston, Massachusetts, USA.,Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Boston, Massachusetts, USA
| | - Theodora Cohen
- Tufts Medical Center, Tufts Clinical and Translational Science Institute, Boston, Massachusetts, USA.,Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Boston, Massachusetts, USA
| | - Ralph B D'Agostino
- Department of Mathematics and Statistics, Boston University, Boston, Massachusetts, USA.,Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - Willard H Dere
- Department of Internal Medicine, Utah Center for Clinical and Translational Science, University of Utah, Salt Lake City, Utah, USA.,University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - S Nassir Ghaemi
- Psychiatry, Tufts University School of Medicine, Boston, Massachusetts, USA.,Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Kenneth I Kaitin
- Tufts Center for the Study of Drug Development, Tufts University, Boston, Massachusetts, USA
| | - Heather C Kaplan
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Richard L Kravitz
- Department of Internal Medicine, University of California, Davis, Davis, California, USA
| | - Kay Larholt
- Center for Biomedical Innovation, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Newell E McElwee
- Health Economics and Outcomes Research, Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, Connecticut, USA
| | - Kenneth A Oye
- Department of Political Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA.,Center for Biomedical Innovation, Cambridge, Massachusetts, USA
| | - Marisha E Palm
- Tufts Medical Center, Tufts Clinical and Translational Science Institute, Boston, Massachusetts, USA.,Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Boston, Massachusetts, USA
| | - Eleanor Perfetto
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA.,National Health Council, Washington, District of Columbia, USA
| | | | | | | | - Mark Trusheim
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Hans-Georg Eichler
- Regulatory Science and Innovation Task Force, European Medicines Agency, Amsterdam, The Netherlands.,Medical University of Vienna, Vienna, Austria
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McDonald S, Vieira R, Johnston DW. Analysing N-of-1 observational data in health psychology and behavioural medicine: a 10-step SPSS tutorial for beginners. Health Psychol Behav Med 2020; 8:32-54. [PMID: 34040861 PMCID: PMC8114402 DOI: 10.1080/21642850.2019.1711096] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background: N-of-1 observational studies can be used to describe natural intra-individual changes in health-related behaviours or symptoms over time, to test behavioural theories and to develop highly personalised health interventions. To date, N-of-1 observational methods have been under-used in health psychology and behavioural medicine. One reason for this may be the perceived complexity of statistical analysis of N-of-1 data. Objective: This tutorial paper describes a 10-step procedure for the analysis of N-of-1 observational data using dynamic regression modelling in SPSS for researchers, students and clinicians who are new to this area. The 10-step procedure is illustrated using real data from an N-of-1 observational study exploring the relationship between pain and physical activity. Conclusion: The availability of a user-friendly and robust statistical technique for the analysis of N-of-1 data using SPSS may foster increased awareness, knowledge and skills and establish N-of-1 designs as a useful methodological tool in health psychology and behavioural medicine.
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Affiliation(s)
- Suzanne McDonald
- Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - Rute Vieira
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Derek W Johnston
- School of Psychology, University of Aberdeen, Aberdeen, United Kingdom
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