1
|
Vickers A, Vertosick E, Langsetmo L, Dahm P, Steineck G, Wilt TJ. Estimating the Effect of Radical Prostatectomy: Combining Data From the SPCG4 and PIVOT Randomized Trials With Contemporary Cohorts. J Urol 2024; 212:310-319. [PMID: 38865734 PMCID: PMC11233245 DOI: 10.1097/ju.0000000000004039] [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: 01/08/2024] [Accepted: 05/06/2024] [Indexed: 06/14/2024]
Abstract
PURPOSE Two randomized trials (SPCG4 and PIVOT) have compared surgery to conservative management for localized prostate cancer. The applicability of these trials to contemporary practice remains uncertain. We aimed to develop an individualized prediction model for prostate cancer mortality comparing immediate surgery at a high-volume center to active surveillance. MATERIALS AND METHODS We determined whether the relative risk of prostate cancer mortality with surgery vs observation varied by baseline risk. We then used various estimates of relative risk to estimate 15-year mortality with and without surgery using, as a predictor, risk of biochemical recurrence calculated from a model. RESULTS We saw no evidence that relative risk varied by baseline risk, supporting the use of a constant relative risk. Compared with observation, surgery was associated with negligible benefit for patients with Grade Group (GG) 1 disease (0.2% mortality reduction at 15 years) and small benefit for patients with GG2 with lower PSA and stage (≤5% mortality reduction). Benefit was greater (6%-9%) for patients with GG3 or GG4 though still modest, but effect estimates varied widely depending on choice of hazard ratio for surgery (6%-36% absolute risk reduction). CONCLUSIONS Surgery should be avoided for men with low-risk (GG1) prostate cancer and for many men with GG2 disease. Surgical benefits are greater in men with higher-risk disease. Integration of findings with a life expectancy model will allow patients to make informed treatment decisions given their oncologic risk, risk of death from other causes, and estimated effects of surgery.
Collapse
Affiliation(s)
- Andrew Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Emily Vertosick
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lisa Langsetmo
- Minneapolis VA Health Care System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Philipp Dahm
- Minneapolis VA Health Care System, Minneapolis, Minnesota
- Department of Urology, University of Minnesota, Minneapolis, Minnesota
| | - Gunnar Steineck
- Department of Oncology, University of Gothenburg, Gothenburg, Sweden
| | - Timothy J Wilt
- Minneapolis VA Health Care System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
- Department of Public Health, University of Minnesota, Minneapolis, Minnesota
| |
Collapse
|
2
|
Chin-Yee N, Yennurajalingam S, Zimmermann C. Putting Methylphenidate for Cancer-Related Fatigue to Rest? J Clin Oncol 2024; 42:2363-2366. [PMID: 38771985 DOI: 10.1200/jco.24.00707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 04/10/2024] [Indexed: 05/23/2024] Open
Affiliation(s)
- Nicolas Chin-Yee
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
- Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Canada
| | | | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
- Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Canada
| |
Collapse
|
3
|
Khera R, Oikonomou EK, Nadkarni GN, Morley JR, Wiens J, Butte AJ, Topol EJ. Transforming Cardiovascular Care With Artificial Intelligence: From Discovery to Practice: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 84:97-114. [PMID: 38925729 DOI: 10.1016/j.jacc.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 05/03/2024] [Accepted: 05/07/2024] [Indexed: 06/28/2024]
Abstract
Artificial intelligence (AI) has the potential to transform every facet of cardiovascular practice and research. The exponential rise in technology powered by AI is defining new frontiers in cardiovascular care, with innovations that span novel diagnostic modalities, new digital native biomarkers of disease, and high-performing tools evaluating care quality and prognosticating clinical outcomes. These digital innovations promise expanded access to cardiovascular screening and monitoring, especially among those without access to high-quality, specialized care historically. Moreover, AI is propelling biological and clinical discoveries that will make future cardiovascular care more personalized, precise, and effective. The review brings together these diverse AI innovations, highlighting developments in multimodal cardiovascular AI across clinical practice and biomedical discovery, and envisioning this new future backed by contemporary science and emerging discoveries. Finally, we define the critical path and the safeguards essential to realizing this AI-enabled future that helps achieve optimal cardiovascular health and outcomes for all.
Collapse
Affiliation(s)
- Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut, USA; Section of Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, Connecticut, USA; Section of Health Informatics, Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA.
| | - Evangelos K Oikonomou
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Girish N Nadkarni
- The Samuel Bronfman Department of Medicine, Division of Data Driven and Digital Medicine (D3M), Icahn School of Medicine at Mount Sinai, New York, New York, USA; The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jessica R Morley
- Digital Ethics Center, Yale University, New Haven, Connecticut, USA
| | - Jenna Wiens
- Electrical Engineering and Computer Science, Computer Science and Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Atul J Butte
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, California, USA; Center for Data-Driven Insights and Innovation, University of California Health, Oakland, California, USA
| | - Eric J Topol
- Molecular Medicine, Scripps Research Translational Institute, Scripps Research, La Jolla, California, USA
| |
Collapse
|
4
|
Zhao X, Liu J, Zhang L, Ma C, Liu Y, Wen H, Li CQ. Gut microbiota, inflammatory factors, and scoliosis: A Mendelian randomization study. Medicine (Baltimore) 2024; 103:e38561. [PMID: 38875409 PMCID: PMC11175948 DOI: 10.1097/md.0000000000038561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/16/2024] Open
Abstract
Several studies have reported a potential association between the gut microbiota (GM) and scoliosis. However, the causal relationship between GM and scoliosis and the role of inflammatory factors (IFs) as mediators remain unclear. This study aimed to analyze the relationship between GM, IFs, and scoliosis. We investigated whether IFs act as mediators in pathways from the GM to scoliosis. Additionally, using reverse Mendelian randomization (MR) analysis, we further investigated the potential impact of genetic predisposition to scoliosis on the GM and IFs. In this study, we searched for publicly available genome-wide association study aggregate data and utilized the MR method to establish bidirectional causal relationships among 211 GM taxa, 91 IFs, and scoliosis. To ensure the reliability of our research findings, we employed 5 MR methods, with the inverse variance weighting approach serving as the primary statistical method, and assessed the robustness of the results through various sensitivity analyses. Additionally, we investigated whether IFs mediate pathways from GM to scoliosis. Three negative causal correlations were observed between the genetic predisposition to GM and scoliosis. Additionally, both positive and negative correlations were found between IFs and scoliosis, with 3 positive and 3 negative correlations observed. IFs do not appear to act as mediators in the pathway from GM to scoliosis. In conclusion, this study demonstrated a causal association between the GM, IFs, and scoliosis, indicating that IFs are not mediators in the pathway from the GM to scoliosis. These findings offer new insights into prevention and treatment strategies for scoliosis.
Collapse
Affiliation(s)
- Xiaojiang Zhao
- Department of Physical Education and Arts, Bengbu Medical College, Bengbu, China
- Graduate School, Adamson University, Manila, Philippines
| | - Jingjing Liu
- Physical Education Department, Bozhou University, Bozhou, China
| | - Lei Zhang
- Department of Physical Education and Arts, Bengbu Medical College, Bengbu, China
| | - Chao Ma
- Department of Physical Education and Arts, Bengbu Medical College, Bengbu, China
| | - Yanan Liu
- Department of Physical Education and Arts, Bengbu Medical College, Bengbu, China
| | - Hebao Wen
- Department of Physical Education and Arts, Bengbu Medical College, Bengbu, China
| | - Chang Qing Li
- Department of Physical Education and Arts, Bengbu Medical College, Bengbu, China
| |
Collapse
|
5
|
Singh A, Schooley B, Mobley J, Mobley P, Lindros S, Brooks JM, Floyd SB. Human-centered Design of a Health Recommender System for Orthopaedic Shoulder Treatment. RESEARCH SQUARE 2024:rs.3.rs-4359437. [PMID: 38826294 PMCID: PMC11142362 DOI: 10.21203/rs.3.rs-4359437/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Abstract
Background Rich data on diverse patients and their treatments and outcomes within Electronic Health Record (EHR) systems can be used to generate real world evidence. A health recommender system (HRS) framework can be applied to a decision support system application to generate data summaries for similar patients during the clinical encounter to assist physicians and patients in making evidence-based shared treatment decisions. Objective A human-centered design (HCD) process was used to develop a HRS for treatment decision support in orthopaedic medicine, the Informatics Consult for Individualized Treatment (I-C-IT). We also evaluate the usability and utility of the system from the physician's perspective, focusing on elements of utility and shared decision-making in orthopaedic medicine. Methods The HCD process for I-C-IT included 6 steps across three phases of analysis, design, and evaluation. A team of informaticians and comparative effectiveness researchers directly engaged with orthopaedic surgeon subject matter experts in a collaborative I-C-IT prototype design process. Ten orthopaedic surgeons participated in a mixed methods evaluation of the I-C-IT prototype that was produced. Results The HCD process resulted in a prototype system, I-C-IT, with 14 data visualization elements and a set of design principles crucial for HRS for decision support. The overall standard system usability scale (SUS) score for the I-C-IT Webapp prototype was 88.75 indicating high usability. In addition, utility questions addressing shared decision-making found that 90% of orthopaedic surgeon respondents either strongly agreed or agreed that I-C-IT would help them make data informed decisions with their patients. Conclusion The HCD process produced an HRS prototype that is capable of supporting orthopaedic surgeons and patients in their information needs during clinical encounters. Future research should focus on refining I-C-IT by incorporating patient feedback in future iterative cycles of system design and evaluation.
Collapse
Affiliation(s)
| | | | - Jack Mobley
- University of South Carolina School of Medicine Greenville
| | | | | | | | | |
Collapse
|
6
|
Selby JV, Maas CCHM, Fireman BH, Kent DM. Impact of the PATH Statement on Analysis and Reporting of Heterogeneity of Treatment Effect in Clinical Trials: A Scoping Review. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.05.06.24306774. [PMID: 38766150 PMCID: PMC11100853 DOI: 10.1101/2024.05.06.24306774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Background The Predictive Approaches to Treatment Effect Heterogeneity (PATH) Statement provides guidance for using predictive modeling to identify differences (i.e., heterogeneity) in treatment effects (benefits and harms) among participants in randomized clinical trials (RCTs). It distinguished risk modeling, which uses a multivariable model to predict risk of trial outcome(s) and then examines treatment effects within strata of predicted risk, from effect modeling, which predicts trial outcomes using models that include treatment, individual participant characteristics and interactions of treatment with selected characteristics. Purpose To describe studies of heterogeneous treatment effects (HTE) that use predictive modeling in RCT data and cite the PATH Statement. Data Sources The Cited By functions in PubMed, Google Scholar, Web of Science and SCOPUS databases (Jan 7, 2020 - June 5, 2023). Study Selection 42 reports presenting 45 predictive models. Data Extraction Double review with adjudication to identify risk and effect modeling and examine consistency with Statement consensus statements. Credibility of HTE findings was assessed using criteria adapted from the Instrument to assess Credibility of Effect Modification Analyses (ICEMAN). Clinical importance of credible HTE findings was also assessed. Data Synthesis The numbers of reports, especially risk modeling reports, increased year-on-year. Consistency with consensus statements was high, except for two: only 15 of 32 studies with positive overall findings included a risk model; and most effect models explored many candidate covariates with little prior evidence for effect modification. Risk modeling was more likely than effect modeling to identify both credible HTE (14/19 vs 5/26) and clinically important HTE (10/19 vs 4/26). Limitations Risk of reviewer bias: reviewers assessing credibility and clinical importance were not blinded to adherence to PATH recommendations. Conclusions The PATH Statement appears to be influencing research practice. Risk modeling often uncovered clinically important HTE; effect modeling was more often exploratory.
Collapse
Affiliation(s)
- Joe V Selby
- Division of Research, Kaiser Permanente Northern California, Oakland, CA (emeritus)
| | - Carolien C H M Maas
- Tufts Predictive Analytics and Comparative Effectiveness Center, Tufts University School of Medicine, Boston MA
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Bruce H Fireman
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - David M Kent
- Tufts Predictive Analytics and Comparative Effectiveness Center, Tufts University School of Medicine, Boston MA
| |
Collapse
|
7
|
Arnold SV, Jones PG, Maron DJ, Cohen DJ, Mark DB, Reynolds HR, Bangalore S, Chen J, Newman JD, Harrington RA, Stone GW, Hochman JS, Spertus JA. Variation in Health Status With Invasive vs Conservative Management of Chronic Coronary Disease. J Am Coll Cardiol 2024; 83:1353-1366. [PMID: 38599711 DOI: 10.1016/j.jacc.2024.02.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 02/08/2024] [Accepted: 02/14/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND The ISCHEMIA trial found that patients with chronic coronary disease randomized to invasive strategy had better health status than those randomized to conservative strategy. It is unclear how best to translate these population-level results to individual patients. OBJECTIVES The authors sought to identify patient characteristics associated with health status from invasive and conservative strategies, and develop a prediction algorithm for shared decision-making. METHODS One-year disease-specific health status was assessed in ISCHEMIA with the Seattle Angina Questionnaire (SAQ) Summary Score (SAQ SS) and Angina Frequency, Physical Limitations (PL), and Quality of Life (QL) domains (range 0-100, higher = less angina/better health status). RESULTS Among 4,617 patients from 320 sites in 37 countries, mean SAQ SS was 74.1 ± 18.9 at baseline and 85.7 ± 15.6 at 1 year. Lower baseline SAQ SS and younger age were associated with better 1-year health status with invasive strategy (P interaction = 0.009 and P interaction = 0.004, respectively). For the individual domains, there were significant treatment interactions for baseline SAQ score (Angina Frequency, PL), age (PL, QL), anterior ischemia (PL), and number of baseline antianginal medications (QL), with more benefit of invasive in patients with worse baseline health status, younger age, anterior ischemia, and on more antianginal medications. Parsimonious prediction models were developed for 1-year SAQ domains with invasive or conservative strategies to support shared decision-making. CONCLUSIONS In the management of chronic coronary disease, individual patient characteristics are associated with 1-year health status, with younger age and poorer angina-related health status showing greater benefit from invasive management. This prediction algorithm can support the translation of the ISCHEMIA trial results to individual patients. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).
Collapse
Affiliation(s)
- Suzanne V Arnold
- University of Missouri-Kansas City's Healthcare Institute for Innovations in Quality and Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA.
| | - Philip G Jones
- University of Missouri-Kansas City's Healthcare Institute for Innovations in Quality and Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - David J Maron
- Stanford University Department of Medicine, Stanford, California, USA
| | - David J Cohen
- St Francis Hospital and Heart Center, Roslyn, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Daniel B Mark
- Duke Clinical Research Institute and Duke University, Durham, North Carolina, USA
| | - Harmony R Reynolds
- Cardiovascular Clinical Research Center, NYU School of Medicine, New York, New York, USA
| | - Sripal Bangalore
- Cardiovascular Clinical Research Center, NYU School of Medicine, New York, New York, USA
| | - Jiyan Chen
- Guangdong General Hospital, Guangzhou, China
| | - Jonathan D Newman
- Cardiovascular Clinical Research Center, NYU School of Medicine, New York, New York, USA
| | | | - Gregg W Stone
- Cardiovascular Research Foundation, New York, New York, USA; Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Judith S Hochman
- Cardiovascular Clinical Research Center, NYU School of Medicine, New York, New York, USA
| | - John A Spertus
- University of Missouri-Kansas City's Healthcare Institute for Innovations in Quality and Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| |
Collapse
|
8
|
Lin L, Poppe K, Wood A, Martin GP, Peek N, Sperrin M. Making predictions under interventions: a case study from the PREDICT-CVD cohort in New Zealand primary care. FRONTIERS IN EPIDEMIOLOGY 2024; 4:1326306. [PMID: 38633209 PMCID: PMC11021700 DOI: 10.3389/fepid.2024.1326306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 03/11/2024] [Indexed: 04/19/2024]
Abstract
Background Most existing clinical prediction models do not allow predictions under interventions. Such predictions allow predicted risk under different proposed strategies to be compared and are therefore useful to support clinical decision making. We aimed to compare methodological approaches for predicting individual level cardiovascular risk under three interventions: smoking cessation, reducing blood pressure, and reducing cholesterol. Methods We used data from the PREDICT prospective cohort study in New Zealand to calculate cardiovascular risk in a primary care setting. We compared three strategies to estimate absolute risk under intervention: (a) conditioning on hypothetical interventions in non-causal models; (b) combining existing prediction models with causal effects estimated using observational causal inference methods; and (c) combining existing prediction models with causal effects reported in published literature. Results The median absolute cardiovascular risk among smokers was 3.9%; our approaches predicted that smoking cessation reduced this to a median between a non-causal estimate of 2.5% and a causal estimate of 2.8%, depending on estimation methods. For reducing blood pressure, the proposed approaches estimated a reduction of absolute risk from a median of 4.9% to a median between 3.2% and 4.5% (both derived from causal estimation). Reducing cholesterol was estimated to reduce median absolute risk from 3.1% to between 2.2% (non-causal estimate) and 2.8% (causal estimate). Conclusions Estimated absolute risk reductions based on non-causal methods were different to those based on causal methods, and there was substantial variation in estimates within the causal methods. Researchers wishing to estimate risk under intervention should be explicit about their causal modelling assumptions and conduct sensitivity analysis by considering a range of possible approaches.
Collapse
Affiliation(s)
- Lijing Lin
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Katrina Poppe
- Schools of Population Health & Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Angela Wood
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
- British Heart Foundation Centre of Research Excellence, University of Cambridge, Cambridge, United Kingdom
- National Institute for Health and Care Research Blood and Transplant Research Unit in Donor Health and Behaviour, University of Cambridge, Cambridge, United Kingdom
- Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, United Kingdom
- Cambridge Centre of Artificial Intelligence in Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Glen P. Martin
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Niels Peek
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Matthew Sperrin
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| |
Collapse
|
9
|
Yarnell CJ, Fralick M. Heterogeneity of Treatment Effect - An Evolution in Subgroup Analysis. NEJM EVIDENCE 2024; 3:EVIDe2400054. [PMID: 38805605 DOI: 10.1056/evide2400054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Affiliation(s)
- Christopher J Yarnell
- Department of Critical Care Medicine, Scarborough Health Network, Toronto
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto
| | - Michael Fralick
- Division of General Internal Medicine, Sinai Health System, Toronto
| |
Collapse
|
10
|
Djulbegovic B, Hozo I, Cuker A, Guyatt G. Improving methods of clinical practice guidelines: From guidelines to pathways to fast-and-frugal trees and decision analysis to develop individualised patient care. J Eval Clin Pract 2024; 30:393-402. [PMID: 38073027 DOI: 10.1111/jep.13953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND Current methods for developing clinical practice guidelines have several limitations: they are characterised by the "black box" operation-a process with defined inputs and outputs but an incomplete understanding of its internal workings; they have "the integration problem"-a lack of framework for explicitly integrating factors such as patient preferences and trade-offs between benefits and harms; they generate one recommendation at a time that typically are not connected in a coherent analytical framework; and they apply to "average" patients, while clinicians and their patients seek advice tailored to individual circumstances. METHODS We propose augmenting the current guideline development method by converting evidence-based pathways into fast-and-frugal decision trees (FFTs) and integrating them with generalised decision curve analysis to formulate clear, individualised management recommendations. RESULTS We illustrate the process by developing recommendations for the management of heparin-induced thrombocytopenia (HIT). We converted evidence-based pathways for HIT, developed by the American Society of Hematology, into an FFT. Here, we consider only thrombotic complications and major bleeding. We leveraged the predictive potential of FFTs to compare the effects of argatroban, bivalirudin, fondaparinux, and direct oral anticoagulants (DOACs) using generalised decision curve analysis. We found that DOACs were superior to other treatments if the FFT-predicted probability of HIT exceeded 3%. CONCLUSIONS The proposed analytical framework connects guidelines, pathways, FFTs, and decision analysis, offering risk-tailored personalised recommendations and addressing current guideline development critiques.
Collapse
Affiliation(s)
- Benjamin Djulbegovic
- Division of Medical Hematology and Oncology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Iztok Hozo
- Department of Mathematics, Indiana University Northwest, Gary, Indiana, USA
| | - Adam Cuker
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
11
|
Brooks JM, Chapman CG, Chen BK, Floyd SB, Hikmet N. Assessing the properties of patient-specific treatment effect estimates from causal forest algorithms under essential heterogeneity. BMC Med Res Methodol 2024; 24:66. [PMID: 38481139 PMCID: PMC10935905 DOI: 10.1186/s12874-024-02187-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 02/21/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Treatment variation from observational data has been used to estimate patient-specific treatment effects. Causal Forest Algorithms (CFAs) developed for this task have unknown properties when treatment effect heterogeneity from unmeasured patient factors influences treatment choice - essential heterogeneity. METHODS We simulated eleven populations with identical treatment effect distributions based on patient factors. The populations varied in the extent that treatment effect heterogeneity influenced treatment choice. We used the generalized random forest application (CFA-GRF) to estimate patient-specific treatment effects for each population. Average differences between true and estimated effects for patient subsets were evaluated. RESULTS CFA-GRF performed well across the population when treatment effect heterogeneity did not influence treatment choice. Under essential heterogeneity, however, CFA-GRF yielded treatment effect estimates that reflected true treatment effects only for treated patients and were on average greater than true treatment effects for untreated patients. CONCLUSIONS Patient-specific estimates produced by CFAs are sensitive to why patients in real-world practice make different treatment choices. Researchers using CFAs should develop conceptual frameworks of treatment choice prior to estimation to guide estimate interpretation ex post.
Collapse
Affiliation(s)
- John M Brooks
- Center for Effectiveness Research in Orthopaedics - Arnold School of Public Health Greenville, 915 Greene Street #302D, Columbia, SC, 29208-0001, USA.
- University of South Carolina Arnold School of Public Health, Health Services Policy & Management, Columbia, SC, USA.
| | - Cole G Chapman
- Department of Pharmacy Practice and Science Iowa City, University of Iowa, Iowa, USA
- Center for Effectiveness Research in Orthopaedics, Greenville, SC, USA
| | - Brian K Chen
- University of South Carolina Arnold School of Public Health, Health Services Policy & Management, Columbia, SC, USA
- Center for Effectiveness Research in Orthopaedics, Greenville, SC, USA
| | - Sarah B Floyd
- Center for Effectiveness Research in Orthopaedics, Greenville, SC, USA
- Clemson University College of Behavioral Social and Health Sciences, Public Health Sciences, Clemson, South Carolina, USA
| | - Neset Hikmet
- Center for Effectiveness Research in Orthopaedics, Greenville, SC, USA
- Department of Integrated Information Technology, Innovation Think Tank Lab @ USC, University of South Carolina College of Engineering and Computing, Columbia, SC, USA
| |
Collapse
|
12
|
Hozo I, Guyatt G, Djulbegovic B. Decision curve analysis based on summary data. J Eval Clin Pract 2024; 30:281-289. [PMID: 38044860 DOI: 10.1111/jep.13945] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND To realize the potential of precision medicine, predictive models should be integrated within the framework of decision analysis, such as the decision curve analysis (DCA). To date, its application has required individual patient data (IPD) that are often unavailable. Performing DCA using aggregate data without requiring IPD may advance the goals of precision medicine. METHODS We present a statistical framework demonstrating that DCA can be conducted by using only the mean and standard deviation (SD) from the raw probabilities of the predictive model. We tested our theoretical framework by performing extensive simulations and comparing the aggregate-based DCA with IPD DCA. The latter was conducted using IPD from four predictive models that employed logistic regression, Cox or competing risk time-to-event modeling including (a) statins for primary prevention of cardiovascular disease (n = 4859), (b) hospice referral for terminally ill patients (n = 9104), (c) use of thromboprophylaxis for preventing venous thromboembolism in patients with cancer (n = 425) and (d) prevention of sinusoidal obstruction syndrome after hematopoietic cell transplantation (SCT) (n = 80). RESULTS Simulations assuming perfect calibration showed that regardless of which probability distributions informed the predictive models, the differences in DCA were negligible. Similarly, for the adequately powered models, the results of DCA based on the summary data were similar to IPD-derived DCA. The inherent instability of the predictive models, based on the smaller sample sizes, resulted in a somewhat larger discrepancy between aggregate and IPD-based DCA. CONCLUSIONS DCA informed by adequately powered and well-calibrated models using only summary statistical estimates (mean and SD) approximates well models using IPD. Use of aggregate data will facilitate broader integration of predictive with decision modeling toward the goals of individualized decision-making.
Collapse
Affiliation(s)
- Iztok Hozo
- Department of Mathematics, Indiana University Northwest, Gary, Indiana, USA
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Benjamin Djulbegovic
- Department of Medicine, Division of Medical Hematology and Oncology, Medical University of South Carolina, Charleston, South Carolina, USA
| |
Collapse
|
13
|
Paules CI, Wang J, Tomashek KM, Bonnett T, Singh K, Marconi VC, Davey RT, Lye DC, Dodd LE, Yang OO, Benson CA, Deye GA, Doernberg SB, Hynes NA, Grossberg R, Wolfe CR, Nayak SU, Short WR, Voell J, Potter GE, Rapaka RR. A Risk Profile Using Simple Hematologic Parameters to Assess Benefits From Baricitinib in Patients Hospitalized With COVID-19: A Post Hoc Analysis of the Adaptive COVID-19 Treatment Trial-2. Ann Intern Med 2024; 177:343-352. [PMID: 38408357 DOI: 10.7326/m23-2593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND The ACTT risk profile, which was developed from ACTT-1 (Adaptive COVID-19 Treatment Trial-1), demonstrated that hospitalized patients with COVID-19 in the high-risk quartile (characterized by low absolute lymphocyte count [ALC], high absolute neutrophil count [ANC], and low platelet count at baseline) benefited most from treatment with the antiviral remdesivir. It is unknown which patient characteristics are associated with benefit from treatment with the immunomodulator baricitinib. OBJECTIVE To apply the ACTT risk profile to the ACTT-2 cohort to investigate potential baricitinib-related treatment effects by risk quartile. DESIGN Post hoc analysis of ACTT-2, a randomized, double-blind, placebo-controlled trial. (ClinicalTrials.gov: NCT04401579). SETTING Sixty-seven trial sites in 8 countries. PARTICIPANTS Adults hospitalized with COVID-19 (n = 999; 85% U.S. participants). INTERVENTION Baricitinib+remdesivir versus placebo+remdesivir. MEASUREMENTS Mortality, progression to invasive mechanical ventilation (IMV) or death, and recovery, all within 28 days; ALC, ANC, and platelet count trajectories. RESULTS In the high-risk quartile, baricitinib+remdesivir was associated with reduced risk for death (hazard ratio [HR], 0.38 [95% CI, 0.16 to 0.86]; P = 0.020), decreased progression to IMV or death (HR, 0.57 [CI, 0.35 to 0.93]; P = 0.024), and improved recovery rate (HR, 1.53 [CI, 1.16 to 2.02]; P = 0.002) compared with placebo+remdesivir. After 5 days, participants receiving baricitinib+remdesivir had significantly larger increases in ALC and significantly larger decreases in ANC compared with control participants, with the largest effects observed in the high-risk quartile. LIMITATION Secondary analysis of data collected before circulation of current SARS-CoV-2 variants. CONCLUSION The ACTT risk profile identifies a subgroup of hospitalized patients who benefit most from baricitinib treatment and captures a patient phenotype of treatment response to an immunomodulator and an antiviral. Changes in ALC and ANC trajectory suggest a mechanism whereby an immunomodulator limits severe COVID-19. PRIMARY FUNDING SOURCE National Institute of Allergy and Infectious Diseases.
Collapse
Affiliation(s)
- Catharine I Paules
- Division of Infectious Diseases, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania (C.I.P.)
| | - Jing Wang
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, Maryland (J.W., T.B.)
| | - Kay M Tomashek
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland (K.M.T., K.S., R.T.D., L.E.D., G.A.D., S.U.N., J.V., G.E.P.)
| | - Tyler Bonnett
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory for Cancer Research, Frederick, Maryland (J.W., T.B.)
| | - Kanal Singh
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland (K.M.T., K.S., R.T.D., L.E.D., G.A.D., S.U.N., J.V., G.E.P.)
| | - Vincent C Marconi
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia (V.C.M.)
| | - Richard T Davey
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland (K.M.T., K.S., R.T.D., L.E.D., G.A.D., S.U.N., J.V., G.E.P.)
| | - David C Lye
- National Centre for Infectious Diseases, Tan Tock Seng Hospital, Yong Loo Lin School of Medicine, and Lee Kong Chian School of Medicine, Singapore (D.C.L.)
| | - Lori E Dodd
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland (K.M.T., K.S., R.T.D., L.E.D., G.A.D., S.U.N., J.V., G.E.P.)
| | - Otto O Yang
- Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California (O.O.Y.)
| | - Constance A Benson
- Division of Infectious Diseases & Global Public Health, University of California San Diego, San Diego, California (C.A.B.)
| | - Gregory A Deye
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland (K.M.T., K.S., R.T.D., L.E.D., G.A.D., S.U.N., J.V., G.E.P.)
| | - Sarah B Doernberg
- Division of Infectious Diseases, Department of Medicine, University of California San Francisco, San Francisco, California (S.B.D.)
| | - Noreen A Hynes
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland (N.A.H.)
| | - Robert Grossberg
- Division of Infectious Diseases, Montefiore Medical Center, Bronx, New York (R.G.)
| | - Cameron R Wolfe
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina (C.R.W.)
| | - Seema U Nayak
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland (K.M.T., K.S., R.T.D., L.E.D., G.A.D., S.U.N., J.V., G.E.P.)
| | - William R Short
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (W.R.S.)
| | - Jocelyn Voell
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland (K.M.T., K.S., R.T.D., L.E.D., G.A.D., S.U.N., J.V., G.E.P.)
| | - Gail E Potter
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland (K.M.T., K.S., R.T.D., L.E.D., G.A.D., S.U.N., J.V., G.E.P.)
| | - Rekha R Rapaka
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland (R.R.R.)
| |
Collapse
|
14
|
Charu V, Liang JW, Chertow GM, Li J, Montez-Rath ME, Geldsetzer P, de Boer IH, Tian L, Tamura MK. Heterogeneous Treatment Effects of Intensive Glycemic Control on Kidney Microvascular Outcomes and Mortality in ACCORD. J Am Soc Nephrol 2024; 35:216-228. [PMID: 38073026 PMCID: PMC10843221 DOI: 10.1681/asn.0000000000000272] [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: 06/21/2023] [Accepted: 10/30/2023] [Indexed: 12/26/2023] Open
Abstract
SIGNIFICANCE STATEMENT Identifying and quantifying treatment effect variation across patients is the fundamental challenge of precision medicine. Here we quantify heterogeneous treatment effects of intensive glycemic control in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, considering three outcomes of interest-a composite kidney outcome (driven by macroalbuminuria), all-cause mortality, and first assisted hypoglycemic event. We demonstrate that the effects of intensive glycemic control vary with risk of kidney failure, as predicted by the kidney failure risk equation (KFRE). Participants at highest risk of kidney failure gain the largest absolute kidney benefit of intensive glycemic control but also experience the largest absolute risk of death and hypoglycemic events. Our findings illustrate the value of identifying clinically meaningful treatment heterogeneity, particularly when treatments have different effects on multiple end points. OBJECTIVE Clear criteria to individualize glycemic targets in patients with type II diabetes are lacking. In this post hoc analysis of the ACCORD, we evaluate whether the KFRE can identify patients for whom intensive glycemic control confers more benefit in preventing kidney microvascular outcomes. RESEARCH DESIGN AND METHODS We divided the ACCORD trial population into quartiles on the basis of 5-year kidney failure risk using the KFRE. We estimated conditional treatment effects within each quartile and compared them with the average treatment effect in the trial. The treatment effects of interest were the 7-year restricted mean survival time (RMST) differences between intensive and standard glycemic control arms on ( 1 ) time-to-first development of severely elevated albuminuria or kidney failure and ( 2 ) all-cause mortality. RESULTS We found evidence that the effect of intensive glycemic control on kidney microvascular outcomes and all-cause mortality varies with baseline risk of kidney failure. Patients with elevated baseline risk of kidney failure derived the most from intensive glycemic control in reducing kidney microvascular outcomes (7-year RMST difference of 114.8 [95% confidence interval 58.1 to 176.4] versus 48.4 [25.3 to 69.6] days in the entire trial population) However, this same patient group also experienced a shorter time to death (7-year RMST difference of -56.7 [-100.2 to -17.5] v. -23.6 [-42.2 to -6.6] days). CONCLUSIONS We found evidence of heterogenous treatment effects of intensive glycemic control on kidney microvascular outcomes in ACCORD as a function of predicted baseline risk of kidney failure. Patients with higher kidney failure risk experienced the most pronounced reduction in kidney microvascular outcomes but also experienced the highest risk of all-cause mortality.
Collapse
Affiliation(s)
- Vivek Charu
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Jane W. Liang
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Glenn M. Chertow
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California
| | - June Li
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California
| | - Maria E. Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Pascal Geldsetzer
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Ian H. de Boer
- Division of Nephrology, Department of Medicine, and the Kidney Research Institute, University of Washington, Seattle, Washington
| | - Lu Tian
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, California
| | - Manjula Kurella Tamura
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California
- Geriatric Research and Education Clinical Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| |
Collapse
|
15
|
Rowe IA. Prediction of outcomes in patients with acute variceal bleeding. Hepatology 2024; 79:15-17. [PMID: 37607729 DOI: 10.1097/hep.0000000000000571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 07/28/2023] [Indexed: 08/24/2023]
Affiliation(s)
- Ian A Rowe
- Leeds Institute for Medical Research, University of Leeds & Leeds Liver Unit, St James's University Hospital, Leeds, UK
| |
Collapse
|
16
|
Lv Y, Bai W, Zhu X, Xue H, Zhao J, Zhuge Y, Sun J, Zhang C, Ding P, Jiang Z, Zhu X, Ren W, Li Y, Zhang K, Zhang W, Li K, Wang Z, Luo B, Li X, Yang Z, Guo W, Xia D, Xie H, Pan Y, Yin Z, Fan D, Han G. Development and validation of a prognostic score to identify the optimal candidate for preemptive TIPS in patients with cirrhosis and acute variceal bleeding. Hepatology 2024; 79:118-134. [PMID: 37594323 DOI: 10.1097/hep.0000000000000548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 06/12/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND AND AIM Baveno VII workshop recommends the use of preemptive TIPS (p-TIPS) in patients with cirrhosis and acute variceal bleeding (AVB) at high- risk of treatment failure. However, the criteria defining "high-risk" have low clinical accessibility or include subjective variables. We aimed to develop and externally validate a model for better identification of p-TIPS candidates. APPROACH AND RESULTS The derivation cohort included 1554 patients with cirrhosis and AVB who were treated with endoscopy plus drug (n = 1264) or p-TIPS (n = 290) from 12 hospitals in China between 2010 and 2017. We first used competing risk regression to develop a score for predicting 6-week and 1-year mortality in patients treated with endoscopy plus drugs, which included age, albumin, bilirubin, international normalized ratio, white blood cell, creatinine, and sodium. The score was internally validated with the bootstrap method, which showed good discrimination (6 wk/1 y concordance-index: 0.766/0.740) and calibration, and outperformed other currently available models. In the second stage, the developed score was combined with treatment and their interaction term to predicate the treatment effect of p-TIPS (mortality risk difference between treatment groups) in the whole derivation cohort. The estimated treatment effect of p-TIPS varied substantially among patients. The prediction model had good discriminative ability (6 wk/1 y c -for-benefit: 0.696/0.665) and was well calibrated. These results were confirmed in the validation dataset of 445 patients with cirrhosis with AVB from 6 hospitals in China between 2017 and 2019 (6-wk/1-y c-for-benefit: 0.675/0.672). CONCLUSIONS We developed and validated a clinical prediction model that can help to identify individuals who will benefit from p-TIPS, which may guide clinical decision-making.
Collapse
Affiliation(s)
- Yong Lv
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Wei Bai
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Xi'an International Medical Center Hospital of Digestive Diseases, Northwest University, Xi'an, China
| | - Xuan Zhu
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Hui Xue
- Department of Gastroenterology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jianbo Zhao
- Department of Interventional Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yuzheng Zhuge
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Junhui Sun
- Hepatobiliary and Pancreatic Intervention Center, Division of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Chunqing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital affiliated to Shandong University, Jinan, China
| | - Pengxu Ding
- Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zaibo Jiang
- Department of interventional Radiology, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaoli Zhu
- Department of interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Weixin Ren
- Department of Interventional Radiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yingchun Li
- Department of Interventional Radiology, Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Kewei Zhang
- Department of Vascular Surgery, Henan Provincial People's Hospital, Zhengzhou, China
| | - Wenguang Zhang
- Department of Interventional Radiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Kai Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhengyu Wang
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Xi'an International Medical Center Hospital of Digestive Diseases, Northwest University, Xi'an, China
| | - Bohan Luo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Xi'an International Medical Center Hospital of Digestive Diseases, Northwest University, Xi'an, China
| | - Xiaomei Li
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Xi'an International Medical Center Hospital of Digestive Diseases, Northwest University, Xi'an, China
| | - Zhiping Yang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Wengang Guo
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Xi'an International Medical Center Hospital of Digestive Diseases, Northwest University, Xi'an, China
| | - Dongdong Xia
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Xi'an International Medical Center Hospital of Digestive Diseases, Northwest University, Xi'an, China
| | - Huahong Xie
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Yanglin Pan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Zhanxin Yin
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Xi'an International Medical Center Hospital of Digestive Diseases, Northwest University, Xi'an, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | - Guohong Han
- Department of Liver Diseases and Digestive Interventional Radiology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
- Department of Liver Diseases and Interventional Radiology, Xi'an International Medical Center Hospital of Digestive Diseases, Northwest University, Xi'an, China
| |
Collapse
|
17
|
Hozo I, Djulbegovic B. Generalised decision curve analysis for explicit comparison of treatment effects. J Eval Clin Pract 2023; 29:1271-1278. [PMID: 37622200 DOI: 10.1111/jep.13915] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 07/24/2023] [Indexed: 08/26/2023]
Abstract
RATIONALE Decision curve analysis (DCA) helps integrate prediction models with treatment assessments to guide personalised therapeutic choices among multiple treatment options. However, the current versions of DCA do not explicitly model treatment effects in the analysis but implicitly or holistically assess therapeutic benefits and harms. In addition, the existing DCA cannot allow the comparison of multiple treatments using a standard metric. AIMS AND OBJECTIVES To develop a generalised version of DCA (gDCA) by decomposing holistically assessed net benefits and harms into patient preferences versus empirical evidence (as obtained in the trials, meta-analyses of clinical studies, etc.) to allow individualised comparison of single or multiple treatments using a common metric. METHODS We reformulated DCA by (1) decomposing holistic, implicit utilities into specific utilities related to treatment effects and patient's relative values (RV) about disease outcomes versus treatment harms, (2) explicitly modelling each treatment effect at the level of probabilities and/or utilities (outcomes) in a decision tree, and (3) avoiding scaling effects employed in the original DCA to enable comparison of treatment effects against the common metrics. We used data from a published network meta-analysis of randomised trials to inform the use of statin treatment according to Framingham Risk Model. RESULTS We illustrate the analysis by modelling the effects of three statins in the primary prevention of cardiovascular disease. We performed simultaneous comparisons against standard metrics (RV) for all treatments. We examined for which RV values, a predictive model for guiding personalised treatment, outperformed the strategies of treating everyone or treating no one. We found that the magnitude of benefits (efficacy) seems more important than the simple ratio of efficacy/harms. CONCLUSION We describe gDCA for evaluating single or multiple treatments to help tailor therapy toward individual risk characteristics. gDCA further helps integrate the principles of evidence-based medicine with decision analysis.
Collapse
Affiliation(s)
- Iztok Hozo
- Department of Mathematics, Indiana University Northwest, Gary, Indiana, USA
| | - Benjamin Djulbegovic
- Division of Medical Hematology and Oncology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| |
Collapse
|
18
|
Al-Shahi Salman R, Greenberg SM. Antiplatelet Agent Use After Stroke due to Intracerebral Hemorrhage. Stroke 2023; 54:3173-3181. [PMID: 37916459 DOI: 10.1161/strokeaha.123.036886] [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] [Indexed: 11/03/2023]
Abstract
This focused update about antiplatelet agents to reduce the high risk of major adverse cardiovascular events after stroke due to spontaneous (nontraumatic) intracerebral hemorrhage (ICH) complements earlier updates about blood pressure-lowering, lipid-lowering, and oral anticoagulation or left atrial appendage occlusion for atrial fibrillation after ICH. When used for secondary prevention in people without ICH, antiplatelet agents reduce the risk of major adverse cardiovascular event (rate ratio, 0.81 [95% CI, 0.75-0.87]) and might increase the risk of ICH (rate ratio, 1.67 [95% CI, 0.97-2.90]). Before 2019, guidance for clinical decisions about antiplatelet agent use after ICH has focused on estimating patients' predicted absolute risks and severities of ischemic and hemorrhagic major adverse cardiovascular event and applying the known effects of these drugs in people without ICH to estimate whether individual ICH survivors in clinical practice might be helped or harmed by antiplatelet agents. In 2019, the main results of the RESTART (Restart or Stop Antithrombotics Randomized Trial) randomized controlled trial including 537 survivors of ICH associated with antithrombotic drug use showed, counterintuitively, that antiplatelet agents might not increase the risk of recurrent ICH compared to antiplatelet agent avoidance over 2 years of follow-up (12/268 [4%] versus 23/268 [9%]; adjusted hazard ratio, 0.51 [95% CI, 0.25-1.03]; P=0.060). Guidelines in the United States, Canada, China, and the United Kingdom and Ireland have classified the level of evidence as B and indicated that antiplatelet agents may be considered/reasonable after ICH associated with antithrombotic agent use. Three subsequent clinical trials have recruited another 174 participants with ICH, but they will not be sufficient to determine the effects of antiplatelet therapy on all major adverse cardiovascular events reliably when pooled with RESTART. Therefore, ASPIRING (Antiplatelet Secondary Prevention International Randomized Study After Intracerebral Hemorrhage) aims to recruit 4148 ICH survivors to determine the effects of antiplatelet agents after ICH definitively overall and in subgroups.
Collapse
Affiliation(s)
| | - Steven M Greenberg
- Massachusetts General Hospital and Harvard Medical School, Boston (S.M.G.)
| |
Collapse
|
19
|
Ninomiya K, Kageyama S, Shiomi H, Kotoku N, Masuda S, Revaiah PC, Garg S, O'Leary N, van Klaveren D, Kimura T, Onuma Y, Serruys PW. Can Machine Learning Aid the Selection of Percutaneous vs Surgical Revascularization? J Am Coll Cardiol 2023; 82:2113-2124. [PMID: 37993203 DOI: 10.1016/j.jacc.2023.09.818] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/15/2023] [Accepted: 09/20/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND In patients with 3-vessel coronary artery disease (CAD) and/or left main CAD, individual risk prediction plays a key role in deciding between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). OBJECTIVES The aim of this study was to assess whether these individualized revascularization decisions can be improved by applying machine learning (ML) algorithms and integrating clinical, biological, and anatomical factors. METHODS In the SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) study, ML algorithms (Lasso regression, gradient boosting) were used to develop a prognostic index for 5-year death, which was combined, in the second stage, with assigned treatment (PCI or CABG) and prespecified effect-modifiers: disease type (3-vessel or left main CAD) and anatomical SYNTAX score. The model's discriminative ability to predict the risk of 5-year death and treatment benefit between PCI and CABG was cross-validated in the SYNTAX trial (n = 1,800) and externally validated in the CREDO-Kyoto (Coronary REvascularization Demonstrating Outcome Study in Kyoto) registry (n = 7,362), and then compared with the original SYNTAX score II 2020 (SSII-2020). RESULTS The hybrid gradient boosting model performed best for predicting 5-year all-cause death with C-indexes of 0.78 (95% CI: 0.75-0.81) in cross-validation and 0.77 (95% CI: 0.76-0.79) in external validation. The ML models discriminated 5-year mortality better than the SSII-2020 in the external validation cohort and identified heterogeneity in the treatment benefit of CABG vs PCI. CONCLUSIONS An ML-based approach for identifying individuals who benefit from CABG or PCI is feasible and effective. Implementation of this model in health care systems-trained to collect large numbers of parameters-may harmonize decision making globally. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES]; NCT03417050; SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries; NCT00114972).
Collapse
Affiliation(s)
- Kai Ninomiya
- Department of Cardiology, University of Galway, Galway, Ireland
| | | | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Nozomi Kotoku
- Department of Cardiology, University of Galway, Galway, Ireland
| | | | | | - Scot Garg
- Department of Cardiology, Royal Blackburn Hospital, Blackburn, United Kingdom
| | - Neil O'Leary
- Department of Cardiology, University of Galway, Galway, Ireland
| | - David van Klaveren
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshinobu Onuma
- Department of Cardiology, University of Galway, Galway, Ireland
| | | |
Collapse
|
20
|
Zhou Z, Jian B, Chen X, Liu M, Zhang S, Fu G, Li G, Liang M, Tian T, Wu Z. Heterogeneous treatment effects of coronary artery bypass grafting in ischemic cardiomyopathy: A machine learning causal forest analysis. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00797-3. [PMID: 37716652 DOI: 10.1016/j.jtcvs.2023.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 08/13/2023] [Accepted: 09/05/2023] [Indexed: 09/18/2023]
Abstract
OBJECTIVES We aim to evaluate the heterogeneous treatment effects of coronary artery bypass grafting in patients with ischemic cardiomyopathy and to identify a group of patients to have greater benefits from coronary artery bypass grafting compared with medical therapy alone. METHODS Machine learning causal forest modeling was performed to identify the heterogeneous treatment effects of coronary artery bypass grafting in patients with ischemic cardiomyopathy from the Surgical Treatment for Ischemic Heart Failure trial. The risks of death from any cause and death from cardiovascular causes between coronary artery bypass grafting and medical therapy alone were assessed in the identified subgroups. RESULTS Among 1212 patients enrolled in the Surgical Treatment for Ischemic Heart Failure trial, left ventricular end-systolic volume index, serum creatinine, and age were identified by the machine learning algorithm to distinguish patients with heterogeneous treatment effects. Among patients with left ventricular end-systolic volume index greater than 84 mL/m2 and age 60.27 years or less, coronary artery bypass grafting was associated with a significantly lower risk of death from any cause (adjusted hazard ratio, 0.61; 95% CI, 0.45-0.84) and death from cardiovascular causes (adjusted hazard ratio, 0.63; 95% CI, 0.45-0.89). By contrast, the survival benefits of coronary artery bypass grafting no longer exist in patients with left ventricular end-systolic volume index 84 mL/m2 or less and serum creatinine 1.04 mg/dL or less, or patients with left ventricular end-systolic volume index greater than 84 mL/m2 and age more than 60.27 years. CONCLUSIONS The current post hoc analysis of the Surgical Treatment for Ischemic Heart Failure trial identified heterogeneous treatment effects of coronary artery bypass grafting in patients with ischemic cardiomyopathy. Younger patients with severe left ventricular enlargement were more likely to derive greater survival benefits from coronary artery bypass grafting.
Collapse
Affiliation(s)
- Zhuoming Zhou
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Bohao Jian
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xuanyu Chen
- School of Mathematics, Sun Yat-sen University, Guangzhou, China
| | - Menghui Liu
- Department of Cardiology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shaozhao Zhang
- Department of Cardiology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Guangguo Fu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Gang Li
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Mengya Liang
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
| | - Ting Tian
- School of Mathematics, Sun Yat-sen University, Guangzhou, China.
| | - Zhongkai Wu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
| |
Collapse
|
21
|
Hoogland J, Takada T, van Smeden M, Rovers MM, de Sutter AI, Merenstein D, Kaiser L, Liira H, Little P, Bucher HC, Moons KGM, Reitsma JB, Venekamp RP. Prognosis and prediction of antibiotic benefit in adults with clinically diagnosed acute rhinosinusitis: an individual participant data meta-analysis. Diagn Progn Res 2023; 7:16. [PMID: 37667327 PMCID: PMC10478354 DOI: 10.1186/s41512-023-00154-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 07/20/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND A previous individual participant data meta-analysis (IPD-MA) of antibiotics for adults with clinically diagnosed acute rhinosinusitis (ARS) showed a marginal overall effect of antibiotics, but was unable to identify patients that are most likely to benefit from antibiotics when applying conventional (i.e. univariable or one-variable-at-a-time) subgroup analysis. We updated the systematic review and investigated whether multivariable prediction of patient-level prognosis and antibiotic treatment effect may lead to more tailored treatment assignment in adults presenting to primary care with ARS. METHODS An IPD-MA of nine double-blind placebo-controlled trials of antibiotic treatment (n=2539) was conducted, with the probability of being cured at 8-15 days as the primary outcome. A logistic mixed effects model was developed to predict the probability of being cured based on demographic characteristics, signs and symptoms, and antibiotic treatment assignment. Predictive performance was quantified based on internal-external cross-validation in terms of calibration and discrimination performance, overall model fit, and the accuracy of individual predictions. RESULTS Results indicate that the prognosis with respect to risk of cure could not be reliably predicted (c-statistic 0.58 and Brier score 0.24). Similarly, patient-level treatment effect predictions did not reliably distinguish between those that did and did not benefit from antibiotics (c-for-benefit 0.50). CONCLUSIONS In conclusion, multivariable prediction based on patient demographics and common signs and symptoms did not reliably predict the patient-level probability of cure and antibiotic effect in this IPD-MA. Therefore, these characteristics cannot be expected to reliably distinguish those that do and do not benefit from antibiotics in adults presenting to primary care with ARS.
Collapse
Affiliation(s)
- Jeroen Hoogland
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
- Department of Epidemiology and Data Science, Amsterdam University Medical Centres, Amsterdam University, Amsterdam, The Netherlands.
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima Medical University, Fukushima, Japan
| | - Maarten van Smeden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Maroeska M Rovers
- Radboud Institute for Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - An I de Sutter
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Daniel Merenstein
- Department of Family Medicine, Georgetown University Medical Center, Washington, DC, USA
| | - Laurent Kaiser
- Department of Medicine, Division of Infectious Diseases, University Hospital Geneva, Geneva, Switzerland
| | - Helena Liira
- Department of General Practice, School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Perth, Australia
- Department of General Practice and Primary Care, University of Helsinki, Helsinki, Finland
| | - Paul Little
- Primary Care & Population Sciences Unit, Aldermoor Health Centre, University of Southampton, Southampton, UK
| | - Heiner C Bucher
- Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Karel G M Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Johannes B Reitsma
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roderick P Venekamp
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
22
|
Harrer M, Cuijpers P, Schuurmans LKJ, Kaiser T, Buntrock C, van Straten A, Ebert D. Evaluation of randomized controlled trials: a primer and tutorial for mental health researchers. Trials 2023; 24:562. [PMID: 37649083 PMCID: PMC10469910 DOI: 10.1186/s13063-023-07596-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/18/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Considered one of the highest levels of evidence, results of randomized controlled trials (RCTs) remain an essential building block in mental health research. They are frequently used to confirm that an intervention "works" and to guide treatment decisions. Given their importance in the field, it is concerning that the quality of many RCT evaluations in mental health research remains poor. Common errors range from inadequate missing data handling and inappropriate analyses (e.g., baseline randomization tests or analyses of within-group changes) to unduly interpretations of trial results and insufficient reporting. These deficiencies pose a threat to the robustness of mental health research and its impact on patient care. Many of these issues may be avoided in the future if mental health researchers are provided with a better understanding of what constitutes a high-quality RCT evaluation. METHODS In this primer article, we give an introduction to core concepts and caveats of clinical trial evaluations in mental health research. We also show how to implement current best practices using open-source statistical software. RESULTS Drawing on Rubin's potential outcome framework, we describe that RCTs put us in a privileged position to study causality by ensuring that the potential outcomes of the randomized groups become exchangeable. We discuss how missing data can threaten the validity of our results if dropouts systematically differ from non-dropouts, introduce trial estimands as a way to co-align analyses with the goals of the evaluation, and explain how to set up an appropriate analysis model to test the treatment effect at one or several assessment points. A novice-friendly tutorial is provided alongside this primer. It lays out concepts in greater detail and showcases how to implement techniques using the statistical software R, based on a real-world RCT dataset. DISCUSSION Many problems of RCTs already arise at the design stage, and we examine some avoidable and unavoidable "weak spots" of this design in mental health research. For instance, we discuss how lack of prospective registration can give way to issues like outcome switching and selective reporting, how allegiance biases can inflate effect estimates, review recommendations and challenges in blinding patients in mental health RCTs, and describe problems arising from underpowered trials. Lastly, we discuss why not all randomized trials necessarily have a limited external validity and examine how RCTs relate to ongoing efforts to personalize mental health care.
Collapse
Affiliation(s)
- Mathias Harrer
- Psychology and Digital Mental Health Care, Technical University Munich, Georg-Brauchle-Ring 60-62, Munich, 80992, Germany.
- Clinical Psychology and Psychotherapy, Institute for Psychology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany.
| | - Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- WHO Collaborating Centre for Research and Dissemination of Psychological Interventions, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Lea K J Schuurmans
- Psychology and Digital Mental Health Care, Technical University Munich, Georg-Brauchle-Ring 60-62, Munich, 80992, Germany
| | - Tim Kaiser
- Methods and Evaluation/Quality Assurance, Freie Universität Berlin, Berlin, Germany
| | - Claudia Buntrock
- Institute of Social Medicine and Health Systems Research (ISMHSR), Medical Faculty, Otto Von Guericke University Magdeburg, Magdeburg, Germany
| | - Annemieke van Straten
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - David Ebert
- Psychology and Digital Mental Health Care, Technical University Munich, Georg-Brauchle-Ring 60-62, Munich, 80992, Germany
| |
Collapse
|
23
|
Sollfrank L, Linn SC, Hauptmann M, Jóźwiak K. A scoping review of statistical methods in studies of biomarker-related treatment heterogeneity for breast cancer. BMC Med Res Methodol 2023; 23:154. [PMID: 37386356 PMCID: PMC10308726 DOI: 10.1186/s12874-023-01982-w] [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: 11/08/2022] [Accepted: 06/19/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Many scientific papers are published each year and substantial resources are spent to develop biomarker-based tests for precision oncology. However, only a handful of tests is currently used in daily clinical practice, since development is challenging. In this situation, the application of adequate statistical methods is essential, but little is known about the scope of methods used. METHODS A PubMed search identified clinical studies among women with breast cancer comparing at least two different treatment groups, one of which chemotherapy or endocrine treatment, by levels of at least one biomarker. Studies presenting original data published in 2019 in one of 15 selected journals were eligible for this review. Clinical and statistical characteristics were extracted by three reviewers and a selection of characteristics for each study was reported. RESULTS Of 164 studies identified by the query, 31 were eligible. Over 70 different biomarkers were evaluated. Twenty-two studies (71%) evaluated multiplicative interaction between treatment and biomarker. Twenty-eight studies (90%) evaluated either the treatment effect in biomarker subgroups or the biomarker effect in treatment subgroups. Eight studies (26%) reported results for one predictive biomarker analysis, while the majority performed multiple evaluations, either for several biomarkers, outcomes and/or subpopulations. Twenty-one studies (68%) claimed to have found significant differences in treatment effects by biomarker level. Fourteen studies (45%) mentioned that the study was not designed to evaluate treatment effect heterogeneity. CONCLUSIONS Most studies evaluated treatment heterogeneity via separate analyses of biomarker-specific treatment effects and/or multiplicative interaction analysis. There is a need for the application of more efficient statistical methods to evaluate treatment heterogeneity in clinical studies.
Collapse
Affiliation(s)
- L Sollfrank
- Institute of Biostatistics and Registry Research, Brandenburg Medical School Theodor Fontane, Fehrbelliner Straße 39, Neuruppin, 16816, Germany
| | - S C Linn
- Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Pathology, University Medical Center, Utrecht, The Netherlands
| | - M Hauptmann
- Institute of Biostatistics and Registry Research, Brandenburg Medical School Theodor Fontane, Fehrbelliner Straße 39, Neuruppin, 16816, Germany
| | - K Jóźwiak
- Institute of Biostatistics and Registry Research, Brandenburg Medical School Theodor Fontane, Fehrbelliner Straße 39, Neuruppin, 16816, Germany.
| |
Collapse
|
24
|
Charu V, Liang JW, Chertow GM, Li ZJ, Montez-Rath ME, Geldsetzer P, de Boer IH, Tian L, Tamura MK. Heterogeneous treatment effects of intensive glycemic control on kidney microvascular outcomes in ACCORD. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.06.14.23291396. [PMID: 37398349 PMCID: PMC10312895 DOI: 10.1101/2023.06.14.23291396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Objective Clear criteria to individualize glycemic targets are lacking. In this post-hoc analysis of the Action to Control Cardiovascular Risk in Diabetes trial (ACCORD), we evaluate whether the kidney failure risk equation (KFRE) can identify patients who disproportionately benefit from intensive glycemic control on kidney microvascular outcomes. Research design and methods We divided the ACCORD trial population in quartiles based on 5-year kidney failure risk using the KFRE. We estimated conditional treatment effects within each quartile and compared them to the average treatment effect in the trial. The treatment effects of interest were the 7-year restricted-mean-survival-time (RMST) differences between intensive and standard glycemic control arms on (1) time-to-first development of severely elevated albuminuria or kidney failure and (2) all-cause mortality. Results We found evidence that the effect of intensive glycemic control on kidney microvascular outcomes and all-cause mortality varies with baseline risk of kidney failure. Patients with elevated baseline risk of kidney failure benefitted the most from intensive glycemic control on kidney microvascular outcomes (7-year RMST difference of 115 v. 48 days in the entire trial population) However, this same patient group also experienced shorter times to death (7-year RMST difference of -57 v. -24 days). Conclusions We found evidence of heterogenous treatment effects of intensive glycemic control on kidney microvascular outcomes in ACCORD as a function of predicted baseline risk of kidney failure. Patients with higher kidney failure risk experienced the most pronounced benefits of treatment on kidney microvascular outcomes but also experienced the highest risk of all-cause mortality.
Collapse
Affiliation(s)
- Vivek Charu
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, CA
- Department of Pathology, Stanford University School of Medicine, Stanford, CA
| | - Jane W. Liang
- Quantitative Sciences Unit, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Glenn M. Chertow
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Zhuo Jun Li
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA
| | - Maria E. Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Pascal Geldsetzer
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Ian H. de Boer
- Division of Nephrology, Department of Medicine, and the Kidney Research Institute, University of Washington, Seattle, WA
| | - Lu Tian
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, CA
| | - Manjula Kurella Tamura
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, CA
- Geriatric Research and Education Clinical Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| |
Collapse
|
25
|
Ohata E, Nakatani E, Kaneda H, Fujimoto Y, Tanaka K, Takagi A. Use of the Shizuoka Hip Fracture Prognostic Score (SHiPS) to Predict Long-Term Mortality in Patients With Hip Fracture in Japan: A Cohort Study Using the Shizuoka Kokuho Database. JBMR Plus 2023; 7:e10743. [PMID: 37283648 PMCID: PMC10241087 DOI: 10.1002/jbm4.10743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 03/21/2023] [Indexed: 06/08/2023] Open
Abstract
Hip fractures are common in patients of advanced age and are associated with excess mortality. Rapid and accurate prediction of the prognosis using information that can be easily obtained before surgery would be advantageous to clinical management. We performed a population-based retrospective cohort study using an 8.5-year Japanese claims database (April 2012-September 2020) to develop and validate a predictive model for long-term mortality after hip fracture. The study included 43,529 patients (34,499 [79.3%] women) aged ≥65 years with first-onset hip fracture. During the observation period, 43% of the patients died. Cox regression analysis identified the following prognostic predictors: sex, age, fracture site, nursing care certification, and several comorbidities (any malignancy, renal disease, congestive heart failure, chronic pulmonary disease, liver disease, metastatic solid tumor, and deficiency anemia). We then developed a scoring system called the Shizuoka Hip Fracture Prognostic Score (SHiPS); this system was established by scoring based on each hazard ratio and classifying the degree of mortality risk into four categories based on decision tree analysis. The area under the receiver operating characteristic (ROC) curve (AUC) (95% confidence interval [CI]) of 1-year, 3-year, and 5-year mortality based on the SHiPS was 0.718 (95% CI, 0.706-0.729), 0.736 (95% CI, 0.728-0.745), and 0.758 (95% CI, 0.747-0.769), respectively, indicating good predictive performance of the SHiPS for as long as 5 years after fracture onset. Even when the SHiPS was individually applied to patients with or without surgery after fracture, the prediction performance by the AUC was >0.7. These results indicate that the SHiPS can predict long-term mortality using preoperative information regardless of whether surgery is performed after hip fracture.
Collapse
Affiliation(s)
- Emi Ohata
- Graduate School of Public HealthShizuoka Graduate University of Public HealthShizuokaJapan
- 4DIN LtdTokyoJapan
| | - Eiji Nakatani
- Graduate School of Public HealthShizuoka Graduate University of Public HealthShizuokaJapan
| | - Hideaki Kaneda
- Translational Research Center for Medical Innovation, Foundation for Biomedical Research and Innovation at KobeKobeJapan
| | - Yoh Fujimoto
- Graduate School of Public HealthShizuoka Graduate University of Public HealthShizuokaJapan
- Department of Pediatric OrthopedicsShizuoka Children's HospitalShizuokaJapan
| | - Kiyoshi Tanaka
- Department of General Internal MedicineShizuoka General HospitalShizuokaJapan
- Faculty of NutritionKobe Gakuin UniversityKobeJapan
| | - Akira Takagi
- Graduate School of Public HealthShizuoka Graduate University of Public HealthShizuokaJapan
- Department of OtolaryngologyShizuoka General HospitalShizuokaJapan
| |
Collapse
|
26
|
Kent DM. Overall average treatment effects from clinical trials, one-variable-at-a-time subgroup analyses and predictive approaches to heterogeneous treatment effects: Toward a more patient-centered evidence-based medicine. Clin Trials 2023:17407745231171897. [PMID: 37148125 DOI: 10.1177/17407745231171897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Despite the predominance of the evidence-based medicine paradigm, a fundamental incongruity remains: Evidence is derived from groups of people, yet medical decisions are made by and for individuals. Randomization ensures the comparability of treatment groups within a clinical trial, which allows for unbiased estimation of average treatment effects. If we treated groups of patients instead of individuals, or if patients with the same disease were identical to one another in all factors that determined the harms and the benefits of therapy, then these group-level averages would make a perfectly sound foundation for medical decision-making. But patients differ from one another in many ways that determine the likelihood of an outcome, both with and without a treatment. Nevertheless, popular approaches to evidence-based medicine have encouraged a reliance on the average treatment effects estimated from clinical trials and meta-analysis as guides to decision-making for individuals. Here, we discuss the limitations of this approach as well as limitations of conventional, one-variable-at-a-time subgroup analysis; finally, we discuss the rationale for "predictive" approaches to heterogeneous treatment effects. Predictive approaches to heterogeneous treatment effects combine methods for causal inference (e.g. randomization) with methods for prediction that permit inferences about which patients are likely to benefit and which are not, taking into account multiple relevant variables simultaneously to yield "personalized" estimates of benefit-harm trade-offs. We focus on risk modeling approaches, which rely on the mathematical dependence of the absolute treatment effect with the baseline risk, which varies substantially "across patients" in most trials. While there are a number of examples of risk modeling approaches that have been practice-changing, risk modeling does not provide ideal estimates of individual treatment effects, since risk modeling does not account for how individual variables might modify the effects of therapy. In "effect modeling," prediction models are developed directly on clinical trial data, including terms for treatment and treatment effect interactions. These more flexible approaches may better uncover individualized treatment effects, but are also prone to overfitting when dimensionality is high, power is low, and there is limited prior knowledge about effect modifiers.
Collapse
|
27
|
Gentle SJ, Rysavy MA, Li L, Laughon MM, Patel RM, Jensen EA, Hintz S, Ambalavanan N, Carlo WA, Watterberg K. Heterogeneity of Treatment Effects of Hydrocortisone by Risk of Bronchopulmonary Dysplasia or Death Among Extremely Preterm Infants in the National Institute of Child Health and Human Development Neonatal Research Network Trial: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2315315. [PMID: 37256621 PMCID: PMC10233424 DOI: 10.1001/jamanetworkopen.2023.15315] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 04/11/2023] [Indexed: 06/01/2023] Open
Abstract
Importance Extremely preterm infants who develop bronchopulmonary dysplasia (BPD) are at a higher risk for adverse pulmonary and neurodevelopmental outcomes. In the National Institute of Child Health and Human Development Neonatal Research Network (NICHD NRN) Hydrocortisone Trial, hydrocortisone neither reduced rates of BPD or death nor increased rates of neurodevelopmental impairment (NDI) or death. Objective To determine whether estimated risk for grades 2 to 3 BPD or death is associated with the effect of hydrocortisone on the composite outcomes of (1) grades 2 to 3 BPD or death and (2) moderate or severe NDI or death. Design, Setting, and Participants This secondary post hoc analysis used data from the NICHD NRN Hydrocortisone Trial, which was a double-masked, placebo-controlled, randomized clinical trial conducted in 19 US academic centers. The NICHD HRN Hydrocortisone Trial enrolled infants born at a gestational age of less than 30 weeks who received mechanical ventilation for at least 7 days, including at the time of enrollment, and who were aged 14 to 28 postnatal days. Infants were enrolled between August 22, 2011, and February 4, 2018, with follow-up between 22 and 26 months of corrected age completed on March 29, 2020. Data were analyzed from September 13, 2021, to March 25, 2023. Intervention Infants were randomized to 10 days of hydrocortisone or placebo treatment. Main Outcomes and Measures Infants' baseline risk of grades 2 to 3 BPD or death was estimated using the NICHD Neonatal BPD Outcome Estimator. Differences in absolute and relative treatment effects by baseline risk were evaluated using interaction terms in models fitted to the efficacy outcome of grades 2 to 3 BPD or death and the safety outcome of moderate or severe NDI or death by follow-up. Results Among the 799 infants included in the analysis (421 boys [52.7%]), the mean (SD) gestational age was 24.9 (1.5) weeks, and the mean (SD) birth weight was 715 (167) g. The mean estimated baseline risk for grades 2 to 3 BPD or death was 54% (range, 18%-84%) in the study population. The interaction between treatment group and baseline risk was not statistically significant on a relative or absolute scale for grades 2 to 3 BPD or death; the size of the effect ranged from a relative risk of 1.13 (95% CI, 0.82-1.55) in quartile 1 to 0.94 (95% CI, 0.81-1.09) in quartile 4. Similarly, the interaction between treatment group and baseline risk was not significant on a relative or absolute scale for moderate or severe NDI or death; the size of the effect ranged from a relative risk of 1.04 (95% CI, 0.80-1.36) in quartile 1 to 0.99 (95% CI, 0.80-1.22) in quartile 4. Conclusions and Relevance In this secondary analysis of a randomized clinical trial, the effect of hydrocortisone vs placebo was not appreciably modified by baseline risk for grades 2 to 3 BPD or death. Trial Registration ClinicalTrials.gov Identifier: NCT01353313.
Collapse
Affiliation(s)
| | - Matthew A. Rysavy
- Department of Pediatrics, University of Texas Health Science Center at Houston
| | - Lei Li
- Statistics and Epidemiology Division, RTI International, Research Triangle Park, North Carolina
| | | | - Ravi M. Patel
- Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Erik A. Jensen
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Susan Hintz
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | | | | | - Kristi Watterberg
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque
| |
Collapse
|
28
|
Ghazi L, Shen J, Ying J, Derington CG, Cohen JB, Marcum ZA, Herrick JS, King JB, Cheung AK, Williamson JD, Pajewski NM, Bryan N, Supiano M, Sonnen J, Weintraub WS, Greene TH, Bress AP. Identifying Patients for Intensive Blood Pressure Treatment Based on Cognitive Benefit: A Secondary Analysis of the SPRINT Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2314443. [PMID: 37204788 PMCID: PMC10199351 DOI: 10.1001/jamanetworkopen.2023.14443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 03/25/2023] [Indexed: 05/20/2023] Open
Abstract
Importance Intensive vs standard treatment to lower systolic blood pressure (SBP) reduces risk of mild cognitive impairment (MCI) or dementia; however, the magnitude of cognitive benefit likely varies among patients. Objective To estimate the magnitude of cognitive benefit of intensive vs standard systolic BP (SBP) treatment. Design, Setting, and Participants In this ad hoc secondary analysis of the Systolic Blood Pressure Intervention Trial (SPRINT), 9361 randomized clinical trial participants 50 years or older with high cardiovascular risk but without a history of diabetes, stroke, or dementia were followed up. The SPRINT trial was conducted between November 1, 2010, and August 31, 2016, and the present analysis was completed on October 31, 2022. Intervention Systolic blood pressure treatment to an intensive (<120 mm Hg) vs standard (<140 mm Hg) target. Main Outcomes and Measures The primary outcome was a composite of adjudicated probable dementia or amnestic MCI. Results A total of 7918 SPRINT participants were included in the analysis; 3989 were in the intensive treatment group (mean [SD] age, 67.9 [9.2] years; 2570 [64.4%] men; 1212 [30.4%] non-Hispanic Black) and 3929 were in the standard treatment group (mean [SD] age, 67.9 [9.4] years; 2570 [65.4%] men; 1249 [31.8%] non-Hispanic Black). Over a median follow-up of 4.13 (IQR, 3.50-5.88) years, there were 765 and 828 primary outcome events in the intensive treatment group and standard treatment group, respectively. Older age (hazard ratio [HR] per 1 SD, 1.87 [95% CI, 1.78-1.96]), Medicare enrollment (HR per 1 SD, 1.42 [95% CI, 1.35-1.49]), and higher baseline serum creatinine level (HR per 1 SD, 1.24 [95% CI, 1.19-1.29]) were associated with higher risk of the primary outcome, while better baseline cognitive functioning (HR per 1 SD, 0.43 [95% CI, 0.41-0.44]) and active employment status (HR per 1 SD, 0.44 [95% CI, 0.42-0.46]) were associated with lower risk of the primary outcome. Risk of the primary outcome by treatment goal was estimated accurately based on similar projected and observed absolute risk differences (C statistic = 0.79). Higher baseline risk for the primary outcome was associated with greater benefit (ie, larger absolute reduction of probable dementia or amnestic MCI) of intensive vs standard treatment across the full range of estimated baseline risk. Conclusions and Relevance In this secondary analysis of the SPRINT trial, participants with higher baseline projected risk of probable dementia or amnestic MCI gained greater absolute cognitive benefit from intensive vs standard SBP treatment in a monotonic fashion. Trial Registration ClinicalTrials.gov Identifier: NCT01206062.
Collapse
Affiliation(s)
- Lama Ghazi
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham
| | - Jincheng Shen
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City
| | - Jian Ying
- Department of Internal Medicine, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
| | - Catherine G. Derington
- Intermountain Healthcare Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
| | - Jordana B. Cohen
- Department of Medicine, Renal-Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Zachary A. Marcum
- Department of Pharmacy, University of Washington School of Pharmacy, Seattle
| | - Jennifer S. Herrick
- Intermountain Healthcare Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah
| | - Jordan B. King
- Intermountain Healthcare Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | - Alfred K. Cheung
- Department of Internal Medicine, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah
| | - Jeff D. Williamson
- The Sticht Center for Healthy Aging and Alzheimer’s Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Nicholas M. Pajewski
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Nick Bryan
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Mark Supiano
- Division of Geriatrics, University of Utah School of Medicine, and The Center on Aging, University of Utah, Salt Lake City
| | - Josh Sonnen
- Department of Pathology and Neurology and Neurosurgery, McGill University School of Medicine, Montreal, Quebec, Canada
| | | | - Tom H. Greene
- Intermountain Healthcare Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
| | - Adam P. Bress
- Intermountain Healthcare Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah
| |
Collapse
|
29
|
Efthimiou O, Hoogland J, Debray TP, Seo M, Furukawa TA, Egger M, White IR. Measuring the performance of prediction models to personalize treatment choice. Stat Med 2023; 42:1188-1206. [PMID: 36700492 PMCID: PMC7615726 DOI: 10.1002/sim.9665] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 11/07/2022] [Accepted: 12/31/2022] [Indexed: 01/27/2023]
Abstract
When data are available from individual patients receiving either a treatment or a control intervention in a randomized trial, various statistical and machine learning methods can be used to develop models for predicting future outcomes under the two conditions, and thus to predict treatment effect at the patient level. These predictions can subsequently guide personalized treatment choices. Although several methods for validating prediction models are available, little attention has been given to measuring the performance of predictions of personalized treatment effect. In this article, we propose a range of measures that can be used to this end. We start by defining two dimensions of model accuracy for treatment effects, for a single outcome: discrimination for benefit and calibration for benefit. We then amalgamate these two dimensions into an additional concept, decision accuracy, which quantifies the model's ability to identify patients for whom the benefit from treatment exceeds a given threshold. Subsequently, we propose a series of performance measures related to these dimensions and discuss estimating procedures, focusing on randomized data. Our methods are applicable for continuous or binary outcomes, for any type of prediction model, as long as it uses baseline covariates to predict outcomes under treatment and control. We illustrate all methods using two simulated datasets and a real dataset from a trial in depression. We implement all methods in the R package predieval. Results suggest that the proposed measures can be useful in evaluating and comparing the performance of competing models in predicting individualized treatment effect.
Collapse
Affiliation(s)
- Orestis Efthimiou
- Institute of Social and Preventive Medicine (ISPM), University of BernBernSwitzerland
- Institute of Primary Health Care (BIHAM), University of BernBernSwitzerland
- Department of PsychiatryUniversity of OxfordOxfordUK
| | - Jeroen Hoogland
- Julius Center for Health Sciences and Primary CareUniversity Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
- Department of Epidemiology and Data ScienceAmsterdam University Medical CentersAmsterdamThe Netherlands
| | - Thomas P.A. Debray
- Julius Center for Health Sciences and Primary CareUniversity Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
- Smart Data Analysis and Statistics B.V.UtrechtThe Netherlands
| | - Michael Seo
- Institute of Social and Preventive Medicine (ISPM), University of BernBernSwitzerland
- Graduate School for Health SciencesUniversity of BernBernSwitzerland
| | - Toshiaki A. Furukawa
- Departments of Health Promotion and Human Behavior and of Clinical EpidemiologyKyoto University Graduate School of Medicine/School of Public HealthKyotoJapan
| | - Matthias Egger
- Institute of Social and Preventive Medicine (ISPM), University of BernBernSwitzerland
- Centre for Infectious Disease Epidemiology and Research, Faculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Ian R. White
- MRC Clinical Trials Unit at UCLUniversity College LondonLondonUK
| |
Collapse
|
30
|
Liu P, Wu Y, Xiao Z, Gold LS, Heagerty PJ, Annaswamy T, Friedly J, Turner JA, Jarvik JG, Suri P. Estimating individualized treatment effects using a risk-modeling approach: an application to epidural steroid injections for lumbar spinal stenosis. Pain 2023; 164:811-819. [PMID: 36036907 PMCID: PMC9968359 DOI: 10.1097/j.pain.0000000000002768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 08/16/2022] [Indexed: 11/25/2022]
Abstract
ABSTRACT Conventional "1-variable-at-a-time" analyses to identify treatment effect modifiers are often underpowered and prone to false-positive results. This study used a "risk-modeling" approach guided by the Predictive Approaches to Treatment effect Heterogeneity (PATH) Statement framework: (1) developing and validating a multivariable model to estimate predicted future back-related functional limitations as measured by the Roland-Morris Disability Questionnaire (RMDQ) and (2) stratifying patients from a randomized controlled trial (RCT) of lumbar epidural steroid injections (LESIs) for the treatment of lumbar spinal stenosis into subgroups with different individualized treatment effects on RMDQ scores at the 3-week follow-up. Model development and validation were conducted in a cohort (n = 3259) randomly split into training and testing sets in a 4:1 ratio. The model was developed in the testing set using linear regression with least absolute shrinkage and selection regularization and 5-fold cross-validation. The model was then applied in the testing set and subsequently in patients receiving the control treatment in the RCT of LESI. R2 values in the training set, testing set, and RCT were 0.38, 0.32, and 0.34, respectively. There was statistically significant modification ( P = 0.03) of the LESI treatment effect according to predicted risk quartile, with clinically relevant LESI treatment effect point estimates in the 2 quartiles with greatest predicted risk (-3.7 and -3.3 RMDQ points) and no effect in the lowest 2 quartiles. A multivariable risk-modeling approach identified subgroups of patients with lumbar spinal stenosis with a clinically relevant treatment effect of LESI on back-related functional limitations.
Collapse
Affiliation(s)
- Pinyan Liu
- Department of Biostatistics, University of Washington, 1705 NE Pacific Street, Box 357232,Seattle, WA 98104, USA
| | - Yitao Wu
- Department of Biostatistics, University of Washington, 1705 NE Pacific Street, Box 357232,Seattle, WA 98104, USA
| | - Ziyu Xiao
- Department of Biostatistics, University of Washington, 1705 NE Pacific Street, Box 357232,Seattle, WA 98104, USA
| | - Laura S. Gold
- Clinical Learning, Evidence, and Research Center, University of Washington, 4333 Brooklyn Ave NE, Box 359455, Seattle, WA 98104, USA
| | - Patrick J. Heagerty
- Department of Biostatistics, University of Washington, 1705 NE Pacific Street, Box 357232,Seattle, WA 98104, USA
- Clinical Learning, Evidence, and Research Center, University of Washington, 4333 Brooklyn Ave NE, Box 359455, Seattle, WA 98104, USA
| | - Thiru Annaswamy
- Dallas VA Medical Center, 4500 S. Lancaster Rd. Dallas, TX 75216, USA
| | - Janna Friedly
- Clinical Learning, Evidence, and Research Center, University of Washington, 4333 Brooklyn Ave NE, Box 359455, Seattle, WA 98104, USA
- Department of Rehabilitation Medicine, University of Washington, 325 Ninth Avenue, Box 359612, Seattle, WA 98104, USA
| | - Judith A. Turner
- Department of Psychiatry & Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific St., Seattle, WA 98195, USA
| | - Jeffrey G. Jarvik
- Clinical Learning, Evidence, and Research Center, University of Washington, 4333 Brooklyn Ave NE, Box 359455, Seattle, WA 98104, USA
- Departments of Radiology and Neurological Surgery, University of Washington, Seattle, USA, 325 Ninth Avenue, Box 359612 Seattle, WA 98104, USA
| | - Pradeep Suri
- Clinical Learning, Evidence, and Research Center, University of Washington, 4333 Brooklyn Ave NE, Box 359455, Seattle, WA 98104, USA
- Department of Rehabilitation Medicine, University of Washington, 325 Ninth Avenue, Box 359612, Seattle, WA 98104, USA
- Seattle Epidemiologic Research and Information Center, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, USA
- Division of Rehabilitation Care Services, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, USA
| |
Collapse
|
31
|
Samuels N, van de Graaf RA, Mulder MJHL, Brown S, Roozenbeek B, van Doormaal PJ, Goyal M, Campbell BCV, Muir KW, Agrinier N, Bracard S, White PM, Román LS, Jovin TG, Hill MD, Mitchell PJ, Demchuk AM, Bonafe A, Devlin TG, van Es ACGM, Lingsma HF, Dippel DWJ, van der Lugt A. Admission systolic blood pressure and effect of endovascular treatment in patients with ischaemic stroke: an individual patient data meta-analysis. Lancet Neurol 2023; 22:312-319. [PMID: 36931806 DOI: 10.1016/s1474-4422(23)00076-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 02/06/2023] [Accepted: 02/20/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND Current guidelines for ischaemic stroke treatment recommend a strict, but arbitrary, upper threshold of 185/110 mm Hg for blood pressure before endovascular thrombectomy. Nevertheless, whether admission blood pressure influences the effect of endovascular thrombectomy on outcome remains unknown. Our aim was to study the influence of admission systolic blood pressure (SBP) on functional outcome and on the effect of endovascular thrombectomy. METHODS We used individual patient data from seven randomised controlled trials (MR CLEAN, ESCAPE, EXTEND-IA, SWIFT PRIME, REVASCAT, PISTE, and THRACE) that randomly assigned patients with anterior circulation ischaemic stroke to endovascular thrombectomy (predominantly using stent retrievers) or standard medical therapy (control) between June 1, 2010, and April 30, 2015. We included all patients for whom SBP data were available at hospital admission. The primary outcome was functional outcome (modified Rankin Scale) at 90 days. We assessed the association of SBP with outcome in both the endovascular thrombectomy group and the control group using multilevel regression analysis and tested for non-linearity and for interaction between SBP and effect of endovascular thrombectomy, taking into account treatment with intravenous thrombolysis. FINDINGS We included 1753 patients (867 assigned to endovascular thrombectomy, 886 assigned to control) after excluding 11 patients for whom SBP data were missing. We found a non-linear association between SBP and functional outcome with an inflection point at 140 mm Hg (732 [42%] of 1753 patients had SBP <140 mm Hg and 1021 [58%] had SBP ≥140 mm Hg). Among patients with SBP of 140 mm Hg or higher, admission SBP was associated with worse functional outcome (adjusted common odds ratio [acOR] 0·86 per 10 mm Hg SBP increase; 95% CI 0·81-0·91). We found no association between SBP and functional outcome in patients with SBP less than 140 mm Hg (acOR 0·97 per 10 mm Hg SBP decrease, 95% CI 0·88-1·05). There was no significant interaction between SBP and effect of endovascular thrombectomy on functional outcome (p=0·96). INTERPRETATION In our meta-analysis, high admission SBP was associated with worse functional outcome after stroke, but SBP did not seem to negate the effect of endovascular thrombectomy. This finding suggests that admission SBP should not form the basis for decisions to withhold or delay endovascular thrombectomy for ischaemic stroke, but randomised trials are needed to further investigate this possibility. FUNDING Medtronic.
Collapse
Affiliation(s)
- Noor Samuels
- Department of Neurology, Erasmus MC University Medical Centre, Rotterdam, Netherlands; Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands; Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, Netherlands.
| | - Rob A van de Graaf
- Department of Neurology, Erasmus MC University Medical Centre, Rotterdam, Netherlands; Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Maxim J H L Mulder
- Department of Neurology, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Scott Brown
- BRIGHT Research Partners, Mooresville, NC, USA
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Centre, Rotterdam, Netherlands; Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Pieter Jan van Doormaal
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Mayank Goyal
- Departments of Clinical Neuroscience and Radiology, Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
| | - Nelly Agrinier
- Centre Hospitalier Régional Universitaire Nancy, INSERM, Université de Lorraine, CIC, Epidémiologie clinique, Nancy, France
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, University of Lorraine and University Hospital of Nancy, France
| | - Phil M White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Luis San Román
- Neuroradiology Service, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Tudor G Jovin
- Department of Neurology, Cooper University Hospital, Camden, NJ, USA
| | - Michael D Hill
- Departments of Clinical Neuroscience and Radiology, Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Andrew M Demchuk
- Departments of Clinical Neuroscience and Radiology, Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Alain Bonafe
- Department of Neuroradiology, Centre Hospitalier Universitaire de Montpellier-Guy de Chauliac, Montpellier, France
| | - Thomas G Devlin
- Department of Neurology, University of Tennessee College of Medicine, Chattanooga, TN, USA
| | - Adriaan C G M van Es
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| | - Aad van der Lugt
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, Netherlands
| |
Collapse
|
32
|
Rekkas A, van Klaveren D, Ryan PB, Steyerberg EW, Kent DM, Rijnbeek PR. A standardized framework for risk-based assessment of treatment effect heterogeneity in observational healthcare databases. NPJ Digit Med 2023; 6:58. [PMID: 36991144 DOI: 10.1038/s41746-023-00794-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 03/10/2023] [Indexed: 03/31/2023] Open
Abstract
Treatment effects are often anticipated to vary across groups of patients with different baseline risk. The Predictive Approaches to Treatment Effect Heterogeneity (PATH) statement focused on baseline risk as a robust predictor of treatment effect and provided guidance on risk-based assessment of treatment effect heterogeneity in a randomized controlled trial. The aim of this study is to extend this approach to the observational setting using a standardized scalable framework. The proposed framework consists of five steps: (1) definition of the research aim, i.e., the population, the treatment, the comparator and the outcome(s) of interest; (2) identification of relevant databases; (3) development of a prediction model for the outcome(s) of interest; (4) estimation of relative and absolute treatment effect within strata of predicted risk, after adjusting for observed confounding; (5) presentation of the results. We demonstrate our framework by evaluating heterogeneity of the effect of thiazide or thiazide-like diuretics versus angiotensin-converting enzyme inhibitors on three efficacy and nine safety outcomes across three observational databases. We provide a publicly available R software package for applying this framework to any database mapped to the Observational Medical Outcomes Partnership Common Data Model. In our demonstration, patients at low risk of acute myocardial infarction receive negligible absolute benefits for all three efficacy outcomes, though they are more pronounced in the highest risk group, especially for acute myocardial infarction. Our framework allows for the evaluation of differential treatment effects across risk strata, which offers the opportunity to consider the benefit-harm trade-off between alternative treatments.
Collapse
Affiliation(s)
- Alexandros Rekkas
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - David van Klaveren
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center, Boston, MA, USA
| | - Patrick B Ryan
- Janssen Research and Development, 125 Trenton Harbourton Road, Titusville, NJ, 08560, USA
- Department of Biomedical Informatics, Columbia University Irving Medical Center, New York, New York, USA
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - David M Kent
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center, Boston, MA, USA
| | - Peter R Rijnbeek
- Department of Medical Informatics, Erasmus University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
33
|
Rekkas A, Rijnbeek PR, Kent DM, Steyerberg EW, van Klaveren D. Estimating individualized treatment effects from randomized controlled trials: a simulation study to compare risk-based approaches. BMC Med Res Methodol 2023; 23:74. [PMID: 36977990 PMCID: PMC10045909 DOI: 10.1186/s12874-023-01889-6] [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: 05/17/2022] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Baseline outcome risk can be an important determinant of absolute treatment benefit and has been used in guidelines for "personalizing" medical decisions. We compared easily applicable risk-based methods for optimal prediction of individualized treatment effects. METHODS We simulated RCT data using diverse assumptions for the average treatment effect, a baseline prognostic index of risk, the shape of its interaction with treatment (none, linear, quadratic or non-monotonic), and the magnitude of treatment-related harms (none or constant independent of the prognostic index). We predicted absolute benefit using: models with a constant relative treatment effect; stratification in quarters of the prognostic index; models including a linear interaction of treatment with the prognostic index; models including an interaction of treatment with a restricted cubic spline transformation of the prognostic index; an adaptive approach using Akaike's Information Criterion. We evaluated predictive performance using root mean squared error and measures of discrimination and calibration for benefit. RESULTS The linear-interaction model displayed optimal or close-to-optimal performance across many simulation scenarios with moderate sample size (N = 4,250; ~ 785 events). The restricted cubic splines model was optimal for strong non-linear deviations from a constant treatment effect, particularly when sample size was larger (N = 17,000). The adaptive approach also required larger sample sizes. These findings were illustrated in the GUSTO-I trial. CONCLUSIONS An interaction between baseline risk and treatment assignment should be considered to improve treatment effect predictions.
Collapse
Affiliation(s)
- Alexandros Rekkas
- Department of Medical Informatics, Erasmus Medical Center, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Peter R Rijnbeek
- Department of Medical Informatics, Erasmus Medical Center, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands
| | - David M Kent
- Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - David van Klaveren
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
34
|
Boissonneault A, O Hara N, Pogorzelski D, Marchand L, Higgins T, Gitajn L, Gage MJ, Natoli RM, Sharma I, Pierrie S, O'Toole RV, Sprague S, Slobogean G. The impact of heterotopic ossification prophylaxis after surgical fixation of acetabular fractures: national treatment patterns and related outcomes. Injury 2023; 54:S0020-1383(23)00197-3. [PMID: 37002119 PMCID: PMC10480339 DOI: 10.1016/j.injury.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 03/04/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Heterotopic ossification (HO) is a common complication after surgical fixation of acetabular fractures. Numerous strategies have been employed to prevent HO formation, but results are mixed and optimal treatment strategy remains controversial. The purpose of the study was to describe current national heterotopic ossification (HO) prophylaxis patterns among academic trauma centers, determine the association between prophylaxis type and radiographic HO, and identify if heterogeneity in treatment effects exist based on outcome risk strata. METHODS We used data from a subset of participants enrolled in the Pragmatic Randomized Trial Evaluating Pre-Operative Alcohol Skin Solutions in Fractured Extremities (PREPARE) trial. We included only patients with closed AO-type 62 acetabular fractures that were surgically treated via a posterior (Kocher-Langenbeck), combined anterior and posterior, or extensile exposure. PREPARE Clinical Trial Registration Number: NCT03523962 Patient population This cohort study was nested within the Pragmatic Randomized Trial Evaluating Pre-Operative Alcohol Skin Solutions in Fractured Extremities (PREPARE) trial. The PREPARE trial is a multicenter cluster-randomized crossover trial evaluating the effectiveness of two alcohol-based pre-operative antiseptic skin solutions. All PREPARE trial clinical centers that enrolled at least one patient with a closed AO-type 62 acetabular fracture were invited to participate in the nested study. RESULTS 277 patients from 20 level 1 and level 2 trauma centers in the U.S. and Canada were included in this study. 32 patients (12%) received indomethacin prophylaxis, 100 patients (36%) received XRT prophylaxis, and 145 patients (52%) received no prophylaxis. Administration of XRT was associated with a 68% reduction in the adjusted odds of overall HO (OR 0.32, 95% CI, 0.14 - 0.69, p = 0.005). The overall severe HO (Brooker classes III or IV) rate was 8% for the entire cohort; XRT reduced the rate of severe HO in high-risk patients only (p=0.03). CONCLUSION HO prophylaxis patterns after surgical fixation of acetabular fractures have changed dramatically over the last two decades. Most centers included in this study did not administer HO prophylaxis. XRT was associated with a marked reduction in the rate of overall HO and the rate of severe HO in high-risk patients. Randomized trials are needed to fully elucidate the potential benefit of XRT. PREPARE Clinical Trial Registration Number: NCT03523962.
Collapse
Affiliation(s)
- Adam Boissonneault
- R Adams Cowley Shock Trauma Center, University of Maryland, MD, 22 S Greene St, Baltimore, MD 21201, USA.
| | - Nathan O Hara
- R Adams Cowley Shock Trauma Center, University of Maryland, MD, 22 S Greene St, Baltimore, MD 21201, USA
| | - David Pogorzelski
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Lucas Marchand
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Thomas Higgins
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Leah Gitajn
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Mark J Gage
- Department of Orthopaedic Surgery, Section of Orthopaedic Trauma, Duke University, Durham, North Carolina
| | - Roman M Natoli
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ishani Sharma
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sarah Pierrie
- Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, TX, USA
| | - Robert V O'Toole
- R Adams Cowley Shock Trauma Center, University of Maryland, MD, 22 S Greene St, Baltimore, MD 21201, USA
| | - Sheila Sprague
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Gerard Slobogean
- R Adams Cowley Shock Trauma Center, University of Maryland, MD, 22 S Greene St, Baltimore, MD 21201, USA
| |
Collapse
|
35
|
Granholm A, Munch MW, Andersen‐Ranberg N, Myatra SN, Vijayaraghavan BKT, Venkatesh B, Jha V, Wahlin RR, Jakob SM, Cioccari L, Møller MH, Perner A. Heterogeneous treatment effects of dexamethasone 12 mg versus 6 mg in patients with COVID-19 and severe hypoxaemia-Post hoc exploratory analyses of the COVID STEROID 2 trial. Acta Anaesthesiol Scand 2023; 67:195-205. [PMID: 36314057 PMCID: PMC9874464 DOI: 10.1111/aas.14167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/12/2022] [Accepted: 10/17/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Corticosteroids improve outcomes in patients with severe COVID-19. In the COVID STEROID 2 randomised clinical trial, we found high probabilities of benefit with dexamethasone 12 versus 6 mg daily. While no statistically significant heterogeneity in treatment effects (HTE) was found in the conventional, dichotomous subgroup analyses, these analyses have limitations, and HTE could still exist. METHODS We assessed whether HTE was present for days alive without life support and mortality at Day 90 in the trial according to baseline age, weight, number of comorbidities, category of respiratory failure (type of respiratory support system and oxygen requirements) and predicted risk of mortality using an internal prediction model. We used flexible models for continuous variables and logistic regressions for categorical variables without dichotomisation of the baseline variables of interest. HTE was assessed both visually and with p and S values from likelihood ratio tests. RESULTS There was no strong evidence for substantial HTE on either outcome according to any of the baseline variables assessed with all p values >.37 (and all S values <1.43) in the planned analyses and no convincingly strong visual indications of HTE. CONCLUSIONS We found no strong evidence for HTE with 12 versus 6 mg dexamethasone daily on days alive without life support or mortality at Day 90 in patients with COVID-19 and severe hypoxaemia, although these results cannot rule out HTE either.
Collapse
Affiliation(s)
- Anders Granholm
- Department of Intensive CareRigshospitalet—Copenhagen University HospitalCopenhagenDenmark,Collaboration for Research in Intensive CareCopenhagenDenmark
| | - Marie Warrer Munch
- Department of Intensive CareRigshospitalet—Copenhagen University HospitalCopenhagenDenmark,Collaboration for Research in Intensive CareCopenhagenDenmark
| | - Nina Andersen‐Ranberg
- Collaboration for Research in Intensive CareCopenhagenDenmark,Department of Anaesthesiology and Intensive Care MedicineZealand University HospitalKøgeDenmark
| | - Sheila Nainan Myatra
- Department of Anaesthesia, Critical Care and PainTata Memorial Hospital, Homi Bhabha National InstituteMumbaiIndia
| | | | | | - Vivekanand Jha
- Chennai Critical Care ConsultantsChennaiIndia,Prasanna School of Public HealthManipal Academy of Higher EducationManipalIndia,School of Public HealthImperial College LondonLondonUK
| | - Rebecka Rubenson Wahlin
- Department of Clinical Science and Education, SödersjukhusetKarolinska InstitutetStockholmSweden
| | - Stephan M. Jakob
- Department of Intensive Care Medicine, InselspitalBern University Hospital, University of BernBernSwitzerland
| | - Luca Cioccari
- Department of Intensive Care Medicine, InselspitalBern University Hospital, University of BernBernSwitzerland,Department of Intensive Care MedicineKantonsspital AarauAarauSwitzerland
| | - Morten Hylander Møller
- Department of Intensive CareRigshospitalet—Copenhagen University HospitalCopenhagenDenmark,Collaboration for Research in Intensive CareCopenhagenDenmark
| | - Anders Perner
- Department of Intensive CareRigshospitalet—Copenhagen University HospitalCopenhagenDenmark,Collaboration for Research in Intensive CareCopenhagenDenmark
| |
Collapse
|
36
|
Lyman GH, Msaouel P, Kuderer NM. Risk Model Development and Validation in Clinical Oncology: Lessons Learned. Cancer Invest 2023; 41:1-11. [PMID: 36254812 DOI: 10.1080/07357907.2022.2137914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Reliable risk models can greatly facilitate patient-centered inferences and decisions. Herein we summarize key considerations related to risk modeling in clinical oncology. Often overlooked challenges include data quality, missing data, effective sample size estimation, and selecting the variables to be included in the risk model. The stability and quality of the model should be carefully interrogated with particular emphasis on rigorous internal validation.
Collapse
Affiliation(s)
- Gary H Lyman
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Pavlos Msaouel
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | |
Collapse
|
37
|
de Winkel J, Roozenbeek B, Dijkland SA, Dammers R, van Doormaal PJ, van der Jagt M, van Klaveren D, Dippel DWJ, Lingsma HF. Endovascular versus neurosurgical aneurysm treatment: study protocol for the development and validation of a clinical prediction tool for individualised decision making. BMJ Open 2022; 12:e065903. [PMID: 36572493 PMCID: PMC9806002 DOI: 10.1136/bmjopen-2022-065903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Treatment decisions for aneurysmal subarachnoid haemorrhage patients should be supported by individualised predictions of the effects of aneurysm treatment. We present a study protocol and analysis plan for the development and external validation of models to predict benefit of neurosurgical versus endovascular aneurysm treatment on functional outcome and durability of treatment. METHODS AND ANALYSIS We will use data from the International Subarachnoid Aneurysm Trial for model development. The outcomes are functional outcome, measured with modified Rankin Scale at 12 months, and any retreatment or rebleed of the target aneurysm during follow-up. We will develop an ordinal logistic regression model and Cox regression model, considering age, World Federation of Neurological Surgeons grade, Fisher grade, vasospasm at presentation, aneurysm lumen size, aneurysm neck size, aneurysm location and time-to-aneurysm-treatment as predictors. We will test for interactions with treatment and with baseline risk and derive individualised predicted probabilities of treatment benefit. A benefit of ≥5% will be considered clinically relevant. Discriminative performance of the outcome predictions will be assessed with the c-statistic. Calibration will be assessed with calibration plots. Discriminative performance of the benefit predictions will be assessed with the c-for benefit. We will assess internal validity with bootstrapping and external validity with leave-one-out internal-external cross-validation. ETHICS AND DISSEMINATION The medical ethical research committee of the Erasmus MC University Medical Center Rotterdam approved the study protocol under the exemption category and waived the need for written informed consent (MEC-2020-0810). We will disseminate our results through an open-access peer-reviewed scientific publication and with a web-based clinical prediction tool.
Collapse
Affiliation(s)
- Jordi de Winkel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Simone A Dijkland
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Pieter-Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - David van Klaveren
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
38
|
Dryer RA, Salem A, Saroha V, Greenberg RG, Rysavy MA, Chawla S, Patel RM. Evaluation and validation of a prediction model for extubation success in very preterm infants. J Perinatol 2022; 42:1674-1679. [PMID: 36153409 DOI: 10.1038/s41372-022-01517-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 09/06/2022] [Accepted: 09/08/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To perform an external validation of a publicly available model predicting extubation success in very preterm infants. STUDY DESIGN Retrospective study of infants born <1250 g at a single center. Model performance evaluated using the area under the receiver operating characteristic curve (AUROC) and comparing observed and expected probabilities of extubation success, defined as survival ≥5 d without an endotracheal tube. RESULTS Of 177 infants, 120 (68%) were extubated successfully. The median (IQR) gestational age was 27 weeks (25-28) and weight at extubation was 915 g (755-1050). The model had acceptable discrimination (AUROC 0.72 [95% CI 0.65-0.80]) and adequate calibration (calibration slope 0.96, intercept -0.06, mean observed-to-expected difference in probability of extubation success -0.08 [95% CI -0.01, -0.15]). CONCLUSIONS The extubation success prediction model has acceptable performance in an external cohort. Additional prospective studies are needed to determine if the model can be improved or how it can be used for clinical benefit.
Collapse
Affiliation(s)
- Rebecca A Dryer
- Emory University School of Medicine, Atlanta, GA, USA.,Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anand Salem
- Emory University School of Medicine, Atlanta, GA, USA.,Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Vivek Saroha
- Emory University School of Medicine, Atlanta, GA, USA.,Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Rachel G Greenberg
- Duke University School of Medicine, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Matthew A Rysavy
- University of Iowa, Iowa City, IA, USA.,University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sanjay Chawla
- Children's Hospital of Michigan, Central Michigan University, Mt Pleasant, MI, USA
| | - Ravi M Patel
- Emory University School of Medicine, Atlanta, GA, USA. .,Children's Healthcare of Atlanta, Atlanta, GA, USA.
| |
Collapse
|
39
|
Kent DM, Steyerberg EW. Machine learning to deal with missing disability status: Ascertainment and imputation of outcomes should be distinguished. Mult Scler J Exp Transl Clin 2022; 8:20552173221128874. [PMID: 36311695 PMCID: PMC9597018 DOI: 10.1177/20552173221128874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- David M Kent
- David M Kent, Predictive
Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical
Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, Box
63, Boston, MA 02111, USA.
| | | |
Collapse
|
40
|
Browne JA, Springer B, Spindler KP. Optimizing Use of Large Databases in Joint Arthroplasty and Orthopaedics. J Bone Joint Surg Am 2022; 104:28-32. [PMID: 36260041 DOI: 10.2106/jbjs.22.00562] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The potential users of "big data" need to consider many factors when choosing whether to use a large observational database for their research question and, if so, which database is the best fit for the scientific question. The first section of this paper, written by Dr. James A. Browne, provides a framework (who, what, where, when, and why?) to assess the critical elements that are included in a large database, which allows the user to determine if interrogation of the data is likely to answer the research question. The next section of this paper, written by Dr. Bryan Springer, focuses on the importance of having an a priori research question before deciding the best data source to answer the question; it also elaborates on the differences between administrative databases and clinical databases. The final section of the paper, written by Dr. Kurt P. Spindler, reviews the concepts of hypothesis-generating and hypothesis-testing studies and discusses in detail the differences, strengths, limitations, and appropriate uses of observational data versus randomized controlled trials.
Collapse
Affiliation(s)
| | - Bryan Springer
- OrthoCarolina Hip and Knee Center, Atrium Musculoskeletal Institute, Charlotte, North Carolina
| | | |
Collapse
|
41
|
Hancock MJ, Kent P. Research Note: Treatment effect moderators. J Physiother 2022; 68:283-287. [PMID: 36244961 DOI: 10.1016/j.jphys.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 08/10/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Mark J Hancock
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Australia
| | - Peter Kent
- Curtin School of Allied Health, Curtin University, Australia
| |
Collapse
|
42
|
Duan N, Norman D, Schmid C, Sim I, Kravitz RL. Personalized Data Science and Personalized (N-of-1) Trials: Promising Paradigms for Individualized Health Care. HARVARD DATA SCIENCE REVIEW 2022; 4:10.1162/99608f92.8439a336. [PMID: 38009133 PMCID: PMC10673628 DOI: 10.1162/99608f92.8439a336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2023] Open
Abstract
The term 'data science' usually refers to the process of extracting value from big data obtained from a large group of individuals. An alternative rendition, which we call personalized data science (Per-DS), aims to collect, analyze, and interpret personal data to inform personal decisions. This article describes the main features of Per-DS, and reviews its current state and future outlook. A Per-DS investigation is of, by, and for an individual, the Per-DS investigator, acting simultaneously as her own investigator, study participant, and beneficiary, and making personalized decisions for study design and implementation. The scope of Per-DS studies may include systematic monitoring of physiological or behavioral patterns, case-crossover studies for symptom triggers, pre-post trials for exposure-outcome relationships, and personalized (N-of-1) trials for effectiveness. Per-DS studies produce personal knowledge generalizable to the individual's future self (thus benefiting herself) rather than knowledge generalizable to an external population (thus benefiting others). This endeavor requires a pivot from data mining or extraction to data gardening, analogous to home gardeners producing food for home consumption-the Per-DS investigator needs to 'cultivate the field' by setting goals, specifying study design, identifying necessary data elements, and assembling instruments and tools for data collection. Then, she can implement the study protocol, harvest her personal data, and mine the data to extract personal knowledge. To facilitate Per-DS studies, Per-DS investigators need support from community-based, scientific, philanthropic, business, and government entities, to develop and deploy resources such as peer forums, mobile apps, 'virtual field guides,' and scientific and regulatory guidance.
Collapse
Affiliation(s)
- Naihua Duan
- Department of Psychiatry, Columbia University, New York, NY)
| | - Daniel Norman
- Santa Monica Sleep Disorders Center, Los Angeles, CA
| | | | - Ida Sim
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | | |
Collapse
|
43
|
Msaouel P, Lee J, Karam JA, Thall PF. A Causal Framework for Making Individualized Treatment Decisions in Oncology. Cancers (Basel) 2022; 14:cancers14163923. [PMID: 36010916 PMCID: PMC9406391 DOI: 10.3390/cancers14163923] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/12/2022] [Accepted: 08/12/2022] [Indexed: 12/23/2022] Open
Abstract
Simple Summary Physicians routinely make individualized treatment decisions by accounting for the joint effects of patient prognostic covariates and treatments on clinical outcomes. Ideally, this is performed using historical randomized clinical trial (RCT) data. Randomization ensures that unbiased estimates of causal treatment effect parameters can be obtained from the historical RCT data and used to predict each new patient’s outcome based on the joint effect of their baseline covariates and each treatment being considered. However, this process becomes problematic if a patient seen in the clinic is very different from the patients who were enrolled in the RCT. That is, if a new patient does not satisfy the entry criteria of the RCT, then the patient does not belong to the population represented by the patients who were studied in the RCT. In such settings, it still may be possible to utilize the RCT data to help choose a new patient’s treatment. This may be achieved by combining the RCT data with data from other clinical trials, or possibly preclinical experiments, and using the combined dataset to predict the patient’s expected outcome for each treatment being considered. In such settings, combining data from multiple sources in a way that is statistically reliable is not entirely straightforward, and correctly identifying and estimating the effects of treatments and patient covariates on clinical outcomes can be complex. Causal diagrams provide a rational basis to guide this process. The first step is to construct a causal diagram that reflects the plausible relationships between treatment variables, patient covariates, and clinical outcomes. If the diagram is correct, it can be used to determine what additional data may be needed, how to combine data from multiple sources, how to formulate a statistical model for clinical outcomes as a function of treatment and covariates, and how to compute an unbiased treatment effect estimate for each new patient. We use adjuvant therapy of renal cell carcinoma to illustrate how causal diagrams may be used to guide these steps. Abstract We discuss how causal diagrams can be used by clinicians to make better individualized treatment decisions. Causal diagrams can distinguish between settings where clinical decisions can rely on a conventional additive regression model fit to data from a historical randomized clinical trial (RCT) to estimate treatment effects and settings where a different approach is needed. This may be because a new patient does not meet the RCT’s entry criteria, or a treatment’s effect is modified by biomarkers or other variables that act as mediators between treatment and outcome. In some settings, the problem can be addressed simply by including treatment–covariate interaction terms in the statistical regression model used to analyze the RCT dataset. However, if the RCT entry criteria exclude a new patient seen in the clinic, it may be necessary to combine the RCT data with external data from other RCTs, single-arm trials, or preclinical experiments evaluating biological treatment effects. For example, external data may show that treatment effects differ between histological subgroups not recorded in an RCT. A causal diagram may be used to decide whether external observational or experimental data should be obtained and combined with RCT data to compute statistical estimates for making individualized treatment decisions. We use adjuvant treatment of renal cell carcinoma as our motivating example to illustrate how to construct causal diagrams and apply them to guide clinical decisions.
Collapse
Affiliation(s)
- Pavlos Msaouel
- Department of Genitourinary Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- David H. Koch Center for Applied Research of Genitourinary Cancers, The University of Texas, MD Anderson Cancer Center, Houston, TX 77030, USA
- Correspondence:
| | - Juhee Lee
- Department of Statistics, University of California, Santa Cruz, CA 95064, USA
| | - Jose A. Karam
- Department of Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Peter F. Thall
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| |
Collapse
|
44
|
Brooks JM, Chapman CG, Floyd SB, Chen BK, Thigpen CA, Kissenberth M. Assessing the ability of an instrumental variable causal forest algorithm to personalize treatment evidence using observational data: the case of early surgery for shoulder fracture. BMC Med Res Methodol 2022; 22:190. [PMID: 35818028 PMCID: PMC9275148 DOI: 10.1186/s12874-022-01663-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 06/20/2022] [Indexed: 11/24/2022] Open
Abstract
Background Comparative effectiveness research (CER) using observational databases has been suggested to obtain personalized evidence of treatment effectiveness. Inferential difficulties remain using traditional CER approaches especially related to designating patients to reference classes a priori. A novel Instrumental Variable Causal Forest Algorithm (IV-CFA) has the potential to provide personalized evidence using observational data without designating reference classes a priori, but the consistency of the evidence when varying key algorithm parameters remains unclear. We investigated the consistency of IV-CFA estimates through application to a database of Medicare beneficiaries with proximal humerus fractures (PHFs) that previously revealed heterogeneity in the effects of early surgery using instrumental variable estimators. Methods IV-CFA was used to estimate patient-specific early surgery effects on both beneficial and detrimental outcomes using different combinations of algorithm parameters and estimate variation was assessed for a population of 72,751 fee-for-service Medicare beneficiaries with PHFs in 2011. Classification and regression trees (CART) were applied to these estimates to create ex-post reference classes and the consistency of these classes were assessed. Two-stage least squares (2SLS) estimators were applied to representative ex-post reference classes to scrutinize the estimates relative to known 2SLS properties. Results IV-CFA uncovered substantial early surgery effect heterogeneity across PHF patients, but estimates for individual patients varied with algorithm parameters. CART applied to these estimates revealed ex-post reference classes consistent across algorithm parameters. 2SLS estimates showed that ex-post reference classes containing older, frailer patients with more comorbidities, and lower utilizers of healthcare were less likely to benefit and more likely to have detriments from higher rates of early surgery. Conclusions IV-CFA provides an illuminating method to uncover ex-post reference classes of patients based on treatment effects using observational data with a strong instrumental variable. Interpretation of treatment effect estimates within each ex-post reference class using traditional CER methods remains conditional on the extent of measured information in the data. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-022-01663-0.
Collapse
Affiliation(s)
- John M Brooks
- Center for Effectiveness Research in Orthopaedics - Arnold School of Public Health Greenville, 915 Greene Street #302D, 29208, Columbia, SC, 29208-0001, USA. .,Health Services Policy & Management, University of South Carolina Arnold School of Public Health, Columbia, USA.
| | - Cole G Chapman
- Department of Pharmacy Practice and Science, University of Iowa, Iowa City, USA.,Center for Effectiveness Research in Orthopaedics, Greenville, USA
| | - Sarah B Floyd
- Center for Effectiveness Research in Orthopaedics, Greenville, USA.,Clemson University College of Behavioral Social and Health Sciences, Public Health Sciences, Clemson, USA
| | - Brian K Chen
- Health Services Policy & Management, University of South Carolina Arnold School of Public Health, Columbia, USA.,Center for Effectiveness Research in Orthopaedics, Greenville, USA
| | - Charles A Thigpen
- Center for Effectiveness Research in Orthopaedics, Greenville, USA.,ATI Physical Therapy, Greenville, USA
| | - Michael Kissenberth
- Center for Effectiveness Research in Orthopaedics, Greenville, USA.,Prisma Health, Steadman Hawkins Clinic of the Carolinas, Greenville, USA
| |
Collapse
|
45
|
Chevance A, Ravaud P, Cornelius V, Mayo-Wilson E, Furukawa TA. Designing clinically useful psychopharmacological trials: challenges and ways forward. Lancet Psychiatry 2022; 9:584-594. [PMID: 35525252 DOI: 10.1016/s2215-0366(22)00041-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 01/15/2022] [Accepted: 02/01/2022] [Indexed: 12/23/2022]
Abstract
The clinical guidelines that underpin the use of drugs for mental disorders are informed by evidence from randomised controlled trials (RCTs). RCTs are performed to obtain marketing authorisation from regulators. The methods used in these RCTs could be appropriate for early phases of drug development because they identify drugs with important harms and drugs that are efficacious for specific health problems and populations. RCTs done before marketing authorisation do not tend to address clinical questions that concern the effectiveness of a drug in heterogeneous and comorbid populations, the optimisation of drug sequencing and discontinuation, or the comparative benefits and harms of different drugs that could be used for the same health problem. This Review proposes an overview of some shortcomings of RCTs, at an individual level and at the whole portfolio level, and identifies some methods in planning, conducting, and carrying out analyses in RCTs that could enhance their ability to support therapeutic decisions. These suggestions include: identifying patient-important questions to be investigated by psychopharmacological RCTs; embedding pragmatic RCTs within clinical practice to improve generalisability to target populations; collecting evidence about drugs in overlooked populations; developing methods to facilitate the recruitment of patients with mental disorders and to reduce the number of patients who drop out, using specific methods; using core outcome sets to standardise the assessment of benefits and harms; and recording systematically serious objective outcomes, such as suicide or hospitalisation, to be evaluated in meta-analyses. This work is a call to address questions relevant to patients using diverse design of RCTs, thus contributing to the development of a patient-centred, evidence-based psychiatry.
Collapse
Affiliation(s)
- Astrid Chevance
- Université Paris Cité, CRESS, INSERM, INRAE, Paris, France; Centre d'Epidémiologie Clinique, Hôpital Hôtel-Dieu, AP-HP, Paris, France.
| | - Philippe Ravaud
- Université Paris Cité, CRESS, INSERM, INRAE, Paris, France; Centre d'Epidémiologie Clinique, Hôpital Hôtel-Dieu, AP-HP, Paris, France
| | - Victoria Cornelius
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK
| | - Evan Mayo-Wilson
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health-Bloomington, Bloomington, IN, USA
| | - Toshi A Furukawa
- Department of Health Promotion and Human Behavior and Department of Clinical Epidemiology, School of Public Health, Kyoto University Graduate School of Medicine, Kyoto, Japan
| |
Collapse
|
46
|
de Winkel J, Cras TY, Dammers R, van Doormaal PJ, van der Jagt M, Dippel DWJ, Lingsma HF, Roozenbeek B. Early predictors of functional outcome in poor-grade aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. BMC Neurol 2022; 22:239. [PMID: 35773634 PMCID: PMC9245240 DOI: 10.1186/s12883-022-02734-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) often receive delayed or no aneurysm treatment, although recent studies suggest that functional outcome following early aneurysm treatment has improved. We aimed to systematically review and meta-analyze early predictors of functional outcome in poor-grade aSAH patients. METHODS: We included studies investigating the association of early predictors and functional outcome in adult patients with confirmed poor-grade aSAH, defined as World Federation of Neurological Surgeons (WFNS) grade or Hunt and Hess (H-H) grade IV-V. Studies had to use multivariable regression analysis to estimate independent predictor effects of favorable functional outcome measured with the Glasgow Outcome Scale or modified Rankin Scale. We calculated pooled adjusted odds ratios (aOR) and 95% confidence intervals (CI) with random effects models. RESULTS: We included 27 studies with 3287 patients. The likelihood of favorable outcome increased with WFNS grade or H-H grade IV versus V (aOR 2.9, 95% CI 1.9-4.3), presence of clinical improvement before aneurysm treatment (aOR 3.3, 95% CI 2.0-5.3), and intact pupillary light reflex (aOR 2.9, 95% CI 1.6-5.1), and decreased with older age (aOR 0.7, 95% CI 0.5-1.0, per decade), increasing modified Fisher grade (aOR 0.4, 95% CI 0.3-0.5, per grade), and presence of intracerebral hematoma on admission imaging (aOR 0.4, 95% CI 0.2-0.8). CONCLUSIONS We present a summary of early predictors of functional outcome in poor-grade aSAH patients that can help to discriminate between patients with favorable and with unfavorable prognosis and may aid in selecting patients for early aneurysm treatment.
Collapse
Affiliation(s)
- Jordi de Winkel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands. .,Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Tim Y Cras
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Pieter-Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
47
|
Sadique Z, Grieve R, Diaz-Ordaz K, Mouncey P, Lamontagne F, O’Neill S. A Machine-Learning Approach for Estimating Subgroup- and Individual-Level Treatment Effects: An Illustration Using the 65 Trial. Med Decis Making 2022; 42:923-936. [PMID: 35607982 PMCID: PMC9459357 DOI: 10.1177/0272989x221100717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Personalizing treatment recommendations or guidelines requires evidence about the
heterogeneity of treatment effects (HTE). Machine-learning (ML) approaches can
explore HTE by considering many covariates, including complex interactions
between them. Causal ML approaches can avoid overfitting, which arises when the
same dataset is used to select covariate by treatment interaction terms as to
make inferences and reduce reliance on the correct specification of fixed
parametric models. We investigate causal forests (CF), a ML method based on
modified decision trees that can estimate subgroup- and individual-level
treatment effects, without requiring correct prespecification of the effect
model. We consider CF alongside parametric approaches for estimating HTE, within
the 65 Trial, which evaluates the effect of a permissive hypotension strategy
versus usual care on 90-d mortality for critically ill patients aged 65 y or
older with vasodilatory hypotension. Here, the CF approach provides similar
estimates of treatment effectiveness for prespecified and post hoc subgroups to
the parametric approach, and the results of a test for overall HTE show weak
evidence of heterogeneity. The CF estimates of individual-level treatment
effects, the expected effects of treatment for individuals in subpopulations
defined by their covariates, suggest that the permissive hypotension strategy is
expected to reduce 90-d mortality for 98.7% of patients but with 95% confidence
intervals that include zero for 71.6% of patients. A ML approach is then used to
assess the patient characteristics associated with these individual-level
effects, and to help target future research that can identify those patient
subgroups for whom the intervention is most effective.
Collapse
Affiliation(s)
- Zia Sadique
- Department of Health Services Research and
Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Richard Grieve
- R. Grieve, Department of Health Services
Research and Policy, London School of Hygiene and Tropical Medicine, 15-17
Tavistock Place, WC1H 9SH, London;
()
| | - Karla Diaz-Ordaz
- Department of Medical Statistics, London School
of Hygiene & Tropical Medicine, London, UK
| | - Paul Mouncey
- Clinical Trials Unit, Intensive Care National
Audit & Research Centre (ICNARC), London, UK
| | - Francois Lamontagne
- Université de Sherbrooke, Quebec, Canada
- Centre de Recherche du Centre Hospitalier
Universitaire de Sherbrooke, Quebec, Canada
| | - Stephen O’Neill
- Department of Health Services Research and
Policy, London School of Hygiene & Tropical Medicine, London, UK
| |
Collapse
|
48
|
Advancing the Surgical Treatment of Intracerebral Hemorrhage: Study Design and Research Directions. World Neurosurg 2022; 161:367-375. [DOI: 10.1016/j.wneu.2022.01.084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 12/23/2022]
|
49
|
Takahashi K, Serruys PW, Fuster V, Farkouh ME, Spertus JA, Cohen DJ, Park SJ, Park DW, Ahn JM, Onuma Y, Kent DM, Steyerberg EW, van Klaveren D. External Validation of the FREEDOM Score for Individualized Decision Making Between CABG and PCI. J Am Coll Cardiol 2022; 79:1458-1473. [PMID: 35422242 DOI: 10.1016/j.jacc.2022.01.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 01/20/2022] [Accepted: 01/25/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Although randomized trials have established that coronary artery bypass grafting (CABG) is, on average, the most effective revascularization strategy compared with percutaneous coronary intervention (PCI) in patients with diabetes and multivessel disease (MVD), individual patients differ in many characteristics that can affect the benefits and harms of treatment. The FREEDOM (Future Revascularization Evaluation in Patients with Diabetes Mellitus) score was developed to predict different outcomes with CABG vs PCI on the basis of 8 patient characteristics and the smoking-treatment interaction. OBJECTIVES This study aimed to assess the ability of the 5-year major adverse cardiovascular event (MACE) model to predict treatment benefit of CABG vs PCI in the SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) and BEST (Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multivessel Coronary Artery Disease) trials. METHODS This study identified 702 patients with diabetes and MVD to mirror the FREEDOM participants. Discrimination was assessed by C-index, and calibration was assessed by calibration plots in the PCI and CABG arms, respectively. The ability of the FREEDOM score to predict treatment benefit of CABG vs PCI was assessed. RESULTS Overall, CABG was associated with a lower rate of 5-year MACE compared with PCI (12.4% vs 20.3%; log-rank P = 0.021) irrespective of a history of smoking (Pinteraction = 0.975). Both discrimination and calibration were helpful in the PCI arm (C-index: 0.69; slope: 0.96, intercept: -0.24), but moderate in the CABG arm (C-index: 0.61; slope: 0.61; intercept: -0.53). The FREEDOM score showed some heterogeneity of treatment benefit. CONCLUSIONS The FREEDOM score could identify some heterogeneity of treatment benefit of CABG vs PCI for 5-year MACE. Until further prospective validations are performed, these results should be taken into consideration when using the FREEDOM score in patients with diabetes and MVD. (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery [SYNTAX]; NCT00114972) (Bypass Surgery and Everolimus-Eluting Stent Implantation in the Treatment of Patients with Multivessel Coronary Artery Disease [BEST]; NCT00997828) (Future Revascularization Evaluation in Patients with Diabetes Mellitus [FREEDOM]; NCT00086450).
Collapse
Affiliation(s)
- Kuniaki Takahashi
- Department of Cardiology, Amsterdam Universities Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland Galway, Galway, Ireland.
| | - Valentin Fuster
- The Zena and Michael Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
| | - Michael E Farkouh
- Peter Munk Cardiac Centre and the Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada
| | - John A Spertus
- Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; Department of Cardiology, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - David J Cohen
- Cardiovascular Research Foundation, New York, New York, USA; St. Francis Hospital and Heart Center, Roslyn, New York, USA
| | | | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, Seoul, Korea
| | - Jung-Min Ahn
- Department of Cardiology, Asan Medical Center, Seoul, Korea
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland Galway, Galway, Ireland
| | - David M Kent
- Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, the Netherlands
| | - David van Klaveren
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | |
Collapse
|
50
|
Kent DM, Nelson J, Pittas A, Colangelo F, Koenig C, van Klaveren D, Ciemins E, Cuddeback J. An Electronic Health Record-Compatible Model to Predict Personalized Treatment Effects From the Diabetes Prevention Program: A Cross-Evidence Synthesis Approach Using Clinical Trial and Real-World Data. Mayo Clin Proc 2022; 97:703-715. [PMID: 34782125 DOI: 10.1016/j.mayocp.2021.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 07/30/2021] [Accepted: 09/09/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To develop an electronic health record (EHR)-based risk tool that provides point-of-care estimates of diabetes risk to support targeting interventions to patients most likely to benefit. PATIENTS AND METHODS A risk prediction model was developed and validated in a large observational database of patients with an index visit date between January 1, 2012, and December 31, 2016, with treatment effect estimates from risk-based reanalysis of clinical trial data. The risk model development cohort included 1.1 million patients with prediabetes from the OptumLabs Data Warehouse (OLDW); the validation cohort included a distinct sample of 1.1 million patients in OLDW. The randomly assigned clinical trial cohort included 3081 people from the Diabetes Prevention Program (DPP) study. RESULTS Eleven variables reliably obtainable from the EHR were used to predict diabetes risk. This model validated well in the OLDW (C statistic = 0.76; observed 3-year diabetes rate was 1.8% (95% confidence interval [CI], 1.7 to 1.9) in the lowest-risk quarter and 19.6% (19.4 to 19.8) in the highest-risk quarter). In the DPP, the hazard ratio (HR) for lifestyle modification was constant across all levels of risk (HR, 0.43; 95% CI, 0.35 to 0.53), whereas the HR for metformin was highly risk dependent (HR, 1.1; 95% CI, 0.61 to 2.0 in the lowest-risk quarter vs HR, 0.45; 95% CI, 0.35 to 0.59 in the highest-risk quarter). Fifty-three percent of the benefits of population-wide dissemination of the DPP lifestyle modification and 73% of the benefits of population-wide metformin therapy can be obtained by targeting the highest-risk quarter of patients. CONCLUSION The Tufts-Predictive Analytics and Comparative Effectiveness DPP Risk model is an EHR-compatible tool that might support targeted diabetes prevention to more efficiently realize the benefits of the DPP interventions.
Collapse
Affiliation(s)
- David M Kent
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center, Boston, MA.
| | - Jason Nelson
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center, Boston, MA
| | | | | | | | - David van Klaveren
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center, Boston, MA; Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | | |
Collapse
|