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Leviton A, Loddenkemper T. Design, implementation, and inferential issues associated with clinical trials that rely on data in electronic medical records: a narrative review. BMC Med Res Methodol 2023; 23:271. [PMID: 37974111 PMCID: PMC10652539 DOI: 10.1186/s12874-023-02102-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 11/08/2023] [Indexed: 11/19/2023] Open
Abstract
Real world evidence is now accepted by authorities charged with assessing the benefits and harms of new therapies. Clinical trials based on real world evidence are much less expensive than randomized clinical trials that do not rely on "real world evidence" such as contained in electronic health records (EHR). Consequently, we can expect an increase in the number of reports of these types of trials, which we identify here as 'EHR-sourced trials.' 'In this selected literature review, we discuss the various designs and the ethical issues they raise. EHR-sourced trials have the potential to improve/increase common data elements and other aspects of the EHR and related systems. Caution is advised, however, in drawing causal inferences about the relationships among EHR variables. Nevertheless, we anticipate that EHR-CTs will play a central role in answering research and regulatory questions.
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Affiliation(s)
- Alan Leviton
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Tobias Loddenkemper
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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2
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Tang M, Pearson SA, Simes RJ, Chua BH. Harnessing Real-World Evidence to Advance Cancer Research. Curr Oncol 2023; 30:1844-1859. [PMID: 36826104 PMCID: PMC9955401 DOI: 10.3390/curroncol30020143] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/16/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
Randomized controlled trials (RCTs) form a cornerstone of oncology research by generating evidence about the efficacy of therapies in selected patient populations. However, their implementation is often resource- and cost-intensive, and their generalisability to patients treated in routine practice may be limited. Real-world evidence leverages data collected about patients receiving clinical care in routine practice outside of clinical trial settings and provides opportunities to identify and address gaps in clinical trial evidence. This review outlines the strengths and limitations of real-world and RCT evidence and proposes a framework for the complementary use of the two bodies of evidence to advance cancer research. There are challenges to the implementation of real-world research in oncology, including heterogeneity of data sources, timely access to high-quality data, and concerns about the quality of methods leveraging real-world data, particularly causal inference. Improved understanding of the strengths and limitations of real-world data and ongoing efforts to optimise the conduct of real-world evidence research will improve its reliability, understanding and acceptance, and enable the full potential of real-world evidence to be realised in oncology practice.
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Affiliation(s)
- Monica Tang
- Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick 2031, Australia
- Correspondence:
| | | | - Robert J. Simes
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown 2050, Australia
| | - Boon H. Chua
- Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick 2031, Australia
- Faculty of Medicine and Health, UNSW Sydney, Sydney 2052, Australia
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3
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Pencina MJ, Thompson BT. Clinical Trials in the 21st Century - Promising Avenues for Better Studies. NEJM EVIDENCE 2022; 1:EVIDctw2200060. [PMID: 38319278 DOI: 10.1056/evidctw2200060] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Innovation in Clinical Trials in the 21st CenturyMedical evidence is rooted in randomized controlled trials but there is a pressing need for innovative designs. Pencina and Thompson introduce a new series that reviews the most promising innovations in trial design and interpretation.
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Affiliation(s)
- Michael J Pencina
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
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4
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Lin LA, Zhang Y, Straus W, Wang W. Integrative Analysis of Randomized Clinical Trial and Observational Study Data to Inform Post-marketing Safety Decision-Making. Ther Innov Regul Sci 2022; 56:423-432. [PMID: 35138577 DOI: 10.1007/s43441-021-00349-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 10/27/2021] [Indexed: 11/30/2022]
Abstract
Safety evaluation is a continual and iterative process throughout the drug development life cycle and requires long time horizons and large amounts of data to fully understand the safety profile of a medical product. Although randomized clinical trials (RCT) provide high-quality data for an initial assessment of safety signals, the safety signals may not all have been known at the time of approval because safety data collected from RCT only involve a relatively small number of subjects during a relatively short follow-up period. The increased accumulation of post-marketing real-world data (RWD) presents an opportunity to utilize them for safety decision-making; these include identifying new safety signals, further characterization of safety concerns that are raised in pre-marketing RCT, and further generalization of RCT findings to the broader patient populations not previously studied in RCT. In this paper, we use cardiovascular safety outcome trial for antidiabetic therapies as an illustrative example and discuss how integrative analysis of RCT and observational study data can answer regulatory concerns about cardiovascular risk in a post-marketing setting. A novel statistical analysis strategy is proposed to combine both sources of safety data in a data fusion approach. The proposed approach includes three stages: (1) feasibility analysis that uses an RCT to validate an observational study, applying estimand framework and emulating RCT with RWD; (2) integrative analysis that combines evidence from the RCT and observational study data cooperatively; and (3) sensitivity analysis that examines the consistency of the previous analyses. Two potential utilities of the proposed integrative analysis for the cardiovascular safety outcome trial are discussed.
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Affiliation(s)
- Li-An Lin
- Clinical Safety Statistics, Merck & Co., Inc, Kenilworth, NJ, USA.
| | - Yafei Zhang
- Clinical Safety Statistics, Merck & Co., Inc, Kenilworth, NJ, USA
| | | | - William Wang
- Clinical Safety Statistics, Merck & Co., Inc, Kenilworth, NJ, USA
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Zhang Y, Lin LA, Starkopf L, Chen J, Wang WWB. Estimation of causal effect in integrating randomized clinical trial and observational data - An example application to cardiovascular outcome trial. Contemp Clin Trials 2021; 107:106492. [PMID: 34175491 DOI: 10.1016/j.cct.2021.106492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/21/2021] [Accepted: 06/18/2021] [Indexed: 10/21/2022]
Abstract
Safety evaluation of drug development is a comprehensive process across the product lifecycle. While a randomized clinical trial (RCT) can provide high-quality data to assess the efficacy and safety of a new intervention, the pre-marketing trials are limited in statistical power to detect causal elevation of rare but potentially serious adverse events. On the other hand, real-world data (RWD) sources play a critical role in further understanding the safety profile of the new intervention. Bringing together the breadth and strength of RWD and RCT data, we can maximize the utility of RWD and answer broader questions. In this manuscript, we propose a three-step statistical framework to corroborate findings from both RCT and RWD for evaluating important safety concerns identified in the pre-marketing setting. By the proposed approach, we first match the observational study to RCT, then the causal estimation is validated via the matched observational study with the target RCT by targeted maximum likelihood estimation (TMLE) method, and lastly the evidence from RCT and RWD can be combined in an integrative analysis. A potential application to cardiovascular outcome trials for type 2 diabetes mellitus is illustrated. Finally, simulation results suggest that the heterogeneity of patient population from RCT and RWD can lead to varying degrees of treatment effect estimation and the proposed approach may be able to mitigate such difference in the integrative analysis.
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Affiliation(s)
- Yafei Zhang
- Biostatistics and Research Decision Sciences, Merck & Co., Inc., Kenilworth, NJ, USA
| | - Li-An Lin
- Biostatistics and Research Decision Sciences, Merck & Co., Inc., Kenilworth, NJ, USA.
| | - Liis Starkopf
- Biostatistics and Research Decision Sciences, Merck & Co., Inc., Kenilworth, NJ, USA
| | - Jie Chen
- Overland Pharmaceuticals, Dover, DE, USA
| | - William W B Wang
- Biostatistics and Research Decision Sciences, Merck & Co., Inc., Kenilworth, NJ, USA
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Dworkin RH, Kerns RD, McDermott MP, Turk DC, Veasley C. The ACTTION Guide to Clinical Trials of Pain Treatments, part II: mitigating bias, maximizing value. Pain Rep 2021; 6:e886. [PMID: 33521484 PMCID: PMC7838005 DOI: 10.1097/pr9.0000000000000886] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 11/14/2020] [Indexed: 12/28/2022] Open
Abstract
Summaries of the articles included in part II of the ACTTION Guide to Clinical Trials of Pain Treatments are followed by brief overviews of methodologic considerations involving precision pain medicine, pragmatic clinical trials, real world evidence, and patient engagement in clinical trials.
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Affiliation(s)
- Robert H. Dworkin
- Departments of Anesthesiology and Perioperative Medicine, Neurology, and Psychiatry, Center for Health + Technology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Robert D. Kerns
- Departments of Psychiatry, Neurology, and Psychology, Yale University, New Haven, CT, USA
| | - Michael P. McDermott
- Departments of Biostatistics and Computational Biology and Neurology, Center for Health + Technology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Dennis C. Turk
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
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Abstract
Real-world evidence (RWE) is the clinical evidence about benefits or risks of medical products derived from analyzing real world data (RWD), which are data collected through routine clinical practice. This article discusses the advantages and disadvantages of RWE studies, how these studies differ from randomized controlled trials (RCTs), how to overcome barriers to current skepticism about RWE, how FDA is using RWE, how to improve the quality of RWE, and finally the future of RWE trials.
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Affiliation(s)
- David C. Klonoff
- Diabetes Research Institute;
Mills-Peninsula Health Services, San Mateo, CA, USA
- David C. Klonoff, MD, FACP, FRCP (Edin),
Fellow AIMBE, Diabetes Research Institute, Mills-Peninsula Health Services, 100
S San Mateo Dr, Rm 5147, San Mateo, CA 94401, USA.
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Divney AA, Lopez PM, Huang TT, Thorpe LE, Trinh-Shevrin C, Islam NS. Research-grade data in the real world: challenges and opportunities in data quality from a pragmatic trial in community-based practices. J Am Med Inform Assoc 2019; 26:847-854. [PMID: 31181144 PMCID: PMC6696500 DOI: 10.1093/jamia/ocz062] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 04/12/2019] [Accepted: 04/16/2019] [Indexed: 12/17/2022] Open
Abstract
Randomized controlled trials face cost, logistic, and generalizability limitations, including difficulty engaging racial/ethnic minorities. Real-world data (RWD) from pragmatic trials, including electronic health record (EHR) data, may produce intervention evaluation findings generalizable to diverse populations. This case study of Project IMPACT describes unique barriers and facilitators of optimizing RWD to improve health outcomes and advance health equity in small immigrant-serving community-based practices. Project IMPACT tested the effect of an EHR-based health information technology intervention on hypertension control among small urban practices serving South Asian patients. Challenges in acquiring accurate RWD included EHR field availability and registry capabilities, cross-sector communication, and financial, personnel, and space resources. Although using RWD from community-based practices can inform health equity initiatives, it requires multidisciplinary collaborations, clinic support, procedures for data input (including social determinants), and standardized field logic/rules across EHR platforms.
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Affiliation(s)
- Anna A Divney
- CUNY Graduate School of Public Health and Health Policy, Center for Systems and Community Design, New York, New York, USA
- NYU-CUNY Prevention Research Center, New York, New York, USA
| | - Priscilla M Lopez
- NYU-CUNY Prevention Research Center, New York, New York, USA
- Department of Population Health, NYU School of Medicine, New York, New York, USA
| | - Terry T Huang
- CUNY Graduate School of Public Health and Health Policy, Center for Systems and Community Design, New York, New York, USA
- NYU-CUNY Prevention Research Center, New York, New York, USA
| | - Lorna E Thorpe
- NYU-CUNY Prevention Research Center, New York, New York, USA
- Department of Population Health, NYU School of Medicine, New York, New York, USA
| | - Chau Trinh-Shevrin
- NYU-CUNY Prevention Research Center, New York, New York, USA
- Department of Population Health, NYU School of Medicine, New York, New York, USA
| | - Nadia S Islam
- NYU-CUNY Prevention Research Center, New York, New York, USA
- Department of Population Health, NYU School of Medicine, New York, New York, USA
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Baker SG. Deriving Real-World Insights From Real-World Data. Ann Intern Med 2019; 170:664-665. [PMID: 31060070 DOI: 10.7326/l19-0084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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