1
|
Campbell AJ, Anpalagan K, Best EJ, Britton PN, Gwee A, Hatcher J, Manley BJ, Marsh J, Webb RH, Davis JS, Mahar RK, McGlothlin A, McMullan B, Meyer M, Mora J, Murthy S, Nourse C, Papenburg J, Schwartz KL, Scheuerman O, Snelling T, Strunk T, Stark M, Voss L, Tong SYC, Bowen AC. Whole-of-Life Inclusion in Bayesian Adaptive Platform Clinical Trials. JAMA Pediatr 2024:2822488. [PMID: 39158898 DOI: 10.1001/jamapediatrics.2024.2697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/20/2024]
Abstract
Importance There is a recognized unmet need for clinical trials to provide evidence-informed care for infants, children and adolescents. This Special Communication outlines the capacity of 3 distinct trial design strategies, sequential, parallel, and a unified adult-pediatric bayesian adaptive design, to incorporate children into clinical trials and transform this current state of evidence inequity. A unified adult-pediatric whole-of-life clinical trial is demonstrated through the Staphylococcus aureus Network Adaptive Platform (SNAP) trial. Observations Bayesian methods provide a framework for synthesizing data in the form of a probability model that can be used in the design and analysis of a clinical trial. Three trial design strategies are compared: (1) a sequential adult-pediatric bayesian approach that involves a separate, deferred pediatric trial that incorporates existing adult trial data into the analysis model to potentially reduce the pediatric trial sample size; (2) a parallel adult-pediatric bayesian trial whereby separate pediatric enrollment occurs in a parallel trial, running alongside an adult randomized clinical trial; and (3) a unified adult-pediatric bayesian adaptive design that supports the enrollment of both children and adults simultaneously in a whole-of-life bayesian adaptive randomized clinical trial. The SNAP trial whole-of-life design uses a bayesian hierarchical model that allows information sharing (also known as borrowing) between trial age groups by linking intervention effects of children and adults, thereby improving inference in both groups. Conclusion and Relevance Bayesian hierarchical models may provide more precision for estimates of safety and efficacy of treatments in trials with heterogenous populations compared to traditional methods of analysis. They facilitate the inclusion of children in clinical trials and a shift from children deemed therapeutic orphans to the vision of no child left behind in clinical trials to ensure evidence for clinical practice exists across the life course. The SNAP trial provides an example of a bayesian adaptive whole-of-life inclusion design that enhances trial population inclusivity and diversity overall, as well as generalizability and translation of findings into clinical practice.
Collapse
Affiliation(s)
- Anita J Campbell
- Department of Infectious Diseases, Perth Children's Hospital, Perth, Western Australia, Australia
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Keerthi Anpalagan
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Emma J Best
- Department of Paediatrics, Child and Youth Health, The University of Auckland, Auckland, New Zealand
- The National Immunisation Advisory Centre, The University of Auckland, Auckland, New Zealand
- Department of Infectious Diseases, Starship Children's Hospital, Auckland, New Zealand
| | - Philip N Britton
- Sydney Medical School and Sydney Infectious Diseases, University of Sydney, Sydney, New South Wales, Australia
- Department of Infectious Diseases and Microbiology, the Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Amanda Gwee
- Department of General Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Antimicrobials Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - James Hatcher
- Department of Microbiology, Great Ormond Street Hospital for Children, London, United Kingdom
- Infection, Immunity, and Inflammation Research Department, University College London, London, United Kingdom
| | - Brett J Manley
- The Royal Women's Hospital, Melbourne, Victoria, Australia
- The Department of Obstetrics, Gynaecology and Newborn Health, The University of Melbourne, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Julie Marsh
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
- Centre for Child Health research, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Rachel H Webb
- Department of Paediatrics, Child and Youth Health, The University of Auckland, Auckland, New Zealand
- Department of Infectious Diseases, Starship Children's Hospital, Auckland, New Zealand
- Department of Paediatrics, Kidz First Children's 'Hospital, Auckland, New Zealand
| | - Joshua S Davis
- Menzies School of Health Research, Charles Darwin Hospital, Darwin, Northern Territory, Australia
- John Hunter Hospital, University of Newcastle, Newcastle, New South Wales, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Robert K Mahar
- Clinical Epidemiology and Biostatistics, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Centre for Epidemiology and Biostatistics Unit, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
- Centre for Data Science, Queensland University of Technology, Brisbane, Queensland, Australia
| | | | - Brendan McMullan
- Department of Infectious Diseases, Sydney Children's Hospital, Randwick, Sydney, New South Wales, Australia
- School of Clinical Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Michael Meyer
- Neonatal Unit, Kidz First Middlemore Hospital Auckland, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health University of Auckland, Auckland, Auckland, New Zealand
| | - Jocelyn Mora
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Srinivas Murthy
- Division of Critical Care, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Clare Nourse
- Queensland Children's Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Queensland, Australia
| | - Jesse Papenburg
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, Quebec, Canada
- Division of Microbiology, Department of Clinical Laboratory Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Kevin L Schwartz
- Division of Infectious Diseases, St Joseph's Health Centre - Unity Health Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Oded Scheuerman
- Pediatrics B and Pediatric Infectious Diseases Unit, Schneider Children Medical Center Israel, Petach Tikva, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Thomas Snelling
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Tobias Strunk
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
- Neonatal Directorate Child and Adolescent Health Service, King Edward Memorial Hospital for Women, Subiaco, Western Australia, Australia
- Telethon Kids Institute, Perth, Western Australia, Australia
| | - Michael Stark
- The Robinson Research Institute, University of Adelaide, Adelaide, South Australia, Australia
- The Department of Neonatal Medicine, The Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Lesley Voss
- Department of Infectious Diseases, Starship Children's Hospital, Auckland, New Zealand
| | - Steven Y C Tong
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Asha C Bowen
- Department of Infectious Diseases, Perth Children's Hospital, Perth, Western Australia, Australia
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia
| |
Collapse
|
2
|
Brown AR, Gajewski BJ, Mudaranthakam DP, Pasnoor M, Dimachkie MM, Jawdat O, Herbelin L, Mayo MS, Barohn RJ. Conducting a bayesian multi-armed trial with response adaptive randomization for comparative effectiveness of medications for CSPN. Contemp Clin Trials Commun 2023; 36:101220. [PMID: 37965484 PMCID: PMC10641102 DOI: 10.1016/j.conctc.2023.101220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 08/02/2023] [Accepted: 10/07/2023] [Indexed: 11/16/2023] Open
Abstract
Background Response adaptive randomization is popular in adaptive trial designs, but the literature detailing its execution is lacking. These designs are desirable for patients/stakeholders, particularly in comparative effectiveness research, due to the potential benefits including improving participant buy-in by providing more participants with better treatment during the trial. Frequentist approaches have often been used, but adaptive designs naturally fit the Bayesian methodology; it was developed to deal with data as they come in by updating prior information. Methods PAIN-CONTRoLS was a comparative-effectiveness trial utilizing Bayesian response adaptive randomization to four drugs, nortriptyline, duloxetine, pregabalin, or mexiline, for cryptogenic sensory polyneuropathy (CSPN) patients. The aim was to determine which treatment was most tolerable and effective in reducing pain. Quit and efficacy rates were combined into a utility function to develop a single outcome, which with treatment sample size, drove the adaptive randomization. Prespecified interim analyses allowed the study to stop for early success or update the randomization probabilities to the better-performing treatments. Results Seven adaptations to the randomization occurred before the trial ended due to reaching the maximum sample size, with more participants receiving nortriptyline and duloxetine. At the end of the follow-up, nortriptyline and duloxetine had lower probabilities of participants that had stopped taking the study medication and higher probabilities were efficacious. Mexiletine had the highest quit rate, but had an efficacy rate higher than pregabalin. Conclusions Response adaptive randomization has become a popular trial tool, especially for those utilizing Bayesian methods for analyses. By illustrating the execution of a Bayesian adaptive design, using the PAIN-CONTRoLS trial data, this paper continues the work to provide literature for conducting Bayesian response adaptive randomized trials.
Collapse
Affiliation(s)
- Alexandra R. Brown
- Department of Biostatistics & Data Science, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Byron J. Gajewski
- Department of Biostatistics & Data Science, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Dinesh Pal Mudaranthakam
- Department of Biostatistics & Data Science, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Mamatha Pasnoor
- Department of Neurology, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Mazen M. Dimachkie
- Department of Neurology, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Omar Jawdat
- Department of Neurology, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Laura Herbelin
- Department of Neurology, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Matthew S. Mayo
- Department of Biostatistics & Data Science, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Richard J. Barohn
- Department of Neurology, The University of Missouri School of Medicine, Columbia, MO, USA
| |
Collapse
|
3
|
Yu Z, Wu L, Bunn V, Li Q, Lin J. Evolution of Phase II Oncology Trial Design: from Single Arm to Master Protocol. Ther Innov Regul Sci 2023; 57:823-838. [PMID: 36871111 DOI: 10.1007/s43441-023-00500-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 02/10/2023] [Indexed: 03/06/2023]
Abstract
The recent development of novel anticancer treatments with diverse mechanisms of action has accelerated the detection of treatment candidates tremendously. The rapidly changing drug development landscapes and the high failure rates in Phase III trials both underscore the importance of more efficient and robust phase II designs. The goals of phase II oncology studies are to explore the preliminary efficacy and toxicity of the investigational product and to inform future drug development strategies such as go/no-go decisions for phase III development, or dose/indication selection. These complex purposes of phase II oncology designs call for efficient, flexible, and easy-to-implement clinical trial designs. Therefore, innovative adaptive study designs with the potential of improving the efficiency of the study, protecting patients, and improving the quality of information gained from trials have been commonly used in Phase II oncology studies. Although the value of adaptive clinical trial methods in early phase drug development is generally well accepted, there is no comprehensive review and guidance on adaptive design methods and their best practice for phase II oncology trials. In this paper, we review the recent development and evolution of phase II oncology design, including frequentist multistage design, Bayesian continuous monitoring, master protocol design, and innovative design methods for randomized phase II studies. The practical considerations and the implementation of these complex design methods are also discussed.
Collapse
Affiliation(s)
- Ziji Yu
- , 95 Hayden Ave, Lexington, MA, 02421, USA.
- Takeda Pharmaceuticals, Lexington, USA.
| | - Liwen Wu
- Takeda Pharmaceuticals, Lexington, USA
| | | | | | | |
Collapse
|
4
|
Bon JJ, Bretherton A, Buchhorn K, Cramb S, Drovandi C, Hassan C, Jenner AL, Mayfield HJ, McGree JM, Mengersen K, Price A, Salomone R, Santos-Fernandez E, Vercelloni J, Wang X. Being Bayesian in the 2020s: opportunities and challenges in the practice of modern applied Bayesian statistics. PHILOSOPHICAL TRANSACTIONS. SERIES A, MATHEMATICAL, PHYSICAL, AND ENGINEERING SCIENCES 2023; 381:20220156. [PMID: 36970822 PMCID: PMC10041356 DOI: 10.1098/rsta.2022.0156] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 01/06/2023] [Indexed: 06/18/2023]
Abstract
Building on a strong foundation of philosophy, theory, methods and computation over the past three decades, Bayesian approaches are now an integral part of the toolkit for most statisticians and data scientists. Whether they are dedicated Bayesians or opportunistic users, applied professionals can now reap many of the benefits afforded by the Bayesian paradigm. In this paper, we touch on six modern opportunities and challenges in applied Bayesian statistics: intelligent data collection, new data sources, federated analysis, inference for implicit models, model transfer and purposeful software products. This article is part of the theme issue 'Bayesian inference: challenges, perspectives, and prospects'.
Collapse
Affiliation(s)
- Joshua J. Bon
- Centre for Data Science, Queensland University of Technology, Brisbane, Queensland, Australia
- School of Mathematical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Adam Bretherton
- Centre for Data Science, Queensland University of Technology, Brisbane, Queensland, Australia
- School of Mathematical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Katie Buchhorn
- Centre for Data Science, Queensland University of Technology, Brisbane, Queensland, Australia
- School of Mathematical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Susanna Cramb
- Centre for Data Science, Queensland University of Technology, Brisbane, Queensland, Australia
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Christopher Drovandi
- Centre for Data Science, Queensland University of Technology, Brisbane, Queensland, Australia
- School of Mathematical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Conor Hassan
- Centre for Data Science, Queensland University of Technology, Brisbane, Queensland, Australia
- School of Mathematical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Adrianne L. Jenner
- Centre for Data Science, Queensland University of Technology, Brisbane, Queensland, Australia
- School of Mathematical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Helen J. Mayfield
- Centre for Data Science, Queensland University of Technology, Brisbane, Queensland, Australia
- School of Public Health, The University of Queensland, Saint Lucia, Queensland, Australia
| | - James M. McGree
- Centre for Data Science, Queensland University of Technology, Brisbane, Queensland, Australia
- School of Mathematical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Kerrie Mengersen
- Centre for Data Science, Queensland University of Technology, Brisbane, Queensland, Australia
- School of Mathematical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Aiden Price
- Centre for Data Science, Queensland University of Technology, Brisbane, Queensland, Australia
- School of Mathematical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Robert Salomone
- Centre for Data Science, Queensland University of Technology, Brisbane, Queensland, Australia
- School of Computer Science, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Edgar Santos-Fernandez
- Centre for Data Science, Queensland University of Technology, Brisbane, Queensland, Australia
- School of Mathematical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Julie Vercelloni
- Centre for Data Science, Queensland University of Technology, Brisbane, Queensland, Australia
- School of Mathematical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Xiaoyu Wang
- Centre for Data Science, Queensland University of Technology, Brisbane, Queensland, Australia
- School of Mathematical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| |
Collapse
|
5
|
Silbergleit R. What have we learned from the RAMPART and ESETT randomized controlled trials? Epilepsy Behav 2022; 141:109051. [PMID: 36577548 DOI: 10.1016/j.yebeh.2022.109051] [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: 11/01/2022] [Revised: 12/04/2022] [Accepted: 12/04/2022] [Indexed: 12/27/2022]
Abstract
Lessons learned from the Rapid Anticonvulsant Medication Prior to Arrival Trial (RAMPART) and Established Status Epilepticus Treatment Trial (ESETT) trials are considered in three ways. First, by asking about the questions the trials were primarily designed to answer, then about the context of the intervention and characteristics of the patients described in secondary analyses, and finally, about what was learned about how to conduct trials in this space. The talk concludes with suggestions and a vision for how to best conduct future trials investigating status epilepticus. This paper was presented at the 8th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures held in September 2022.
Collapse
|
6
|
Gao G, Gajewski BJ, Wick J, Beall J, Saver JL, Meinzer C. Optimizing a Bayesian hierarchical adaptive platform trial design for stroke patients. Trials 2022; 23:754. [PMID: 36068547 PMCID: PMC9446515 DOI: 10.1186/s13063-022-06664-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 08/16/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Platform trials are well-known for their ability to investigate multiple arms on heterogeneous patient populations and their flexibility to add/drop treatment arms due to efficacy/lack of efficacy. Because of their complexity, it is important to develop highly optimized, transparent, and rigorous designs that are cost-efficient, offer high statistical power, maximize patient benefit, and are robust to changes over time. METHODS To address these needs, we present a Bayesian platform trial design based on a beta-binomial model for binary outcomes that uses three key strategies: (1) hierarchical modeling of subgroups within treatment arms that allows for borrowing of information across subgroups, (2) utilization of response-adaptive randomization (RAR) schemes that seek a tradeoff between statistical power and patient benefit, and (3) adjustment for potential drift over time. Motivated by a proposed clinical trial that aims to find the appropriate treatment for different subgroup populations of ischemic stroke patients, extensive simulation studies were performed to validate the approach, compare different allocation rules, and study the model operating characteristics. RESULTS AND CONCLUSIONS Our proposed approach achieved high statistical power and good patient benefit and was also robust against population drift over time. Our design provided a good balance between the strengths of both the traditional RAR scheme and fixed 1:1 allocation and may be a promising choice for dichotomous outcomes trials investigating multiple subgroups.
Collapse
Affiliation(s)
- Guangyi Gao
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, KS, 66160, USA.
| | - Byron J Gajewski
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, KS, 66160, USA
| | - Jo Wick
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Kansas City, KS, 66160, USA
| | - Jonathan Beall
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, University of California, Los Angeles, CA, 90095, USA
| | - Caitlyn Meinzer
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, 29425, USA
| | | |
Collapse
|
7
|
Aqib A, Lebouché B, Engler K, Schuster T. Feasibility of a Platform Trial Design for the Development of Mobile Health Applications: A Review. Telemed J E Health 2022; 29:501-509. [PMID: 35951018 DOI: 10.1089/tmj.2021.0620] [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: 11/13/2022] Open
Abstract
Background: A novel adaptive trial design called platform trials (PTs) may offer an effective, efficient, and unbiased approach to evaluate different developer versions of mobile health (m-health) apps. However, the feasibility of their use for this purpose is yet to be explored. Objective: This literature review aims to explore the reported challenges associated with the adaptive PT design to assess its feasibility for the development of m-health apps. Methods: A descriptive literature review using two databases (MEDLINE and Embase) was conducted. Documents published in English between 1947 and September 20, 2020, were eligible for inclusion. Results: The titles and abstracts of 758 records were screened after which 179 full-text articles were assessed for eligibility. A total of 41 articles were included in the synthesis, all published after the year 2000. The synthesis yielded eight distinct categories of challenging issues with PTs relevant to their application in m-health app development, along with potential solutions. These categories are ethical issues (e.g., related to informed consent, equipoise, justice) (with 19 articles contributing content), biases (7 articles), temporal drift (4 articles), miscellaneous statistical issues (3 articles), logistical issues (e.g., cost and human resources, frequent amendments; 6 articles), sample size and power conflict (2 articles), generalizability of the results (2 articles), and operational challenges (1 article). Conclusion: Although PT designs are relatively new, they have promising feasibility for the seamless evaluation of interventions that undergo continuous development, including m-health apps; however, various challenges may hinder their successful implementation.
Collapse
Affiliation(s)
- Asma Aqib
- Department of Family Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada.,Department of Internal Medicine, University of Alabama, Montgomery, Alabama, USA
| | - Bertrand Lebouché
- Department of Family Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada.,Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Center, Montreal, Canada.,Chronic Viral Illness Service, Royal Victoria Hospital, McGill University Health Centre, Montreal, Canada
| | - Kim Engler
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Center, Montreal, Canada
| | - Tibor Schuster
- Department of Family Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
| |
Collapse
|
8
|
Bruce Metadata P, Ainscough K, Hatter L, Braithwaite I, Berry LR, Fitzgerald M, Hills T, Brickell K, Cosgrave D, Semprini A, Morpeth S, Berry S, Doran P, Young P, Beasley R, Nichol A. Prophylaxis in healthcare workers during a pandemic: a model for a multi-centre international randomised controlled trial using Bayesian analyses. Trials 2022; 23:534. [PMID: 35761370 PMCID: PMC9235209 DOI: 10.1186/s13063-022-06402-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 05/12/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) has exposed the disproportionate effects of pandemics on frontline workers and the ethical imperative to provide effective prophylaxis. We present a model for a pragmatic randomised controlled trial (RCT) that utilises Bayesian methods to rapidly determine the efficacy or futility of a prophylactic agent. METHODS We initially planned to undertake a multicentre, phase III, parallel-group, open-label RCT, to determine if hydroxychloroquine (HCQ) taken once a week was effective in preventing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in healthcare workers (HCW) aged ≥ 18 years in New Zealand (NZ) and Ireland. Participants were to be randomised 2:1 to either HCQ (800 mg stat then 400 mg weekly) or no prophylaxis. The primary endpoint was time to Nucleic Acid Amplification Test-proven SARS-CoV-2 infection. Secondary outcome variables included mortality, hospitalisation, intensive care unit admissions and length of mechanical ventilation. The trial had no fixed sample size or duration of intervention. Bayesian adaptive analyses were planned to occur fortnightly, commencing with a weakly informative prior for the no prophylaxis group hazard rate and a moderately informative prior on the intervention log hazard ratio centred on 'no effect'. Stopping for expected success would be executed if the intervention had a greater than 0.975 posterior probability of reducing the risk of SARS-CoV-2 infection by more than 10%. Final success would be declared if, after completion of 8 weeks of follow-up (reflecting the long half-life of HCQ), the prophylaxis had at least a 0.95 posterior probability of reducing the risk of SARS-CoV-2 infection by more than 10%. Futility would be declared if HCQ was shown to have less than a 0.10 posterior probability of reducing acquisition of SARS-CoV-2 infection by more than 20%. DISCUSSION This study did not begin recruitment due to the marked reduction in COVID-19 cases in NZ and concerns regarding the efficacy and risks of HCQ treatment in COVID-19. Nonetheless, the model presented can be easily adapted for other potential prophylactic agents and pathogens, and pre-established collaborative models like this should be shared and incorporated into future pandemic preparedness planning. TRIAL REGISTRATION The decision not to proceed with the study was made before trial registration occurred.
Collapse
Affiliation(s)
- Pepa Bruce Metadata
- grid.415117.70000 0004 0445 6830Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington 6242 New Zealand
| | - Kate Ainscough
- grid.7886.10000 0001 0768 2743University College Dublin - Clinical Research Centre at St. Vincent’s University Hospital, Dublin, Ireland
| | - Lee Hatter
- grid.415117.70000 0004 0445 6830Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington 6242 New Zealand
| | - Irene Braithwaite
- grid.415117.70000 0004 0445 6830Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington 6242 New Zealand
| | | | | | - Thomas Hills
- grid.415117.70000 0004 0445 6830Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington 6242 New Zealand ,grid.414057.30000 0001 0042 379XAuckland District Health Board, Auckland, New Zealand
| | - Kathy Brickell
- grid.7886.10000 0001 0768 2743University College Dublin - Clinical Research Centre at St. Vincent’s University Hospital, Dublin, Ireland
| | - David Cosgrave
- grid.6142.10000 0004 0488 0789National University of Ireland, Galway, Ireland ,grid.412440.70000 0004 0617 9371University Hospital Galway, Galway, Ireland
| | - Alex Semprini
- grid.415117.70000 0004 0445 6830Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington 6242 New Zealand
| | - Susan Morpeth
- grid.413188.70000 0001 0098 1855Counties Manukau District Health Board, Auckland, New Zealand
| | | | - Peter Doran
- grid.7886.10000 0001 0768 2743University College Dublin - Clinical Research Centre at St. Vincent’s University Hospital, Dublin, Ireland
| | - Paul Young
- grid.415117.70000 0004 0445 6830Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington 6242 New Zealand
| | - Richard Beasley
- grid.415117.70000 0004 0445 6830Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington 6242 New Zealand
| | - Alistair Nichol
- grid.7886.10000 0001 0768 2743University College Dublin - Clinical Research Centre at St. Vincent’s University Hospital, Dublin, Ireland ,grid.1002.30000 0004 1936 7857Monash University - Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia ,grid.1623.60000 0004 0432 511XDepartment of Intensive Care, Alfred Hospital, Melbourne, Australia
| |
Collapse
|
9
|
Broglio K, Meurer WJ, Durkalski V, Pauls Q, Connor J, Berry D, Lewis RJ, Johnston KC, Barsan WG. Comparison of Bayesian vs Frequentist Adaptive Trial Design in the Stroke Hyperglycemia Insulin Network Effort Trial. JAMA Netw Open 2022; 5:e2211616. [PMID: 35544137 PMCID: PMC9096598 DOI: 10.1001/jamanetworkopen.2022.11616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Bayesian adaptive trial design has the potential to create more efficient clinical trials. However, a barrier to the uptake of bayesian adaptive designs for confirmatory trials is limited experience with how they may perform compared with a frequentist design. OBJECTIVE To compare the performance of a bayesian and a frequentist adaptive clinical trial design. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study compared 2 trial designs for a completed multicenter acute stroke trial conducted within a National Institutes of Health neurologic emergencies clinical trials network, with individual patient-level data, including the timing and order of enrollments and outcome ascertainment, from 1151 patients with acute stroke and hyperglycemia randomized to receive intensive or standard insulin therapy. The implemented frequentist design had group sequential boundaries for efficacy and futility interim analyses at 90 days after randomization for 500, 700, 900, and 1100 patients. The bayesian alternative used predictive probability of trial success to govern early termination for efficacy and futility with a first interim analysis at 500 randomized patients and subsequent interims after every 100 randomizations. MAIN OUTCOMES AND MEASURES The main outcome was the sample size at end of study, which was defined as the sample size at which each of the studies stopped accrual of patients. RESULTS Data were collected from 1151 patients. As conducted, the frequentist design passed the futility boundary after 936 participants were randomized. Using the same sequence and timing of randomization and outcome data, the bayesian alternative crossed the futility boundary approximately 3 months earlier after 800 participants were randomized. CONCLUSIONS AND RELEVANCE Both trial designs stopped for futility before reaching the planned maximum sample size. In both cases, the clinical community and patients would benefit from learning the answer to the trial's primary question earlier. The common feature across the 2 designs was frequent interim analyses to stop early for efficacy or for futility. Differences between how these analyses were implemented between the 2 trials resulted in the differences in early stopping.
Collapse
Affiliation(s)
- Kristine Broglio
- AstraZeneca US, Gaithersburg, Maryland
- Berry Consultants LLC, Austin, Texas
| | - William J. Meurer
- Berry Consultants LLC, Austin, Texas
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- Department of Neurology, University of Michigan, Ann Arbor
- Stroke Program, University of Michigan, Ann Arbor
| | - Valerie Durkalski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Qi Pauls
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Jason Connor
- ConfluenceStat LLC, Cooper City, Florida
- Department of Medical Education, University of Central Florida College of Medicine, Orlando
| | | | - Roger J. Lewis
- Berry Consultants LLC, Austin, Texas
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | | |
Collapse
|
10
|
Das R. An optimal design in a two-stage ethical allocation based on U-statistics. J STAT COMPUT SIM 2021. [DOI: 10.1080/00949655.2021.2006658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Radhakanta Das
- Department of Statistics, Presidency University, Kolkata, India
| |
Collapse
|
11
|
May Lee K, Jack Lee J. Evaluating Bayesian adaptive randomization procedures with adaptive clip methods for multi-arm trials. Stat Methods Med Res 2021; 30:1273-1287. [PMID: 33689524 PMCID: PMC7613973 DOI: 10.1177/0962280221995961] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2024]
Abstract
Bayesian adaptive randomization is a heuristic approach that aims to randomize more patients to the putatively superior arms based on the trend of the accrued data in a trial. Many statistical aspects of this approach have been explored and compared with other approaches; yet only a limited number of works has focused on improving its performance and providing guidance on its application to real trials. An undesirable property of this approach is that the procedure would randomize patients to an inferior arm in some circumstances, which has raised concerns in its application. Here, we propose an adaptive clip method to rectify the problem by incorporating a data-driven function to be used in conjunction with Bayesian adaptive randomization procedure. This function aims to minimize the chance of assigning patients to inferior arms during the early time of the trial. Moreover, we propose a utility approach to facilitate the selection of a randomization procedure. A cost that reflects the penalty of assigning patients to the inferior arm(s) in the trial is incorporated into our utility function along with all patients benefited from the trial, both within and beyond the trial. We illustrate the selection strategy for a wide range of scenarios.
Collapse
Affiliation(s)
- Kim May Lee
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - J Jack Lee
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
12
|
Neligan A, Rajakulendran S, Walker MC. Advances in the management of generalized convulsive status epilepticus: what have we learned? Brain 2021; 144:1336-1341. [PMID: 33778866 DOI: 10.1093/brain/awab049] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/18/2020] [Accepted: 12/09/2020] [Indexed: 12/15/2022] Open
Abstract
Convulsive status epilepticus is the most serious manifestation of an epileptic diathesis. In the early stages (5-30 min), there exists class A evidence to support the efficacy of benzodiazepines as first-line treatment. As status epilepticus progresses into the later stages, the evidence for treatment becomes less robust until we are depending upon short case series and case reports for the treatment of refractory status epilepticus. However, the past year saw the publication of three randomized controlled trials in the setting of benzodiazepine-resistant established convulsive status epilepticus: the EcLiPSE and ConSEPT studies, compared levetiracetam to phenytoin in children; and the ESETT study compared fosphenytoin, levetiracetam and sodium valproate in adults and children. In addition, the emergence of data from the SENSE study, a multicentre multinational prospective cohort study and the publication of a systematic review and meta-analysis of the mortality of status epilepticus over the past 30 years, has brought the treatment of status epilepticus into sharp focus. In this update we provide a detailed analysis of these studies and their impact on clinical practice. We review contentious areas of management in status epilepticus where a consensus is lacking and advance the case for more research on existing and alternative treatment strategies.
Collapse
Affiliation(s)
- Aidan Neligan
- Homerton University Hospital NHS Foundation Trust, Homerton Row, London E9 6SR, UK.,DCEE, UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG, UK
| | - Sanjeev Rajakulendran
- DCEE, UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG, UK.,National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK.,North Middlesex University Hospital, Sterling Way, London N18 1QX, UK
| | - Matthew C Walker
- DCEE, UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG, UK.,National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
| |
Collapse
|
13
|
Ryan EG, Brock K, Gates S, Slade D. Do we need to adjust for interim analyses in a Bayesian adaptive trial design? BMC Med Res Methodol 2020; 20:150. [PMID: 32522284 PMCID: PMC7288484 DOI: 10.1186/s12874-020-01042-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 06/04/2020] [Indexed: 01/30/2023] Open
Abstract
Background Bayesian adaptive methods are increasingly being used to design clinical trials and offer several advantages over traditional approaches. Decisions at analysis points are usually based on the posterior distribution of the treatment effect. However, there is some confusion as to whether control of type I error is required for Bayesian designs as this is a frequentist concept. Methods We discuss the arguments for and against adjusting for multiplicities in Bayesian trials with interim analyses. With two case studies we illustrate the effect of including interim analyses on type I/II error rates in Bayesian clinical trials where no adjustments for multiplicities are made. We propose several approaches to control type I error, and also alternative methods for decision-making in Bayesian clinical trials. Results In both case studies we demonstrated that the type I error was inflated in the Bayesian adaptive designs through incorporation of interim analyses that allowed early stopping for efficacy and without adjustments to account for multiplicity. Incorporation of early stopping for efficacy also increased the power in some instances. An increase in the number of interim analyses that only allowed early stopping for futility decreased the type I error, but also decreased power. An increase in the number of interim analyses that allowed for either early stopping for efficacy or futility generally increased type I error and decreased power. Conclusions Currently, regulators require demonstration of control of type I error for both frequentist and Bayesian adaptive designs, particularly for late-phase trials. To demonstrate control of type I error in Bayesian adaptive designs, adjustments to the stopping boundaries are usually required for designs that allow for early stopping for efficacy as the number of analyses increase. If the designs only allow for early stopping for futility then adjustments to the stopping boundaries are not needed to control type I error. If one instead uses a strict Bayesian approach, which is currently more accepted in the design and analysis of exploratory trials, then type I errors could be ignored and the designs could instead focus on the posterior probabilities of treatment effects of clinically-relevant values.
Collapse
Affiliation(s)
- Elizabeth G Ryan
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK.
| | - Kristian Brock
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Simon Gates
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Daniel Slade
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| |
Collapse
|
14
|
Chamberlain JM, Kapur J, Shinnar S, Elm J, Holsti M, Babcock L, Rogers A, Barsan W, Cloyd J, Lowenstein D, Bleck TP, Conwit R, Meinzer C, Cock H, Fountain NB, Underwood E, Connor JT, Silbergleit R. Efficacy of levetiracetam, fosphenytoin, and valproate for established status epilepticus by age group (ESETT): a double-blind, responsive-adaptive, randomised controlled trial. Lancet 2020; 395:1217-1224. [PMID: 32203691 PMCID: PMC7241415 DOI: 10.1016/s0140-6736(20)30611-5] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/03/2020] [Accepted: 03/05/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Benzodiazepine-refractory, or established, status epilepticus is thought to be of similar pathophysiology in children and adults, but differences in underlying aetiology and pharmacodynamics might differentially affect response to therapy. In the Established Status Epilepticus Treatment Trial (ESETT) we compared the efficacy and safety of levetiracetam, fosphenytoin, and valproate in established status epilepticus, and here we describe our results after extending enrolment in children to compare outcomes in three age groups. METHODS In this multicentre, double-blind, response-adaptive, randomised controlled trial, we recruited patients from 58 hospital emergency departments across the USA. Patients were eligible for inclusion if they were aged 2 years or older, had been treated for a generalised convulsive seizure of longer than 5 min duration with adequate doses of benzodiazepines, and continued to have persistent or recurrent convulsions in the emergency department for at least 5 min and no more than 30 min after the last dose of benzodiazepine. Patients were randomly assigned in a response-adaptive manner, using Bayesian methods and stratified by age group (<18 years, 18-65 years, and >65 years), to levetiracetam, fosphenytoin, or valproate. All patients, investigators, study staff, and pharmacists were masked to treatment allocation. The primary outcome was absence of clinically apparent seizures with improved consciousness and without additional antiseizure medication at 1 h from start of drug infusion. The primary safety outcome was life-threatening hypotension or cardiac arrhythmia. The efficacy and safety outcomes were analysed by intention to treat. This study is registered in ClinicalTrials.gov, NCT01960075. FINDINGS Between Nov 3, 2015, and Dec 29, 2018, we enrolled 478 patients and 462 unique patients were included: 225 children (aged <18 years), 186 adults (18-65 years), and 51 older adults (>65 years). 175 (38%) patients were randomly assigned to levetiracetam, 142 (31%) to fosphenyltoin, and 145 (31%) were to valproate. Baseline characteristics were balanced across treatments within age groups. The primary efficacy outcome was met in those treated with levetiracetam for 52% (95% credible interval 41-62) of children, 44% (33-55) of adults, and 37% (19-59) of older adults; with fosphenytoin in 49% (38-61) of children, 46% (34-59) of adults, and 35% (17-59) of older adults; and with valproate in 52% (41-63) of children, 46% (34-58) of adults, and 47% (25-70) of older adults. No differences were detected in efficacy or primary safety outcome by drug within each age group. With the exception of endotracheal intubation in children, secondary safety outcomes did not significantly differ by drug within each age group. INTERPRETATION Children, adults, and older adults with established status epilepticus respond similarly to levetiracetam, fosphenytoin, and valproate, with treatment success in approximately half of patients. Any of the three drugs can be considered as a potential first-choice, second-line drug for benzodiazepine-refractory status epilepticus. FUNDING National Institute of Neurological Disorders and Stroke, National Institutes of Health.
Collapse
Affiliation(s)
- James M Chamberlain
- Division of Emergency Medicine Children's National Hospital, Washington, DC, USA
| | - Jaideep Kapur
- Department of Neurology, University of Virginia Health Sciences Center, Charlottesville, VA, USA
| | - Shlomo Shinnar
- Neurology, Pediatrics and Epidemiology and Population Health Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jordan Elm
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Maija Holsti
- Division of Pediatric Emergency Medicine, University of Utah, Salt Lake City, UT, USA
| | - Lynn Babcock
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Alex Rogers
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA; Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - William Barsan
- Department of Emergency Medicine, Neuro Emergencies Research, University of Michigan, Ann Arbor, MI, USA
| | - James Cloyd
- Center for Orphan Drug Research, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Daniel Lowenstein
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Thomas P Bleck
- Division of Stroke and Neurocritical Care, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Robin Conwit
- National Institute of Neurological Disorders and Stroke, National Institutes of Health Neuroscience Center, Bethesda, MD, USA
| | - Caitlyn Meinzer
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Hannah Cock
- Institute of Molecular and Clinical Sciences, St George's University of London, London, UK
| | - Nathan B Fountain
- Department of Neurology, University of Virginia Health Sciences Center, Charlottesville, VA, USA
| | - Ellen Underwood
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Jason T Connor
- ConfluenceStat LLC and University of Central Florida College of Medicine, Cooper City, FL, USA
| | - Robert Silbergleit
- Department of Emergency Medicine, Neuro Emergencies Research, University of Michigan, Ann Arbor, MI, USA.
| |
Collapse
|
15
|
Viele K, Saville BR, McGlothlin A, Broglio K. Comparison of response adaptive randomization features in multiarm clinical trials with control. Pharm Stat 2020; 19:602-612. [DOI: 10.1002/pst.2015] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 01/27/2020] [Accepted: 03/02/2020] [Indexed: 12/27/2022]
Affiliation(s)
- Kert Viele
- Berry Consultants Austin Texas USA
- Department of Biostatistics University of Kentucky Lexington Kentucky USA
| | - Benjamin R. Saville
- Berry Consultants Austin Texas USA
- Department of Biostatistics Vanderbilt University Nashville Tennessee USA
| | | | | |
Collapse
|
16
|
Ryan EG, Lamb SE, Williamson E, Gates S. Bayesian adaptive designs for multi-arm trials: an orthopaedic case study. Trials 2020; 21:83. [PMID: 31937341 PMCID: PMC6961269 DOI: 10.1186/s13063-019-4021-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 12/20/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Bayesian adaptive designs can be more efficient than traditional methods for multi-arm randomised controlled trials. The aim of this work was to demonstrate how Bayesian adaptive designs can be constructed for multi-arm phase III clinical trials and assess potential benefits that these designs offer. METHODS We constructed several alternative Bayesian adaptive designs for the Collaborative Ankle Support Trial (CAST), which was a randomised controlled trial that compared four treatments for severe ankle sprain. These designs incorporated response adaptive randomisation (RAR), arm dropping, and early stopping for efficacy or futility. We studied the operating characteristics of the Bayesian designs via simulation. We then virtually re-executed the trial by implementing the Bayesian adaptive designs using patient data sampled from the CAST study to demonstrate the practical applicability of the designs. RESULTS We constructed five Bayesian adaptive designs, each of which had high power and recruited fewer patients on average than the original designs target sample size. The virtual executions showed that most of the Bayesian designs would have led to trials that declared superiority of one of the interventions over the control. Bayesian adaptive designs with RAR or arm dropping were more likely to allocate patients to better performing arms at each interim analysis. Similar estimates and conclusions were obtained from the Bayesian adaptive designs as from the original trial. CONCLUSIONS Using CAST as an example, this case study shows how Bayesian adaptive designs can be constructed for phase III multi-arm trials using clinically relevant decision criteria. These designs demonstrated that they can potentially generate earlier results and allocate more patients to better performing arms. We recommend the wider use of Bayesian adaptive approaches in phase III clinical trials. TRIAL REGISTRATION CAST study registration ISRCTN, ISRCTN37807450. Retrospectively registered on 25 April 2003.
Collapse
Affiliation(s)
- Elizabeth G Ryan
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, B15 2TT, UK.
| | - Sarah E Lamb
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences (NDORMS), Botnar Research Centre, University of Oxford, Oxford, OX3 7LD, UK
- College of Medicine and Health, University of Exeter, Exeter, EX1 2LU, UK
| | - Esther Williamson
- Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences (NDORMS), Botnar Research Centre, University of Oxford, Oxford, OX3 7LD, UK
| | - Simon Gates
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, B15 2TT, UK
| |
Collapse
|
17
|
Cock HR, Coles LD, Elm J, Silbergleit R, Chamberlain JM, Cloyd JC, Fountain N, Shinnar S, Lowenstein D, Conwit R, Bleck TP, Kapur J. Lessons from the Established Status Epilepticus Treatment Trial. Epilepsy Behav 2019; 101:106296. [PMID: 31653603 PMCID: PMC6944752 DOI: 10.1016/j.yebeh.2019.04.049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 04/27/2019] [Indexed: 01/10/2023]
Abstract
Convulsive status epilepticus (SE) is a relatively common emergency condition affecting individuals of all ages. The primary goal of treatment is prompt termination of seizures. Where first-line treatment with benzodiazepine has failed to achieve this, a condition known as established SE (ESE), there is uncertainty about which agent to use next. The Established Status Epilepticus Treatment Trial (ESETT) is a 3-arm (valproate (VPA), fosphenytoin (FOS), levetiracetam (LEV)), phase III, double-blind randomized comparative effectiveness study in patients aged 2 years and above with established convulsive SE. Enrollment was completed in January 2019, and the results are expected later this year. We discuss lessons learnt during the conduct of the study in relation to the following: ethical considerations; trial design and practical implementation in emergency settings, including pediatric and adult populations; quality assurance; and outcome determination where treating emergency clinicians may lack specialist expertise. We consider that the ESETT is already informing both clinical practice and future trial design. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".
Collapse
Affiliation(s)
- Hannah R. Cock
- St George’s University of London and Consultant Neurologist, Atkinson Morley Regional Epilepsy Network, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Lisa D. Coles
- Department of Experimental and Clinical Pharmacology, College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis, MN, USA
| | - Jordan Elm
- Department of Public Health Science, Medical University of South, Carolina, Charleston, SC, USA
| | - Robert Silbergleit
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - James M. Chamberlain
- Division of Emergency Medicine, Children’s National Health System and the Department of Pediatrics and Emergency Medicine, School of Medicine and Health Sciences, George Washington University Washington, DC, USA
| | - James C. Cloyd
- Department of Experimental and Clinical Pharmacology, College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis, MN, USA
| | - Nathan Fountain
- Department of Neurology (Fountain, Kapur), Brain Institute, University of Virginia, Charlottesville, VA, USA
| | - Shlomo Shinnar
- Departments of Neurology, Pediatrics and Epidemiology and Population Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY USA
| | - Dan Lowenstein
- Department of Neurology, University of California, San Francisco, CA
| | - Robin Conwit
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Thomas P. Bleck
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago IL USA
| | - Jaideep Kapur
- Department of Neurology (Fountain, Kapur), Brain Institute, University of Virginia, Charlottesville, VA, USA,Department of Neuroscience (Kapur), Brain Institute, University of Virginia, Charlottesville, VA, USA
| |
Collapse
|
18
|
King BT, Lawrence PD, Milling TJ, Warach SJ. Optimal delay time to initiate anticoagulation after ischemic stroke in atrial fibrillation (START): Methodology of a pragmatic, response-adaptive, prospective randomized clinical trial. Int J Stroke 2019; 14:977-982. [PMID: 31423922 PMCID: PMC7401695 DOI: 10.1177/1747493019870651] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
RATIONALE An estimated 15% of all strokes are associated with untreated atrial fibrillation. Long-term secondary stroke prevention in atrial fibrillation is anticoagulation, increasingly with non-vitamin K oral anticoagulants. The optimal time to initiate anticoagulation following an atrial fibrillation-related stroke that balances hemorrhagic conversion with recurrent stroke is not yet known. AIMS To determine if there is an optimal delay time to initiate anticoagulation after atrial fibrillation-related stroke that optimizes the composite outcome of hemorrhagic conversion and recurrent ischemic stroke. SAMPLE SIZE ESTIMATES The study will enroll 1500 total subjects split between a mild to moderate stroke cohort (1000) and a severe stroke cohort (500). METHODS AND DESIGN This study is a multi-center, prospective, randomized, pragmatic, adaptive trial that randomizes subjects to four arms of time to start of anticoagulation. The four arms for mild to moderate stroke are: Day 3, Day 6, Day 10, and Day 14. The time intervals for severe stroke are: Day 6, Day 10, Day 14, and Day 21. Allocation involves a response adaptive randomization via interim analyses to favor the arms that have a better risk-benefit profile. STUDY OUTCOMES The primary outcome event is the composite occurrence of an ischemic or hemorrhagic event within 30 days of the index stroke. Secondary outcomes are also collected at 30 and 90 days. DISCUSSION The optimal timing of direct oral anticoagulants post-ischemic stroke requires prospective randomized testing. A pragmatically designed trial with adaptive allocation and randomization to multiple time intervals such as the START trial is best suited to answer this question in order to directly inform current practice on this question.
Collapse
Affiliation(s)
- Benjamin T King
- Department of Neurology, University of Texas Dell Medical School, Austin, TX, USA
| | - Patrick D Lawrence
- Department of Neurology, University of Texas Dell Medical School, Austin, TX, USA
| | - Truman J Milling
- Department of Neurology, University of Texas Dell Medical School, Austin, TX, USA
- Seton Healthcare Family, Austin, TX, USA
- Department of Surgery and Perioperative Care, University of Texas Dell Medical School, Austin, TX, USA
| | - Steven J Warach
- Department of Neurology, University of Texas Dell Medical School, Austin, TX, USA
| |
Collapse
|
19
|
Kapur J, Elm J, Chamberlain JM, Barsan W, Cloyd J, Lowenstein D, Shinnar S, Conwit R, Meinzer C, Cock H, Fountain N, Connor JT, Silbergleit R. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. N Engl J Med 2019; 381:2103-2113. [PMID: 31774955 PMCID: PMC7098487 DOI: 10.1056/nejmoa1905795] [Citation(s) in RCA: 281] [Impact Index Per Article: 56.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The choice of drugs for patients with status epilepticus that is refractory to treatment with benzodiazepines has not been thoroughly studied. METHODS In a randomized, blinded, adaptive trial, we compared the efficacy and safety of three intravenous anticonvulsive agents - levetiracetam, fosphenytoin, and valproate - in children and adults with convulsive status epilepticus that was unresponsive to treatment with benzodiazepines. The primary outcome was absence of clinically evident seizures and improvement in the level of consciousness by 60 minutes after the start of drug infusion, without additional anticonvulsant medication. The posterior probabilities that each drug was the most or least effective were calculated. Safety outcomes included life-threatening hypotension or cardiac arrhythmia, endotracheal intubation, seizure recurrence, and death. RESULTS A total of 384 patients were enrolled and randomly assigned to receive levetiracetam (145 patients), fosphenytoin (118), or valproate (121). Reenrollment of patients with a second episode of status epilepticus accounted for 16 additional instances of randomization. In accordance with a prespecified stopping rule for futility of finding one drug to be superior or inferior, a planned interim analysis led to the trial being stopped. Of the enrolled patients, 10% were determined to have had psychogenic seizures. The primary outcome of cessation of status epilepticus and improvement in the level of consciousness at 60 minutes occurred in 68 patients assigned to levetiracetam (47%; 95% credible interval, 39 to 55), 53 patients assigned to fosphenytoin (45%; 95% credible interval, 36 to 54), and 56 patients assigned to valproate (46%; 95% credible interval, 38 to 55). The posterior probability that each drug was the most effective was 0.41, 0.24, and 0.35, respectively. Numerically more episodes of hypotension and intubation occurred in the fosphenytoin group and more deaths occurred in the levetiracetam group than in the other groups, but these differences were not significant. CONCLUSIONS In the context of benzodiazepine-refractory convulsive status epilepticus, the anticonvulsant drugs levetiracetam, fosphenytoin, and valproate each led to seizure cessation and improved alertness by 60 minutes in approximately half the patients, and the three drugs were associated with similar incidences of adverse events. (Funded by the National Institute of Neurological Disorders and Stroke; ESETT ClinicalTrials.gov number, NCT01960075.).
Collapse
Affiliation(s)
- Jaideep Kapur
- From the Department of Neurology, University of Virginia, Charlottesville (J.K., N.F.); the Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., C.M.); the Division of Emergency Medicine, Children's National Medical Center, Washington, DC (J.M.C.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.B., R.S.); the College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis (J.C.); the Department of Neurology, University of California, San Francisco, San Francisco (D.L.); the Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, New York (S.S.); the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (R.C.); St. George's University of London and St. George's University Hospitals NHS Foundation Trust, London (H.C.); and ConfluenceStat (J.T.C.) and the University of Central Florida College of Medicine (J.T.C.) - both in Orlando
| | - Jordan Elm
- From the Department of Neurology, University of Virginia, Charlottesville (J.K., N.F.); the Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., C.M.); the Division of Emergency Medicine, Children's National Medical Center, Washington, DC (J.M.C.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.B., R.S.); the College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis (J.C.); the Department of Neurology, University of California, San Francisco, San Francisco (D.L.); the Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, New York (S.S.); the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (R.C.); St. George's University of London and St. George's University Hospitals NHS Foundation Trust, London (H.C.); and ConfluenceStat (J.T.C.) and the University of Central Florida College of Medicine (J.T.C.) - both in Orlando
| | - James M Chamberlain
- From the Department of Neurology, University of Virginia, Charlottesville (J.K., N.F.); the Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., C.M.); the Division of Emergency Medicine, Children's National Medical Center, Washington, DC (J.M.C.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.B., R.S.); the College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis (J.C.); the Department of Neurology, University of California, San Francisco, San Francisco (D.L.); the Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, New York (S.S.); the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (R.C.); St. George's University of London and St. George's University Hospitals NHS Foundation Trust, London (H.C.); and ConfluenceStat (J.T.C.) and the University of Central Florida College of Medicine (J.T.C.) - both in Orlando
| | - William Barsan
- From the Department of Neurology, University of Virginia, Charlottesville (J.K., N.F.); the Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., C.M.); the Division of Emergency Medicine, Children's National Medical Center, Washington, DC (J.M.C.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.B., R.S.); the College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis (J.C.); the Department of Neurology, University of California, San Francisco, San Francisco (D.L.); the Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, New York (S.S.); the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (R.C.); St. George's University of London and St. George's University Hospitals NHS Foundation Trust, London (H.C.); and ConfluenceStat (J.T.C.) and the University of Central Florida College of Medicine (J.T.C.) - both in Orlando
| | - James Cloyd
- From the Department of Neurology, University of Virginia, Charlottesville (J.K., N.F.); the Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., C.M.); the Division of Emergency Medicine, Children's National Medical Center, Washington, DC (J.M.C.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.B., R.S.); the College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis (J.C.); the Department of Neurology, University of California, San Francisco, San Francisco (D.L.); the Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, New York (S.S.); the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (R.C.); St. George's University of London and St. George's University Hospitals NHS Foundation Trust, London (H.C.); and ConfluenceStat (J.T.C.) and the University of Central Florida College of Medicine (J.T.C.) - both in Orlando
| | - Daniel Lowenstein
- From the Department of Neurology, University of Virginia, Charlottesville (J.K., N.F.); the Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., C.M.); the Division of Emergency Medicine, Children's National Medical Center, Washington, DC (J.M.C.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.B., R.S.); the College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis (J.C.); the Department of Neurology, University of California, San Francisco, San Francisco (D.L.); the Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, New York (S.S.); the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (R.C.); St. George's University of London and St. George's University Hospitals NHS Foundation Trust, London (H.C.); and ConfluenceStat (J.T.C.) and the University of Central Florida College of Medicine (J.T.C.) - both in Orlando
| | - Shlomo Shinnar
- From the Department of Neurology, University of Virginia, Charlottesville (J.K., N.F.); the Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., C.M.); the Division of Emergency Medicine, Children's National Medical Center, Washington, DC (J.M.C.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.B., R.S.); the College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis (J.C.); the Department of Neurology, University of California, San Francisco, San Francisco (D.L.); the Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, New York (S.S.); the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (R.C.); St. George's University of London and St. George's University Hospitals NHS Foundation Trust, London (H.C.); and ConfluenceStat (J.T.C.) and the University of Central Florida College of Medicine (J.T.C.) - both in Orlando
| | - Robin Conwit
- From the Department of Neurology, University of Virginia, Charlottesville (J.K., N.F.); the Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., C.M.); the Division of Emergency Medicine, Children's National Medical Center, Washington, DC (J.M.C.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.B., R.S.); the College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis (J.C.); the Department of Neurology, University of California, San Francisco, San Francisco (D.L.); the Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, New York (S.S.); the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (R.C.); St. George's University of London and St. George's University Hospitals NHS Foundation Trust, London (H.C.); and ConfluenceStat (J.T.C.) and the University of Central Florida College of Medicine (J.T.C.) - both in Orlando
| | - Caitlyn Meinzer
- From the Department of Neurology, University of Virginia, Charlottesville (J.K., N.F.); the Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., C.M.); the Division of Emergency Medicine, Children's National Medical Center, Washington, DC (J.M.C.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.B., R.S.); the College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis (J.C.); the Department of Neurology, University of California, San Francisco, San Francisco (D.L.); the Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, New York (S.S.); the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (R.C.); St. George's University of London and St. George's University Hospitals NHS Foundation Trust, London (H.C.); and ConfluenceStat (J.T.C.) and the University of Central Florida College of Medicine (J.T.C.) - both in Orlando
| | - Hannah Cock
- From the Department of Neurology, University of Virginia, Charlottesville (J.K., N.F.); the Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., C.M.); the Division of Emergency Medicine, Children's National Medical Center, Washington, DC (J.M.C.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.B., R.S.); the College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis (J.C.); the Department of Neurology, University of California, San Francisco, San Francisco (D.L.); the Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, New York (S.S.); the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (R.C.); St. George's University of London and St. George's University Hospitals NHS Foundation Trust, London (H.C.); and ConfluenceStat (J.T.C.) and the University of Central Florida College of Medicine (J.T.C.) - both in Orlando
| | - Nathan Fountain
- From the Department of Neurology, University of Virginia, Charlottesville (J.K., N.F.); the Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., C.M.); the Division of Emergency Medicine, Children's National Medical Center, Washington, DC (J.M.C.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.B., R.S.); the College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis (J.C.); the Department of Neurology, University of California, San Francisco, San Francisco (D.L.); the Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, New York (S.S.); the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (R.C.); St. George's University of London and St. George's University Hospitals NHS Foundation Trust, London (H.C.); and ConfluenceStat (J.T.C.) and the University of Central Florida College of Medicine (J.T.C.) - both in Orlando
| | - Jason T Connor
- From the Department of Neurology, University of Virginia, Charlottesville (J.K., N.F.); the Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., C.M.); the Division of Emergency Medicine, Children's National Medical Center, Washington, DC (J.M.C.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.B., R.S.); the College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis (J.C.); the Department of Neurology, University of California, San Francisco, San Francisco (D.L.); the Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, New York (S.S.); the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (R.C.); St. George's University of London and St. George's University Hospitals NHS Foundation Trust, London (H.C.); and ConfluenceStat (J.T.C.) and the University of Central Florida College of Medicine (J.T.C.) - both in Orlando
| | - Robert Silbergleit
- From the Department of Neurology, University of Virginia, Charlottesville (J.K., N.F.); the Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., C.M.); the Division of Emergency Medicine, Children's National Medical Center, Washington, DC (J.M.C.); the Department of Emergency Medicine, University of Michigan, Ann Arbor (W.B., R.S.); the College of Pharmacy, Department of Experimental and Clinical Pharmacology, University of Minnesota, Minneapolis (J.C.); the Department of Neurology, University of California, San Francisco, San Francisco (D.L.); the Departments of Neurology and Pediatrics, Albert Einstein College of Medicine, Montefiore Medical Center, New York (S.S.); the National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (R.C.); St. George's University of London and St. George's University Hospitals NHS Foundation Trust, London (H.C.); and ConfluenceStat (J.T.C.) and the University of Central Florida College of Medicine (J.T.C.) - both in Orlando
| |
Collapse
|
20
|
Schultz A, Saville BR, Marsh JA, Snelling TL. An introduction to clinical trial design. Paediatr Respir Rev 2019; 32:30-35. [PMID: 31427159 DOI: 10.1016/j.prrv.2019.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 06/18/2019] [Indexed: 11/18/2022]
Abstract
Clinicians and other decision makers in healthcare use results from clinical trials to inform practice. Interpretation of clinical trial results can be challenging, as weaknesses in trial design, data collection, analysis or reporting, can compromise the usefulness of results. A good working knowledge of clinical trial design is essential to expertly interpret and determine the validity and generalizability of the results. This manuscript will give a brief overview of clinical trial design including the strengths and limitations of various approaches. The focus will be on confirmatory clinical trials.
Collapse
Affiliation(s)
- A Schultz
- Faculty of Health and Medical Sciences, University of Western Australia Medical School, Crawley, Australia; Department of Respiratory Medicine, Perth Children's Hospital, Nedlands, Australia; Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Australia.
| | - B R Saville
- Berry Consultants, Austin, USA; Vanderbilt University, Department of Biostatistics, Nashville, TN, USA
| | - J A Marsh
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Australia; School of Population & Global Health, University of Western Australia, Nedlands, Australia
| | - T L Snelling
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Australia; School of Public Health, Curtin University, Bentley, Australia; Department of Infectious Diseases, Perth Children's Hospital, Nedlands, Australia; Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia
| |
Collapse
|
21
|
Viele K, Broglio K, McGlothlin A, Saville BR. Comparison of methods for control allocation in multiple arm studies using response adaptive randomization. Clin Trials 2019; 17:52-60. [PMID: 31630567 DOI: 10.1177/1740774519877836] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND/AIMS Response adaptive randomization has many polarizing properties in two-arm settings comparing control to a single treatment. The generalization of these features to the multiple arm setting has been less explored, and existing comparisons in the literature reach disparate conclusions. We investigate several generalizations of two-arm response adaptive randomization methods relating to control allocation in multiple arm trials, exploring how critiques of response adaptive randomization generalize to the multiple arm setting. METHODS We perform a simulation study to investigate multiple control allocation schemes within response adaptive randomization, comparing the designs on metrics such as power, arm selection, mean square error, and the treatment of patients within the trial. RESULTS The results indicate that the generalization of two-arm response adaptive randomization concerns is variable and depends on the form of control allocation employed. The concerns are amplified when control allocation may be reduced over the course of the trial but are mitigated in the methods considered when control allocation is maintained or increased during the trial. In our chosen example, we find minimal advantage to increasing, as opposed to maintaining, control allocation; however, this result reflects an extremely limited exploration of methods for increasing control allocation. CONCLUSION Selection of control allocation in multiple arm response adaptive randomization has a large effect on the performance of the design. Some disparate comparisons of response adaptive randomization to alternative paradigms may be partially explained by these results. In future comparisons, control allocation for multiple arm response adaptive randomization should be chosen to keep in mind the appropriate match between control allocation in response adaptive randomization and the metric or metrics of interest.
Collapse
Affiliation(s)
| | | | | | - Benjamin R Saville
- Berry Consultants LLC, Austin, TX, USA.,Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| |
Collapse
|
22
|
Answering patient-centred questions efficiently: response-adaptive platform trials in primary care. Br J Gen Pract 2019; 68:294-295. [PMID: 29853596 DOI: 10.3399/bjgp18x696569] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
|
23
|
Bashiri FA, Hamad MH, Amer YS, Abouelkheir MM, Mohamed S, Kentab AY, Salih MA, Al Nasser MN, Al-Eyadhy AA, Al Othman MA, Al-Ahmadi T, Iqbal SM, Somily AM, Wahabi HA, Hundallah KJ, Alwadei AH, Albaradie RS, Al-Twaijri WA, Jan MM, Al-Otaibi F, Alnemri AM, Al-Ansary LA. Management of convulsive status epilepticus in children: an adapted clinical practice guideline for pediatricians in Saudi Arabia. ACTA ACUST UNITED AC 2019; 22:146-155. [PMID: 28416791 PMCID: PMC5726823 DOI: 10.17712/nsj.2017.2.20170093] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Objective: To increase the use of evidence-based approaches in the diagnosis, investigations and treatment of Convulsive Status Epilepticus (CSE) in children in relevant care settings. Method: A Clinical Practice Guideline (CPG) adaptation group was formulated at a university hospital in Riyadh. The group utilized 2 CPG validated tools including the ADAPTE method and the AGREE II instrument. Results: The group adapted 3 main categories of recommendations from one Source CPG. The recommendations cover; (i)first-line treatment of CSE in the community; (ii)treatment of CSE in the hospital; and (iii)refractory CSE. Implementation tools were built to enhance knowledge translation of these recommendations including a clinical algorithm, audit criteria, and a computerized provider order entry. Conclusion: A clinical practice guideline for the Saudi healthcare context was formulated using a guideline adaptation process to support relevant clinicians managing CSE in children.
Collapse
Affiliation(s)
- Fahad A Bashiri
- Department of Pediatrics, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Kingdom of Saudi Arabia. E-mail:
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Gajewski BJ, Statland J, Barohn R. Using Adaptive Designs to Avoid Selecting the Wrong Arms in Multiarm Comparative Effectiveness Trials. Stat Biopharm Res 2019; 11:375-386. [PMID: 31839873 DOI: 10.1080/19466315.2019.1610044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Limited resources are a challenge when planning comparative effectiveness studies of multiple promising treatments, often prompting study planners to reduce the sample size to meet the financial constraints. The practical solution is often to increase the efficiency of this sample size by selecting a pair of treatments among the pool of promising treatments before the clinical trial begins. The problem with this approach is that the investigator may inadvertently leave out the most beneficial treatment. This paper demonstrates a possible solution to this problem by using Bayesian adaptive designs. We use a planned comparative effectiveness clinical trial of treatments for sialorrhea in amyotrophic lateral sclerosis as an example of the approach. Rather than having to guess at the two best treatments to compare based on limited data, we suggest putting more arms in the trial and letting response adaptive randomization (RAR) determine better arms. To ground this study relative to previous literature we first compare RAR, adaptive equal randomization (ER), arm(s) dropping, and a fixed design. Given the goals of this trial we demonstrate that we may avoid 'type III errors' - inadvertently leaving out the best treatment - with little loss in power compared to a two-arm design, even when choosing the correct two arms for the two-armed design. There are appreciable gains in power when the two arms are prescreened at random.
Collapse
Affiliation(s)
- Byron J Gajewski
- Department of Biostatistics & Data Science, University of Kansas Medical Center, Mail Stop 1026, 3901 Rainbow Blvd., Kansas City, KS 66160, USA
| | - Jeffrey Statland
- Department of Neurology, University of Kansas Medical Center, Mail Stop 2012, 3901 Rainbow Blvd., Kansas City, KS 66160, USA
| | - Richard Barohn
- Department of Neurology, University of Kansas Medical Center, Mail Stop 2012, 3901 Rainbow Blvd., Kansas City, KS 66160, USA
| |
Collapse
|
25
|
Soul JS, Pressler R, Allen M, Boylan G, Rabe H, Portman R, Hardy P, Zohar S, Romero K, Tseng B, Bhatt-Mehta V, Hahn C, Denne S, Auvin S, Vinks A, Lantos J, Marlow N, Davis JM. Recommendations for the design of therapeutic trials for neonatal seizures. Pediatr Res 2019; 85:943-954. [PMID: 30584262 PMCID: PMC6760680 DOI: 10.1038/s41390-018-0242-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 10/04/2018] [Accepted: 10/17/2018] [Indexed: 12/01/2022]
Abstract
Although seizures have a higher incidence in neonates than any other age group and are associated with significant mortality and neurodevelopmental disability, treatment is largely guided by physician preference and tradition, due to a lack of data from well-designed clinical trials. There is increasing interest in conducting trials of novel drugs to treat neonatal seizures, but the unique characteristics of this disorder and patient population require special consideration with regard to trial design. The Critical Path Institute formed a global working group of experts and key stakeholders from academia, the pharmaceutical industry, regulatory agencies, neonatal nurse associations, and patient advocacy groups to develop consensus recommendations for design of clinical trials to treat neonatal seizures. The broad expertise and perspectives of this group were invaluable in developing recommendations addressing: (1) use of neonate-specific adaptive trial designs, (2) inclusion/exclusion criteria, (3) stratification and randomization, (4) statistical analysis, (5) safety monitoring, and (6) definitions of important outcomes. The guidelines are based on available literature and expert consensus, pharmacokinetic analyses, ethical considerations, and parental concerns. These recommendations will ultimately facilitate development of a Master Protocol and design of efficient and successful drug trials to improve the treatment and outcome for this highly vulnerable population.
Collapse
Affiliation(s)
- Janet S Soul
- Boston Children's Hospital & Harvard Medical School, Boston, MA, USA.
| | - Ronit Pressler
- UCL Great Ormond Street Institute of Child Health, London, UK
| | | | - Geraldine Boylan
- INFANT Research Centre & Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Heike Rabe
- Brighton and Sussex Medical School, Brighton, England
| | | | | | - Sarah Zohar
- INSERM, UMRS1138, University Paris V and University Paris VI, Paris, France
| | | | | | - Varsha Bhatt-Mehta
- C.S.Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Cecil Hahn
- Division of Neurology, The Hospital for Sick Children and Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Scott Denne
- Riley Children's Hospital, Indiana University, Indianapolis, Indiana, USA
| | - Stephane Auvin
- Pediatric Neurology Department & INSERM U1141, APHP, Robert Debré University Hospital, Paris, France
| | - Alexander Vinks
- College of Medicine & Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - John Lantos
- Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Neil Marlow
- UCL Institute for Women's Health, University College London, London, UK
| | - Jonathan M Davis
- The Floating Hospital for Children at Tufts Medical Center and the Tufts Clinical and Translational Science Institute, Boston, MA, USA
| |
Collapse
|
26
|
Silbergleit R, Elm JJ. Levetiracetam no better than phenytoin in children with convulsive status epilepticus. Lancet 2019; 393:2101-2102. [PMID: 31005387 DOI: 10.1016/s0140-6736(19)30896-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 04/09/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Robert Silbergleit
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI 48103, USA.
| | - Jordan J Elm
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| |
Collapse
|
27
|
Ryan EG, Bruce J, Metcalfe AJ, Stallard N, Lamb SE, Viele K, Young D, Gates S. Using Bayesian adaptive designs to improve phase III trials: a respiratory care example. BMC Med Res Methodol 2019; 19:99. [PMID: 31088354 PMCID: PMC6515675 DOI: 10.1186/s12874-019-0739-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 04/22/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Bayesian adaptive designs can improve the efficiency of trials, and lead to trials that can produce high quality evidence more quickly, with fewer patients and lower costs than traditional methods. The aim of this work was to determine how Bayesian adaptive designs can be constructed for phase III clinical trials in critical care, and to assess the influence that Bayesian designs would have on trial efficiency and study results. METHODS We re-designed the High Frequency OSCillation in Acute Respiratory distress syndrome (OSCAR) trial using Bayesian adaptive design methods, to allow for the possibility of early stopping for success or futility. We constructed several alternative designs and studied their operating characteristics via simulation. We then performed virtual re-executions by applying the Bayesian adaptive designs using the OSCAR data to demonstrate the practical applicability of the designs. RESULTS We constructed five alternative Bayesian adaptive designs and identified a preferred design based on the simulated operating characteristics, which had similar power to the original design but recruited fewer patients on average. The virtual re-executions showed the Bayesian sequential approach and original OSCAR trial yielded similar trial conclusions. However, using a Bayesian sequential design could have led to a reduced sample size and earlier completion of the trial. CONCLUSIONS Using the OSCAR trial as an example, this case study found that Bayesian adaptive designs can be constructed for phase III critical care trials. If the OSCAR trial had been run using one of the proposed Bayesian adaptive designs, it would have terminated at a smaller sample size with fewer deaths in the trial, whilst reaching the same conclusions. We recommend the wider use of Bayesian adaptive approaches in phase III clinical trials. TRIAL REGISTRATION OSCAR Trial registration ISRCTN, ISRCTN10416500 . Retrospectively registered 13 June 2007.
Collapse
Affiliation(s)
- Elizabeth G. Ryan
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Julie Bruce
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
| | - Andrew J. Metcalfe
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
- Department of Trauma and Orthopaedic Surgery, University Hospital Coventry & Warwick, Coventry, UK
| | - Nigel Stallard
- Statistics and Epidemiology, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Sarah E. Lamb
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
- Centre for Rehabilitation Research and Centre for Statistics in Medicine, Nuffield Department of Orthopaedics Rheumatology & Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | | | - Duncan Young
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Simon Gates
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| |
Collapse
|
28
|
Martina R, Houbiers J, Melis J, Till O. A combined proof of concept and dose finding study with multiple endpoints: A Bayesian adaptive design in chronic prostatitis/chronic pelvic pain syndrome. Biom J 2019; 61:476-487. [DOI: 10.1002/bimj.201700210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 05/24/2018] [Accepted: 07/06/2018] [Indexed: 11/08/2022]
Affiliation(s)
- Reynaldo Martina
- Department of BiostatisticsUniversity of Liverpool Liverpool UK
- Development, Astellas Leiden The Netherlands
| | | | - Joost Melis
- Development, Astellas Leiden The Netherlands
| | | |
Collapse
|
29
|
Jiang Y, Zhao W, Durkalski-Mauldin V. Time-trend impact on treatment estimation in two-arm clinical trials with a binary outcome and Bayesian response adaptive randomization. J Biopharm Stat 2019; 30:69-88. [PMID: 31017843 DOI: 10.1080/10543406.2019.1607368] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Clinical trial design and analysis often assume study population homogeneity, although patient baseline profile and standard of care may evolve over time, especially in trials with long recruitment periods. The time-trend phenomenon can affect the treatment estimation and the operating characteristics of trials with Bayesian response adaptive randomization (BRAR). The mechanism of time-trend impact on BRAR is increasingly being studied but some aspects remain unclear. The goal of this research is to quantify the bias in treatment effect estimation due to the use of BRAR in the presence of time-trend. In addition, simulations are conducted to compare the performance of three commonly used BRAR algorithms under different time-trend patterns with and without early stopping rules. The results demonstrate that using these BRAR methods in a two-arm trial with time-trend may cause type I error inflation and treatment effect estimation bias. The magnitude and direction of the bias are affected by the parameters of the BRAR algorithm and the time-trend pattern.
Collapse
Affiliation(s)
- Yunyun Jiang
- Department of Epidemiology and Biostatistics, George Washington University, Rockville, Maryland, USA
| | - Wenle Zhao
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Valerie Durkalski-Mauldin
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| |
Collapse
|
30
|
Research Note: Adaptive trials. J Physiother 2019; 65:113-116. [PMID: 30926398 DOI: 10.1016/j.jphys.2019.02.004] [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: 02/15/2019] [Accepted: 02/20/2019] [Indexed: 11/24/2022] Open
|
31
|
Schultz A, Marsh JA, Saville BR, Norman R, Middleton PG, Greville HW, Bellgard MI, Berry SM, Snelling T. Trial Refresh: A Case for an Adaptive Platform Trial for Pulmonary Exacerbations of Cystic Fibrosis. Front Pharmacol 2019; 10:301. [PMID: 30983998 PMCID: PMC6447696 DOI: 10.3389/fphar.2019.00301] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 03/11/2019] [Indexed: 12/21/2022] Open
Abstract
Cystic fibrosis is a genetic disease typically characterized by progressive lung damage and premature mortality. Pulmonary exacerbations, or flare-ups of the lung disease, often require hospitalization for intensive treatment. Approximately 25% of patients with cystic fibrosis do not recover their baseline lung function after pulmonary exacerbations. There is a relative paucity of evidence to inform treatment strategies for exacerbations. Compounding this lack of evidence, there are a large number of treatment options already as well as becoming available. This results in significant variability between medication regimens prescribed by different physicians, treatment centers and regions with potentially adverse impact to patients. The conventional strategy is to undertake essential randomized clinical trials to inform treatment decisions and improve outcomes for patients with exacerbations. However, over the past several decades, clinical trials have generally failed to provide information critical to improved treatment and management of exacerbations. Bayesian adaptive platform trials hold the promise of addressing clinical uncertainties and informing treatment. Using modeling and response adaptive randomization, they allow for the evaluation of multiple treatments across different management domains, and progressive improvement in patient outcomes throughout the course of the trial. Bayesian adaptive platform trials require substantial amounts of preparation. Basic preparation includes extensive stakeholder involvement including elicitation of consumer preferences and clinician understanding of the research topic, defining the research questions, determining the best outcome measures, delineating study sub-groups, in depth statistical modeling, designing end-to-end digital solutions seamlessly supporting clinicians, researchers and patients, constructing randomisation algorithms and importantly, defining pre-determined intra-study end-points. This review will discuss the motivation and necessary steps required to embark on a Bayesian adaptive platform trial to optimize medication regimens for the treatment of pulmonary exacerbations of cystic fibrosis.
Collapse
Affiliation(s)
- Andre Schultz
- Faculty of Health and Medical Sciences, The University of Western Australia, Crawley, WA, Australia.,Department of Respiratory Medicine, Perth Children's Hospital, Nedlands, WA, Australia.,Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, The University of Western Australia, Nedlands, WA, Australia
| | - Julie A Marsh
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, The University of Western Australia, Nedlands, WA, Australia.,School of Population and Global Health, The University of Western Australia, Nedlands, WA, Australia
| | - Benjamin R Saville
- Berry Consultants, Austin, TX, United States.,Department of Biostatistics, Vanderbilt University, Nashville, TN, United States
| | - Richard Norman
- School of Public Health, Curtin University, Bentley, WA, Australia
| | - Peter G Middleton
- Ludwig Engel Centre for Respiratory Research, Westmead Institute for Medical Research, Sydney, NSW, Australia
| | - Hugh W Greville
- Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Matthew I Bellgard
- eResearch Office, Queensland University of Technology, Brisbane, QLD, Australia
| | | | - Tom Snelling
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, The University of Western Australia, Nedlands, WA, Australia.,School of Public Health, Curtin University, Bentley, WA, Australia.,Department of Infectious Diseases, Perth Children's Hospital, Nedlands, WA, Australia.,Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| |
Collapse
|
32
|
Harris CD, Rowe EG, Randeniya R, Garrido MI. Bayesian Model Selection Maps for Group Studies Using M/EEG Data. Front Neurosci 2018; 12:598. [PMID: 30356864 PMCID: PMC6190865 DOI: 10.3389/fnins.2018.00598] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 08/08/2018] [Indexed: 11/24/2022] Open
Abstract
Predictive coding postulates that we make (top-down) predictions about the world and that we continuously compare incoming (bottom-up) sensory information with these predictions, in order to update our models and perception so as to better reflect reality. That is, our so-called "Bayesian brains" continuously create and update generative models of the world, inferring (hidden) causes from (sensory) consequences. Neuroimaging datasets enable the detailed investigation of such modeling and updating processes, and these datasets can themselves be analyzed with Bayesian approaches. These offer methodological advantages over classical statistics. Specifically, any number of models can be compared, the models need not be nested, and the "null model" can be accepted (rather than only failing to be rejected as in frequentist inference). This methodological paper explains how to construct posterior probability maps (PPMs) for Bayesian Model Selection (BMS) at the group level using electroencephalography (EEG) or magnetoencephalography (MEG) data. The method has only recently been used for EEG data, after originally being developed and applied in the context of functional magnetic resonance imaging (fMRI) analysis. Here, we describe how this method can be adapted for EEG using the Statistical Parametric Mapping (SPM) software package for MATLAB. The method enables the comparison of an arbitrary number of hypotheses (or explanations for observed responses), at each and every voxel in the brain (source level) and/or in the scalp-time volume (scalp level), both within participants and at the group level. The method is illustrated here using mismatch negativity (MMN) data from a group of participants performing an audio-spatial oddball attention task. All data and code are provided in keeping with the Open Science movement. In doing so, we hope to enable others in the field of M/EEG to implement our methods so as to address their own questions of interest.
Collapse
Affiliation(s)
- Clare D. Harris
- Computational Cognitive Neuroscience Laboratory, Queensland Brain Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Elise G. Rowe
- Monash Neuroscience of Consciousness Laboratory, School of Psychological Sciences, Faculty of Medicine Nursing and Health Science, Monash University, Melbourne, VIC, Australia
| | - Roshini Randeniya
- Computational Cognitive Neuroscience Laboratory, Queensland Brain Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Marta I. Garrido
- Computational Cognitive Neuroscience Laboratory, Queensland Brain Institute, The University of Queensland, Brisbane, QLD, Australia
- School of Mathematics and Physics, The University of Queensland, Brisbane, QLD, Australia
- Australian Research Council Centre of Excellence for Integrative Brain Function, Monash University, Melbourne, VIC, Australia
- Centre for Advanced Imaging, The University of Queensland, Brisbane, QLD, Australia
| |
Collapse
|
33
|
Jung SY, Lee SH, Lee SY, Yang S, Noh H, Chung EK, Lee JI. Antimicrobials for the treatment of drug-resistant Acinetobacter baumannii pneumonia in critically ill patients: a systemic review and Bayesian network meta-analysis. Crit Care 2017; 21:319. [PMID: 29262831 PMCID: PMC5738897 DOI: 10.1186/s13054-017-1916-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 12/04/2017] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND An optimal therapy for the treatment of pneumonia caused by drug-resistant Acinetobacter baumannii remains unclear. This study aims to compare various antimicrobial strategies and to determine the most effective therapy for pneumonia using a network meta-analysis. METHODS Systematic search and quality assessment were performed to select eligible studies reporting one of the following outcomes: all-cause mortality, clinical cure, and microbiological eradication. The primary outcome was all-cause mortality. A network meta-analysis was conducted with a Bayesian approach. Antimicrobial treatments were ranked based on surface under the cumulative ranking curve (SUCRA) value along with estimated median outcome rate and corresponding 95% credible intervals (CrIs). Two treatments were considered significantly different if a posterior probability of superiority (P) was greater than 97.5%. RESULTS Twenty-three studies evaluating 15 antimicrobial treatments were included. Intravenous colistin monotherapy (IV COL) was selected as a common comparator, serving as a bridge for developing the network. Five treatments ranked higher than IV COL (SUCRA, 57.1%; median all-cause mortality 0.45, 95% CrI 0.41-0.48) for reducing all-cause mortality: sulbactam monotherapy (SUL, 100.0%; 0.18, 0.04-0.42), high-dose SUL (HD SUL, 85.7%; 0.31, 0.07-0.71), fosfomycin plus IV COL (FOS + IV COL, 78.6%; 0.34, 0.19-0.54), inhaled COL plus IV COL (IH COL + IV COL, 71.4%; 0.39, 0.32-0.46), and high-dose tigecycline (HD TIG, 71.4%; 0.39, 0.16-0.67). Those five treatments also ranked higher than IV COL (SUCRA, 45.5%) for improving clinical cure (72.7%, 72.7%, 63.6%, 81.8%, and 90.9%, respectively). Among the five treatments, SUL (P = 98.1%) and IH COL + IV COL (P = 99.9%) were significantly superior to IV COL for patient survival and clinical cure, respectively. In terms of microbiological eradication, FOS + IV COL (P = 99.8%) and SUL (P = 98.9%) were significantly superior to IV COL. CONCLUSIONS This Bayesian network meta-analysis demonstrated the comparative effectiveness of fifteen antimicrobial treatments for drug-resistant A. baumannii pneumonia in critically ill patients. For survival benefit, SUL appears to be the best treatment followed by HD SUL, FOS + IV COL, IH COL + IV COL, HD TIG, and IV COL therapy, in numerical order.
Collapse
Affiliation(s)
- Su Young Jung
- Department of Pharmacy, College of Pharmacy, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 08826 Republic of Korea
- Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | - Seung Hee Lee
- Department of Pharmacy, College of Pharmacy, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 08826 Republic of Korea
| | - Soo Young Lee
- Department of Pharmacy, College of Pharmacy, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447 Republic of Korea
- Department of Public Health Science, Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea
| | - Seungwon Yang
- Department of Pharmacy, College of Pharmacy, Yonsei University, Incheon, Republic of Korea
| | - Hayeon Noh
- Department of Pharmacy, College of Pharmacy, Yonsei University, Incheon, Republic of Korea
| | - Eun Kyoung Chung
- Department of Pharmacy, College of Pharmacy, Kyung Hee University, 26 Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447 Republic of Korea
| | - Jangik I. Lee
- Department of Pharmacy, College of Pharmacy, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 08826 Republic of Korea
- Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| |
Collapse
|
34
|
Guetterman TC, Fetters MD, Mawocha S, Legocki LJ, Barsan WG, Lewis RJ, Berry DA, Meurer WJ. The life cycles of six multi-center adaptive clinical trials focused on neurological emergencies developed for the Advancing Regulatory Science initiative of the National Institutes of Health and US Food and Drug Administration: Case studies from the Adaptive Designs Accelerating Promising Treatments Into Trials Project. SAGE Open Med 2017; 5:2050312117736228. [PMID: 29085638 PMCID: PMC5648086 DOI: 10.1177/2050312117736228] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 09/18/2017] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Clinical trials are complicated, expensive, time-consuming, and frequently do not lead to discoveries that improve the health of patients with disease. Adaptive clinical trials have emerged as a methodology to provide more flexibility in design elements to better answer scientific questions regarding whether new treatments are efficacious. Limited observational data exist that describe the complex process of designing adaptive clinical trials. To address these issues, the Adaptive Designs Accelerating Promising Treatments Into Trials project developed six, tailored, flexible, adaptive, phase-III clinical trials for neurological emergencies, and investigators prospectively monitored and observed the processes. The objective of this work is to describe the adaptive design development process, the final design, and the current status of the adaptive trial designs that were developed. METHODS To observe and reflect upon the trial development process, we employed a rich, mixed methods evaluation that combined quantitative data from visual analog scale to assess attitudes about adaptive trials, along with in-depth qualitative data about the development process gathered from observations. RESULTS The Adaptive Designs Accelerating Promising Treatments Into Trials team developed six adaptive clinical trial designs. Across the six designs, 53 attitude surveys were completed at baseline and after the trial planning process completed. Compared to baseline, the participants believed significantly more strongly that the adaptive designs would be accepted by National Institutes of Health review panels and non-researcher clinicians. In addition, after the trial planning process, the participants more strongly believed that the adaptive design would meet the scientific and medical goals of the studies. CONCLUSION Introducing the adaptive design at early conceptualization proved critical to successful adoption and implementation of that trial. Involving key stakeholders from several scientific domains early in the process appears to be associated with improved attitudes towards adaptive designs over the life cycle of clinical trial development.
Collapse
Affiliation(s)
| | - Michael D Fetters
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Samkeliso Mawocha
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Laurie J Legocki
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | - William G Barsan
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Roger J Lewis
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles, CA, USA
| | - Donald A Berry
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William J Meurer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
35
|
Bayesian dose selection design for a binary outcome using restricted response adaptive randomization. Trials 2017; 18:420. [PMID: 28886745 PMCID: PMC5591573 DOI: 10.1186/s13063-017-2004-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 05/19/2017] [Indexed: 11/25/2022] Open
Abstract
Background In phase II trials, the most efficacious dose is usually not known. Moreover, given limited resources, it is difficult to robustly identify a dose while also testing for a signal of efficacy that would support a phase III trial. Recent designs have sought to be more efficient by exploring multiple doses through the use of adaptive strategies. However, the added flexibility may potentially increase the risk of making incorrect assumptions and reduce the total amount of information available across the dose range as a function of imbalanced sample size. Methods To balance these challenges, a novel placebo-controlled design is presented in which a restricted Bayesian response adaptive randomization (RAR) is used to allocate a majority of subjects to the optimal dose of active drug, defined as the dose with the lowest probability of poor outcome. However, the allocation between subjects who receive active drug or placebo is held constant to retain the maximum possible power for a hypothesis test of overall efficacy comparing the optimal dose to placebo. The design properties and optimization of the design are presented in the context of a phase II trial for subarachnoid hemorrhage. Results For a fixed total sample size, a trade-off exists between the ability to select the optimal dose and the probability of rejecting the null hypothesis. This relationship is modified by the allocation ratio between active and control subjects, the choice of RAR algorithm, and the number of subjects allocated to an initial fixed allocation period. While a responsive RAR algorithm improves the ability to select the correct dose, there is an increased risk of assigning more subjects to a worse arm as a function of ephemeral trends in the data. A subarachnoid treatment trial is used to illustrate how this design can be customized for specific objectives and available data. Conclusions Bayesian adaptive designs are a flexible approach to addressing multiple questions surrounding the optimal dose for treatment efficacy within the context of limited resources. While the design is general enough to apply to many situations, future work is needed to address interim analyses and the incorporation of models for dose response.
Collapse
|
36
|
Jiang Y, Zhao W, Durkalski-Mauldin V. Impact of adaptation algorithm, timing, and stopping boundaries on the performance of Bayesian response adaptive randomization in confirmative trials with a binary endpoint. Contemp Clin Trials 2017; 62:114-120. [PMID: 28866294 DOI: 10.1016/j.cct.2017.08.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 07/19/2017] [Accepted: 08/29/2017] [Indexed: 11/15/2022]
Abstract
Despite the concerns of time trend in subject profiles, the use of Bayesian response adaptive randomization (BRAR) in large multicenter phase 3 confirmative trials has been reported in recent years, motivated by the potential benefits in subject ethics and/or trial efficiency. However three issues remain unclear to investigators: 1) among several BRAR algorithms, how to choose one for the specific trial setting; 2) when to start and how frequently to update the allocation ratio; and 3) how to choose the interim analyses stopping boundaries to preserve the type 1 error. In this paper, three commonly used BRAR algorithms are evaluated based on type 1 error, power, sample size, the proportion of subjects assigned to the better performing arm, and the total number of failures, under two specific trial settings and different allocation ratio update timing and frequencies. Simulation studies show that for two-arm superiority trials, none of the three BRAR algorithms has predominant benefits in both patient ethics and trial efficiency when compared to fixed equal allocation design. For a specific trial aiming to identify the best or the worst among three treatments, a properly selected BRAR algorithm and its implementation parameters are able to gain ethical and efficiency benefits simultaneously. Although the simulation results come from a specific trial setting, the methods described in this paper are generally applicable to other trials.
Collapse
Affiliation(s)
- Yunyun Jiang
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA.
| | - Wenle Zhao
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | | |
Collapse
|
37
|
Chappell R, Durkalski V, Joffe S. University of Pennsylvania ninth annual conference on statistical issues in clinical trials: Where are we with adaptive clinical trial designs? (morning panel discussion). Clin Trials 2017; 14:441-450. [PMID: 28825324 DOI: 10.1177/1740774517723590] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
38
|
Faseru B, Ellerbeck EF, Catley D, Gajewski BJ, Scheuermann TS, Shireman TI, Mussulman LM, Nazir N, Bush T, Richter KP. Changing the default for tobacco-cessation treatment in an inpatient setting: study protocol of a randomized controlled trial. Trials 2017; 18:379. [PMID: 28806908 PMCID: PMC5556365 DOI: 10.1186/s13063-017-2119-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 07/26/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Most health care providers do not treat tobacco dependence routinely. This may in part be due to the treatment "default." Current treatment guidelines recommend that providers (1) ask patients if they are willing to quit and (2) provide cessation-focused medications and counseling only to smokers who state that they are willing to quit. The default is that patients have to "opt in" to receive cessation assistance: providers ask smokers if they are willing to quit, and only offer medications and cessation support to those who say "yes." This drastically limits the reach of cessation services because, at any given encounter, only one in three smokers say that they are ready to quit. The objective of this study is to determine the impact of providing all smokers with tobacco-cessation treatment unless they refuse it (OPT OUT) versus current practice-screening for readiness and only offering treatment to smokers who say they are ready to quit (OPT IN). METHODS This individually randomized clinical trial is conducted in a tertiary-care hospital. We will conduct the trial among up to 1000 randomly selected hospitalized smokers to determine the population impact of changing the treatment default, identify mediators of outcome, and determine the cost-effectiveness of this new, highly proactive approach. This is a population-based study that targets an endpoint of vital interest; applies minimal eligibility criteria to broaden generalizability; and utilizes hospital staff for interventions to ensure long-term sustainability. The study employs delayed consent and an innovative Bayesian adaptive design to evaluate a major shift in our approach to care. If effective, this change would expand the reach of tobacco-cessation treatment from 30% to 100% of smokers. DISCUSSION Regardless of outcome, the trial will provide a model of how to alter and evaluate the impact of health care defaults. If OPT OUT proves to be more effective, it will expand the population eligible for cessation treatment by over 300%. It will also simplify the tobacco-cessation treatment algorithm, and relieve busy health care providers of the burden of evaluating readiness to quit. TRIAL REGISTRATION Clinical Trials Registration, ID: NCT02721082 . Registered on 22 March 2016.
Collapse
Affiliation(s)
- Babalola Faseru
- Department of Preventive Medicine and Public Health, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA. .,University of Kansas Cancer Center, 3901 Rainbow Boulevard, Kansas City, KS, USA.
| | - Edward F Ellerbeck
- Department of Preventive Medicine and Public Health, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA.,University of Kansas Cancer Center, 3901 Rainbow Boulevard, Kansas City, KS, USA
| | - Delwyn Catley
- Children's Mercy Hospitals and Clinics, Center for Children's Healthy Lifestyles and Nutrition, Kansas City, MO, USA
| | - Byron J Gajewski
- Department of Preventive Medicine and Public Health, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA.,University of Kansas Cancer Center, 3901 Rainbow Boulevard, Kansas City, KS, USA
| | - Taneisha S Scheuermann
- Department of Preventive Medicine and Public Health, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA.,University of Kansas Cancer Center, 3901 Rainbow Boulevard, Kansas City, KS, USA
| | | | - Laura M Mussulman
- Department of Preventive Medicine and Public Health, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA.,University of Kansas Cancer Center, 3901 Rainbow Boulevard, Kansas City, KS, USA
| | - Niaman Nazir
- Department of Preventive Medicine and Public Health, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA.,University of Kansas Cancer Center, 3901 Rainbow Boulevard, Kansas City, KS, USA
| | | | - Kimber P Richter
- Department of Preventive Medicine and Public Health, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA.,University of Kansas Cancer Center, 3901 Rainbow Boulevard, Kansas City, KS, USA
| |
Collapse
|
39
|
Goldenholz DM, Goldenholz SR, Moss R, French J, Lowenstein D, Kuzniecky R, Haut S, Cristofaro S, Detyniecki K, Hixson J, Karoly P, Cook M, Strashny A, Theodore WH, Pieper C. Does accounting for seizure frequency variability increase clinical trial power? Epilepsy Res 2017; 137:145-151. [PMID: 28781216 DOI: 10.1016/j.eplepsyres.2017.07.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 06/28/2017] [Accepted: 07/21/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Seizure frequency variability is associated with placebo responses in randomized controlled trials (RCT). Increased variability can result in drug misclassification and, hence, decreased statistical power. We investigated a new method that directly incorporated variability into RCT analysis, ZV. METHODS Two models were assessed: the traditional 50%-responder rate (RR50), and the variability-corrected score, ZV. Each predicted seizure frequency upper and lower limits using prior seizures. Accuracy was defined as percentage of time-intervals when the observed seizure frequencies were within the predicted limits. First, we tested the ZV method on three datasets (SeizureTracker: n=3016, Human Epilepsy Project: n=107, and NeuroVista: n=15). An additional independent SeizureTracker validation dataset was used to generate a set of 200 simulated trials each for 5 different sample sizes (total N=100 to 500 by 100), assuming 20% dropout and 30% drug efficacy. "Power" was determined as the percentage of trials successfully distinguishing placebo from drug (p<0.05). RESULTS Prediction accuracy across datasets was, ZV: 91-100%, RR50: 42-80%. Simulated RCT ZV analysis achieved >90% power at N=100 per arm while RR50 required N=200 per arm. SIGNIFICANCE ZV may increase the statistical power of an RCT relative to the traditional RR50.
Collapse
Affiliation(s)
- Daniel M Goldenholz
- Clinical Epilepsy Section, NINDS, NIH, United States; Division of Epilepsy, Beth Israel Deaconess Medical Center.
| | | | | | | | | | | | - Sheryl Haut
- Department of Neurology, Montefiore Medical Center/Albert Einstein College of Medicine, United States.
| | | | | | - John Hixson
- Department of Neurology, UCSF, United States.
| | | | | | - Alex Strashny
- Department of Neurology, Centers for Disease Control, United States.
| | | | - Carl Pieper
- Duke University Medical Center, Dept. of Biostatistics and Bioinformatics, United States.
| |
Collapse
|
40
|
Saville BR, Berry SM. Balanced covariates with response adaptive randomization. Pharm Stat 2017; 16:210-217. [DOI: 10.1002/pst.1803] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 01/23/2017] [Accepted: 01/31/2017] [Indexed: 11/10/2022]
Affiliation(s)
- Benjamin R. Saville
- Berry Consultants; Austin TX 78746 USA
- Adjunct Faculty, Department of Biostatistics; Vanderbilt University School of Medicine; Nashville TN 37232 USA
| | - Scott M. Berry
- Berry Consultants; Austin TX 78746 USA
- Adjunct Faculty, Department of Biostatistics; University of Kansas Medical Center; Kansas City KS 66160 USA
| |
Collapse
|
41
|
Mawocha SC, Fetters MD, Legocki LJ, Guetterman TC, Frederiksen S, Barsan WG, Lewis RJ, Berry DA, Meurer WJ. A conceptual model for the development process of confirmatory adaptive clinical trials within an emergency research network. Clin Trials 2017; 14:246-254. [PMID: 28135827 DOI: 10.1177/1740774516688900] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Adaptive clinical trials use accumulating data from enrolled subjects to alter trial conduct in pre-specified ways based on quantitative decision rules. In this research, we sought to characterize the perspectives of key stakeholders during the development process of confirmatory-phase adaptive clinical trials within an emergency clinical trials network and to build a model to guide future development of adaptive clinical trials. METHODS We used an ethnographic, qualitative approach to evaluate key stakeholders' views about the adaptive clinical trial development process. Stakeholders participated in a series of multidisciplinary meetings during the development of five adaptive clinical trials and completed a Strengths-Weaknesses-Opportunities-Threats questionnaire. In the analysis, we elucidated overarching themes across the stakeholders' responses to develop a conceptual model. RESULTS Four major overarching themes emerged during the analysis of stakeholders' responses to questioning: the perceived statistical complexity of adaptive clinical trials and the roles of collaboration, communication, and time during the development process. Frequent and open communication and collaboration were viewed by stakeholders as critical during the development process, as were the careful management of time and logistical issues related to the complexity of planning adaptive clinical trials. CONCLUSION The Adaptive Design Development Model illustrates how statistical complexity, time, communication, and collaboration are moderating factors in the adaptive design development process. The intensity and iterative nature of this process underscores the need for funding mechanisms for the development of novel trial proposals in academic settings.
Collapse
Affiliation(s)
- Samkeliso C Mawocha
- 1 Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Michael D Fetters
- 2 Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Laurie J Legocki
- 2 Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Shirley Frederiksen
- 1 Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - William G Barsan
- 1 Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Roger J Lewis
- 3 Department of Emergency Medicine, Los Angeles Biomedical Research Institute, David Geffen School of Medicine at UCLA, Harbor-UCLA Medical Center, Torrance, CA, USA.,4 Berry Consultants, Austin, TX, USA
| | | | - William J Meurer
- 1 Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA.,5 Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
42
|
Chamberlain DB, Chamberlain JM. Making Sense of a Negative Clinical Trial Result: A Bayesian Analysis of a Clinical Trial of Lorazepam and Diazepam for Pediatric Status Epilepticus. Ann Emerg Med 2017; 69:117-124. [DOI: 10.1016/j.annemergmed.2016.08.449] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 06/28/2016] [Accepted: 08/15/2016] [Indexed: 10/20/2022]
|
43
|
Cellamare M, Ventz S, Baudin E, Mitnick CD, Trippa L. A Bayesian response-adaptive trial in tuberculosis: The endTB trial. Clin Trials 2016; 14:17-28. [PMID: 27559021 DOI: 10.1177/1740774516665090] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE To evaluate the use of Bayesian adaptive randomization for clinical trials of new treatments for multidrug-resistant tuberculosis. METHODS We built a response-adaptive randomization procedure, adapting on two preliminary outcomes for tuberculosis patients in a trial with five experimental regimens and a control arm. The primary study outcome is treatment success after 73 weeks from randomization; preliminary responses are culture conversion at 8 weeks and treatment success at 39 weeks. We compared the adaptive randomization design with balanced randomization using hypothetical scenarios. RESULTS When we compare the statistical power under adaptive randomization and non-adaptive designs, under several hypothetical scenarios we observe that adaptive randomization requires fewer patients than non-adaptive designs. Moreover, adaptive randomization consistently allocates more participants to effective arm(s). We also show that these advantages are limited to scenarios consistent with the assumptions used to develop the adaptive randomization algorithm. CONCLUSION Given the objective of evaluating several new therapeutic regimens in a timely fashion, Bayesian response-adaptive designs are attractive for tuberculosis trials. This approach tends to increase allocation to the effective regimens.
Collapse
Affiliation(s)
- Matteo Cellamare
- 1 Department of Biostatistics, Dana-Farber Cancer Institute and Harvard T.H. Chan School of Public Health, Boston, MA, USA.,2 Department of Statistical Sciences, Sapienza University of Rome, Rome, Italy
| | - Steffen Ventz
- 1 Department of Biostatistics, Dana-Farber Cancer Institute and Harvard T.H. Chan School of Public Health, Boston, MA, USA.,3 Department of Computer Science and Statistics, The University of Rhode Island, Kingston, RI, USA
| | | | - Carole D Mitnick
- 5 Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA.,6 Partners In Health, Boston, MA, USA
| | - Lorenzo Trippa
- 1 Department of Biostatistics, Dana-Farber Cancer Institute and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| |
Collapse
|
44
|
Meurer WJ, Legocki L, Mawocha S, Frederiksen SM, Guetterman TC, Barsan W, Lewis R, Berry D, Fetters M. Attitudes and opinions regarding confirmatory adaptive clinical trials: a mixed methods analysis from the Adaptive Designs Accelerating Promising Trials into Treatments (ADAPT-IT) project. Trials 2016; 17:373. [PMID: 27473126 PMCID: PMC4966769 DOI: 10.1186/s13063-016-1493-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 07/07/2016] [Indexed: 12/03/2022] Open
Abstract
Background Adaptive designs have been increasingly used in the pharmaceutical and device industries, but adoption within the academic setting has been less widespread — particularly for confirmatory phase trials. We sought to understand perceptions about understanding, acceptability, and scientific validity of adaptive clinical trials (ACTs). Methods We used a convergent mixed methods design using survey and mini-focus group data collection procedures to elucidate attitudes and opinions among “trial community” stakeholders regarding understanding, acceptability, efficiency, scientific validity, and speed of discovery with adaptive designs. Data were collected about various aspects of ACTs using self-administered surveys (paper or Web-based) with visual analog scales (VASs) with free text responses and with mini-focus groups of key stakeholders. Participants were recruited as part of an ongoing NIH/FDA-funded research project exploring the incorporation of ACTs into an existing NIH network that focuses on confirmatory phase clinical trials in neurological emergencies. “Trial community” representatives, namely, clinical investigators, biostatisticians, NIH officials, and FDA scientists involved in the planning of four clinical trials, were eligible to participate. In addition, recent and current members of a clinical trial-oriented NIH study section were also eligible. Results A total of 76 stakeholders completed the survey (out of 91 who were offered it, response rate 84 %). While the VAS attitudinal data showed substantial variability across respondents about acceptability and understanding of ACTs by various constituencies, respondents perceived clinicians to be less likely to understand ACTs and that ACTs probably would increase the efficiency of discovery. Textual and focus group responses emerged into several themes that enhanced understanding of VAS attitudinal data including the following: acceptability of adaptive designs depends on constituency and situation; there is variable understanding of ACTs (limited among clinicians, perceived to be higher at FDA); views about the potential for efficiency depend on the situation and implementation. Participants also frequently mentioned a need for greater education within the academic community. Finally, the empiric, non-quantitative selection of treatments for phase III trials based on limited phase II trials was highlighted as an opportunity for improvement and a potential explanation for the high number of neutral confirmatory trials. Conclusions These data show considerable variations in attitudes and beliefs about ACTs among trial community representatives. For adaptive trials to be fully considered when appropriate and for the research enterprise to realize the full potential of adaptive designs will likely require extensive experience and trust building within the trial community. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1493-z) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- William J Meurer
- Department of Emergency Medicine, University of Michigan, TC B1-354 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA. .,Department of Neurology, University of Michigan, TC B1-354 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Laurie Legocki
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Samkeliso Mawocha
- Department of Emergency Medicine, University of Michigan, TC B1-354 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Shirley M Frederiksen
- Department of Emergency Medicine, University of Michigan, TC B1-354 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Timothy C Guetterman
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | - William Barsan
- Department of Emergency Medicine, University of Michigan, TC B1-354 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Roger Lewis
- Harbor-UCLA Medical Center, Torrance, CA, 90502, USA
| | - Donald Berry
- University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Michael Fetters
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| |
Collapse
|
45
|
Dodd LE, Lantos JD, Pinheiro J. University of Pennsylvania 8th annual conference on statistical issues in clinical trials: Pragmatic clinical trials (morning panel). Clin Trials 2016; 13:493-503. [PMID: 27430711 DOI: 10.1177/1740774516657547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
46
|
Gajewski BJ, Berry SM, Barsan WG, Silbergleit R, Meurer WJ, Martin R, Rockswold GL. Hyperbaric oxygen brain injury treatment (HOBIT) trial: a multifactor design with response adaptive randomization and longitudinal modeling. Pharm Stat 2016; 15:396-404. [PMID: 27306921 DOI: 10.1002/pst.1755] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 04/26/2016] [Accepted: 05/05/2016] [Indexed: 11/10/2022]
Abstract
The goals of phase II clinical trials are to gain important information about the performance of novel treatments and decide whether to conduct a larger phase III trial. This can be complicated in cases when the phase II trial objective is to identify a novel treatment having several factors. Such multifactor treatment scenarios can be explored using fixed sample size trials. However, the alternative design could be response adaptive randomization with interim analyses and additionally, longitudinal modeling whereby more data could be used in the estimation process. This combined approach allows a quicker and more responsive adaptation to early estimates of later endpoints. Such alternative clinical trial designs are potentially more powerful, faster, and smaller than fixed randomized designs. Such designs are particularly challenging, however, because phase II trials tend to be smaller than subsequent confirmatory phase III trials. The phase II trial may need to explore a large number of treatment variations to ensure that the efficacy of optimal clinical conditions is not overlooked. Adaptive trial designs need to be carefully evaluated to understand how they will perform and to take full advantage of their potential benefits. This manuscript discusses a Bayesian response adaptive randomization design with a longitudinal model that uses a multifactor approach for predicting phase III study success via the phase II data. The approach is based on an actual clinical trial design for the hyperbaric oxygen brain injury treatment trial. Specific details of the thought process and the models informing the trial design are provided. Copyright © 2016 John Wiley & Sons, Ltd.
Collapse
Affiliation(s)
- Byron J Gajewski
- Department of Biostatistics, University of Kansas Medical Center, Kansas City, KS, USA.
| | - Scott M Berry
- Department of Biostatistics, University of Kansas Medical Center, Kansas City, KS, USA.,Berry Consultants, Austin, TX, USA
| | - William G Barsan
- Department of Emergency Medicine, University of Michigan, Ann ArborMI, USA
| | - Robert Silbergleit
- Department of Emergency Medicine, University of Michigan, Ann ArborMI, USA
| | - William J Meurer
- Department of Emergency Medicine, University of Michigan, Ann ArborMI, USA.,Department of Neurology and Stroke Program, University of Michigan, and Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan, Ann Arbor, MI, USA
| | - Renee Martin
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Gaylan L Rockswold
- Hennepin County Medical Center, Minneapolis, MN, USA.,Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| |
Collapse
|
47
|
A Bayesian adaptive phase 1 design to determine the optimal dose and schedule of an adoptive T-cell therapy in a mixed patient population. Contemp Clin Trials 2016; 48:153-65. [DOI: 10.1016/j.cct.2016.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 03/05/2016] [Accepted: 04/05/2016] [Indexed: 11/19/2022]
|
48
|
Popławska M, Borowicz KK, Czuczwar SJ. The safety and efficacy of fosphenytoin for the treatment of status epilepticus. Expert Rev Neurother 2015; 15:983-92. [DOI: 10.1586/14737175.2015.1074523] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
49
|
Zhao W. Mass weighted urn design--A new randomization algorithm for unequal allocations. Contemp Clin Trials 2015; 43:209-16. [PMID: 26091947 DOI: 10.1016/j.cct.2015.06.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 06/08/2015] [Accepted: 06/13/2015] [Indexed: 11/25/2022]
Abstract
Unequal allocations have been used in clinical trials motivated by ethical, efficiency, or feasibility concerns. Commonly used permuted block randomization faces a tradeoff between effective imbalance control with a small block size and accurate allocation target with a large block size. Few other unequal allocation randomization designs have been proposed in literature with applications in real trials hardly ever been reported, partly due to their complexity in implementation compared to the permuted block randomization. Proposed in this paper is the mass weighted urn design, in which the number of balls in the urn equals to the number of treatments, and remains unchanged during the study. The chance a ball being randomly selected is proportional to the mass of the ball. After each treatment assignment, a part of the mass of the selected ball is re-distributed to all balls based on the target allocation ratio. This design allows any desired optimal unequal allocations be accurately targeted without approximation, and provides a consistent imbalance control throughout the allocation sequence. The statistical properties of this new design is evaluated with the Euclidean distance between the observed treatment distribution and the desired treatment distribution as the treatment imbalance measure; and the Euclidean distance between the conditional allocation probability and the target allocation probability as the allocation predictability measure. Computer simulation results are presented comparing the mass weighted urn design with other randomization designs currently available for unequal allocations.
Collapse
Affiliation(s)
- Wenle Zhao
- Department of Public Health Sciences, Medical University of South Carolina, 135 Cannon Street, Suite 305H, Charleston, SC 29425, USA.
| |
Collapse
|
50
|
Goldstein JN, Fu R. Exception from informed consent: ethics and logistics. Acad Emerg Med 2015; 22:365-6. [PMID: 25716576 DOI: 10.1111/acem.12618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | - Rongwei Fu
- Academic Emergency Medicine; Oregon Health & Science University; Portland OR
| |
Collapse
|