Streamlining Randomized Clinical Trials for Device Therapies in Heart Failure: Bayesian Borrowing of External Data

BACKGROUND

The Breakthrough Devices Program of the US Food and Drug Administration has accelerated the development and evaluation of medical devices for patients with heart failure. One such device is the Optimizer Smart System, which the US Food and Drug Administration approved in 2019.

METHODS AND RESULTS

The Optimizer device was evaluated in a pivotal randomized clinical trial (FIX-HF-5C [Confirmatory Randomized Trial Evaluating the Optimizer System]) that leveraged Bayesian borrowing of external data to reduce the sample size and determine therapeutic device benefit versus continued medical therapy. Bayesian borrowing is explained in the context of the FIX-HF-5C trial, including an overview of the statistical methodologies, regulatory considerations, and interpretations of trial results.

CONCLUSIONS

The US Food and Drug Administration Breakthrough Devices Program and novel Bayesian statistical methodology accelerated the path to regulatory approval and patient access to a potentially lifesaving device and may serve as a model for future clinical trials.

Bayesian Nonlinear Models for Repeated Measurement Data: An Overview, Implementation, and Applications

Nonlinear mixed effects models have become a standard platform for analysis when data is in the form of continuous and repeated measurements of subjects from a population of interest, while temporal profiles of subjects commonly follow a nonlinear tendency. While frequentist analysis of nonlinear mixed effects models has a long history, Bayesian analysis of the models has received comparatively little attention until the late 1980s, primarily due to the time-consuming nature of Bayesian computation. Since the early 1990s, Bayesian approaches for the models began to emerge to leverage rapid developments in computing power, and have recently received significant attention due to (1) superiority to quantify the uncertainty of parameter estimation; (2) utility to incorporate prior knowledge into the models; and (3) flexibility to match exactly the increasing complexity of scientific research arising from diverse industrial and academic fields. This review article presents an overview of modeling strategies to implement Bayesian approaches for the nonlinear mixed effects models, ranging from designing a scientific question out of real-life problems to practical computations.

Assessing efficacy in important subgroups in confirmatory trials: An example using Bayesian dynamic borrowing

Assessment of efficacy in important subgroups - such as those defined by sex, age, race and region - in confirmatory trials is typically performed using separate analysis of the specific subgroup. This ignores relevant information from the complementary subgroup. Bayesian dynamic borrowing uses an informative prior based on analysis of the complementary subgroup and a weak prior distribution centred on a mean of zero to construct a robust mixture prior. This combination of priors allows for dynamic borrowing of prior information; the analysis learns how much of the complementary subgroup prior information to borrow based on the consistency between the subgroup of interest and the complementary subgroup. A tipping point analysis can be carried out to identify how much prior weight needs to be placed on the complementary subgroup component of the robust mixture prior to establish efficacy in the subgroup of interest. An attractive feature of the tipping point analysis is that it enables the evidence from the source subgroup, the evidence from the target subgroup, and the combined evidence to be displayed alongside each other. This method is illustrated with an example trial in severe asthma where efficacy in the adolescent subgroup was assessed using a mixture prior combining an informative prior from the adult data in the same trial with a non-informative prior.

Statistical consideration when adding new arms to ongoing clinical trials: the potentials and the caveats

BACKGROUND

Platform trials improve the efficiency of the drug development process through flexible features such as adding and dropping arms as evidence emerges. The benefits and practical challenges of implementing novel trial designs have been discussed widely in the literature, yet less consideration has been given to the statistical implications of adding arms. MAIN: We explain different statistical considerations that arise from allowing new research interventions to be added in for ongoing studies. We present recent methodology development on addressing these issues and illustrate design and analysis approaches that might be enhanced to provide robust inference from platform trials. We also discuss the implication of changing the control arm, how patient eligibility for different arms may complicate the trial design and analysis, and how operational bias may arise when revealing some results of the trials. Lastly, we comment on the appropriateness and the application of platform trials in phase II and phase III settings, as well as publicly versus industry-funded trials.

CONCLUSION

Platform trials provide great opportunities for improving the efficiency of evaluating interventions. Although several statistical issues are present, there are a range of methods available that allow robust and efficient design and analysis of these trials.

Bayesian leveraging of historical control data for a clinical trial with time-to-event endpoint

The recent 21st Century Cures Act propagates innovations to accelerate the discovery, development, and delivery of 21st century cures. It includes the broader application of Bayesian statistics and the use of evidence from clinical expertise. An example of the latter is the use of trial-external (or historical) data, which promises more efficient or ethical trial designs. We propose a Bayesian meta-analytic approach to leverage historical data for time-to-event endpoints, which are common in oncology and cardiovascular diseases. The approach is based on a robust hierarchical model for piecewise exponential data. It allows for various degrees of between trial-heterogeneity and for leveraging individual as well as aggregate data. An ovarian carcinoma trial and a non-small cell cancer trial illustrate methodological and practical aspects of leveraging historical data for the analysis and design of time-to-event trials.