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Li W, Goodman JE, Long C. Population attributable fraction of gas cooking and childhood asthma: What was missed? GLOBAL EPIDEMIOLOGY 2024; 7:100141. [PMID: 38510536 PMCID: PMC10951895 DOI: 10.1016/j.gloepi.2024.100141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 02/27/2024] [Accepted: 03/07/2024] [Indexed: 03/22/2024] Open
Affiliation(s)
- Wenchao Li
- Gradient, One Beacon St., 17th Floor, Boston, MA 02108, USA
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Salvatore M, Kundu R, Shi X, Friese CR, Lee S, Fritsche LG, Mondul AM, Hanauer D, Pearce CL, Mukherjee B. To weight or not to weight? The effect of selection bias in 3 large electronic health record-linked biobanks and recommendations for practice. J Am Med Inform Assoc 2024:ocae098. [PMID: 38742457 DOI: 10.1093/jamia/ocae098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 04/14/2024] [Accepted: 04/18/2024] [Indexed: 05/16/2024] Open
Abstract
OBJECTIVES To develop recommendations regarding the use of weights to reduce selection bias for commonly performed analyses using electronic health record (EHR)-linked biobank data. MATERIALS AND METHODS We mapped diagnosis (ICD code) data to standardized phecodes from 3 EHR-linked biobanks with varying recruitment strategies: All of Us (AOU; n = 244 071), Michigan Genomics Initiative (MGI; n = 81 243), and UK Biobank (UKB; n = 401 167). Using 2019 National Health Interview Survey data, we constructed selection weights for AOU and MGI to represent the US adult population more. We used weights previously developed for UKB to represent the UKB-eligible population. We conducted 4 common analyses comparing unweighted and weighted results. RESULTS For AOU and MGI, estimated phecode prevalences decreased after weighting (weighted-unweighted median phecode prevalence ratio [MPR]: 0.82 and 0.61), while UKB estimates increased (MPR: 1.06). Weighting minimally impacted latent phenome dimensionality estimation. Comparing weighted versus unweighted phenome-wide association study for colorectal cancer, the strongest associations remained unaltered, with considerable overlap in significant hits. Weighting affected the estimated log-odds ratio for sex and colorectal cancer to align more closely with national registry-based estimates. DISCUSSION Weighting had a limited impact on dimensionality estimation and large-scale hypothesis testing but impacted prevalence and association estimation. When interested in estimating effect size, specific signals from untargeted association analyses should be followed up by weighted analysis. CONCLUSION EHR-linked biobanks should report recruitment and selection mechanisms and provide selection weights with defined target populations. Researchers should consider their intended estimands, specify source and target populations, and weight EHR-linked biobank analyses accordingly.
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Affiliation(s)
- Maxwell Salvatore
- Department of Epidemiology, University of Michigan, Ann Arbor, MI 48109-2029, United States
- Center for Precision Health Data Science, Department of Biostatistics, University of Michigan, Ann Arbor, MI 48109-2029, United States
| | - Ritoban Kundu
- Center for Precision Health Data Science, Department of Biostatistics, University of Michigan, Ann Arbor, MI 48109-2029, United States
- Department of Biostatistics, University of Michigan, Ann Arbor, MI 48109-2029, United States
| | - Xu Shi
- Department of Biostatistics, University of Michigan, Ann Arbor, MI 48109-2029, United States
| | - Christopher R Friese
- Rogel Cancer Center, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109-2029, United States
- Center for Improving Patient and Population Health, School of Nursing, University of Michigan, Ann Arbor, MI 48109-2029, United States
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI 48109-2029, United States
| | - Seunggeun Lee
- Department of Biostatistics, University of Michigan, Ann Arbor, MI 48109-2029, United States
- Graduate School of Data Science, Seoul National University, Gwanak-gu, Seoul, Republic of Korea
| | - Lars G Fritsche
- Center for Precision Health Data Science, Department of Biostatistics, University of Michigan, Ann Arbor, MI 48109-2029, United States
- Department of Biostatistics, University of Michigan, Ann Arbor, MI 48109-2029, United States
- Rogel Cancer Center, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109-2029, United States
| | - Alison M Mondul
- Department of Epidemiology, University of Michigan, Ann Arbor, MI 48109-2029, United States
- Rogel Cancer Center, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109-2029, United States
| | - David Hanauer
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI 48109-2054, United States
| | - Celeste Leigh Pearce
- Department of Epidemiology, University of Michigan, Ann Arbor, MI 48109-2029, United States
- Rogel Cancer Center, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109-2029, United States
| | - Bhramar Mukherjee
- Department of Epidemiology, University of Michigan, Ann Arbor, MI 48109-2029, United States
- Center for Precision Health Data Science, Department of Biostatistics, University of Michigan, Ann Arbor, MI 48109-2029, United States
- Department of Biostatistics, University of Michigan, Ann Arbor, MI 48109-2029, United States
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Dahabreh IJ. Invited Commentary: Combining Information to Answer Epidemiologic Questions About a Target Population. Am J Epidemiol 2024; 193:741-750. [PMID: 38456780 DOI: 10.1093/aje/kwad014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 11/08/2022] [Accepted: 01/12/2023] [Indexed: 03/09/2024] Open
Abstract
Epidemiologists are attempting to address research questions of increasing complexity by developing novel methods for combining information from diverse sources. Cole et al. (Am J Epidemiol. 2023;192(3)467-474) provide 2 examples of the process of combining information to draw inferences about a population proportion. In this commentary, we consider combining information to learn about a target population as an epidemiologic activity and distinguish it from more conventional meta-analyses. We examine possible rationales for combining information and discuss broad methodological considerations, with an emphasis on study design, assumptions, and sources of uncertainty.
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Gravel CA, Bai W, Douros A. Comparators in Pharmacovigilance: A Quasi-Quantification Bias Analysis. Drug Saf 2024:10.1007/s40264-024-01433-5. [PMID: 38703312 DOI: 10.1007/s40264-024-01433-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND AND OBJECTIVE It is unclear which comparator is the most appropriate for bias reduction in disproportionality analyses based on spontaneous reports. We conducted a quasi-quantitative bias analysis using two well-studied drug-event combinations to assess how different comparators influence the directionality of bias in pharmacovigilance. METHODS We used the US Food and Drug Administration Adverse Event Reporting System focusing on two drug-event combinations with a propensity for stimulated reporting: rivaroxaban and hepatotoxicity, and canagliflozin and acute kidney injury. We assessed the directionality of three disproportionality analysis estimates (reporting odds ratio, proportional reporting ratio, information component) using one unrestricted comparator (full data) and two restricted comparators (active comparator, active comparator with class exclusion). Analyses were conducted within two calendar time periods, defined based on external events (approval of direct oral anticoagulants, Food and Drug Administration safety warning on acute kidney injury with sodium-glucose cotransporter 2 inhibitors) hypothesized to alter reporting rates. RESULTS There were no false-positive signals for rivaroxaban and hepatotoxicity irrespective of the comparator. Restricting to the initial post-approval period led to false-positive signals, with restricted comparators performing worse. There were false-positive signals for canagliflozin and acute kidney injury, with restricted comparators performing better. Restricting to the period before the Food and Drug Administration warning weakened the false-positive signal for canagliflozin and acute kidney injury across comparators. CONCLUSIONS We could not identify a consistent and predictable pattern to the directionality of disproportionality analysis estimates with specific comparators. Calendar time-based restrictions anchored on relevant external events had a considerable impact.
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Affiliation(s)
- Christopher A Gravel
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, OΝ, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- Department of Mathematics and Statistics, University of Ottawa, Ottawa, ON, Canada
- Data Literacy Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - William Bai
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, OΝ, Canada
| | - Antonios Douros
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, OΝ, Canada.
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.
- Institute of Clinical Pharmacology and Toxicology, Charité-Universitätsmedizin Berlin, 10117, Berlin, Germany.
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Walker AR, Venetis CA, Opdahl S, Chambers GM, Jorm LR, Vajdic CM. Estimating the impact of bias in causal epidemiological studies: the case of health outcomes following assisted reproduction. Hum Reprod 2024; 39:869-875. [PMID: 38509860 PMCID: PMC11063565 DOI: 10.1093/humrep/deae053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 02/19/2024] [Indexed: 03/22/2024] Open
Abstract
Researchers interested in causal questions must deal with two sources of error: random error (random deviation from the true mean value of a distribution), and bias (systematic deviance from the true mean value due to extraneous factors). For some causal questions, randomization is not feasible, and observational studies are necessary. Bias poses a substantial threat to the validity of observational research and can have important consequences for health policy developed from the findings. The current piece describes bias and its sources, outlines proposed methods to estimate its impacts in an observational study, and demonstrates how these methods may be used to inform debate on the causal relationship between medically assisted reproduction (MAR) and health outcomes, using cancer as an example. In doing so, we aim to enlighten researchers who work with observational data, especially regarding the health effects of MAR and infertility, on the pitfalls of bias, and how to address them. We hope that, in combination with the provided example, we can convince readers that estimating the impact of bias in causal epidemiologic research is not only important but necessary to inform the development of robust health policy and clinical practice recommendations.
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Affiliation(s)
- Adrian R Walker
- Centre for Big Data Research in Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
| | - Christos A Venetis
- Centre for Big Data Research in Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
- Unit for Human Reproduction, 1st Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Signe Opdahl
- Centre for Big Data Research in Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - Georgina M Chambers
- National Perinatal Epidemiology and Statistics Unit, Centre for Big Data Research in Health and School of Clinical Medicine, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
| | - Louisa R Jorm
- Centre for Big Data Research in Health, Faculty of Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
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Gray C, Ralphs E, Fox MP, Lash TL, Liu G, Kou TD, Rivera DR, Bosco J, Braun KVN, Grimson F, Layton D. Use of quantitative bias analysis to evaluate single-arm trials with real-world data external controls. Pharmacoepidemiol Drug Saf 2024; 33:e5796. [PMID: 38680093 DOI: 10.1002/pds.5796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 03/27/2024] [Accepted: 04/01/2024] [Indexed: 05/01/2024]
Abstract
PURPOSE Use of real-world data (RWD) for external controls added to single-arm trials (SAT) is increasingly prevalent in regulatory submissions. Due to inherent differences in the data-generating mechanisms, biases can arise. This paper aims to illustrate how to use quantitative bias analysis (QBA). METHODS Advanced non-small cell lung cancer (NSCLC) serves as an example, where many small subsets of patients with molecular tumor subtypes exist. First, some sources of bias that may occur in oncology when comparing RWD to SAT are described. Second, using a hypothetical immunotherapy agent, a dataset is simulated based on expert input for survival analysis of advanced NSCLC. Finally, we illustrate the impact of three biases: missing confounder, misclassification of exposure, and outcome evaluation. RESULTS For each simulated scenario, bias was induced by removing or adding data; hazard ratios (HRs) were estimated applying conventional analyses. Estimating the bias-adjusted treatment effect and uncertainty required carefully selecting the bias model and bias factors. Although the magnitude of each biased and bias-adjusted HR appeared moderate in all three hypothetical scenarios, the direction of bias was variable. CONCLUSION These findings suggest that QBA can provide an intuitive framework for bias analysis, providing a key means of challenging assumptions about the evidence. However, the accuracy of bias analysis is itself dependent on correct specification of the bias model and bias factors. Ultimately, study design should reduce bias, but QBA allows us to evaluate the impact of unavoidable bias to assess the quality of the evidence.
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Affiliation(s)
- Christen Gray
- Real World Data Science, Biopharmaceuticals Medical Evidence, AstraZeneca, Cambridge, UK
- Methods and Evidence Generation, Real World Solutions, IQVIA, London, UK
- Health Data Science, London School of Hygiene and Tropical Medicine, London, UK
| | - Eleanor Ralphs
- Methods and Evidence Generation, Real World Solutions, IQVIA, London, UK
| | - Matthew P Fox
- Department of Epidemiology, Department of Global Health, Boston University, Boston, Massachusetts, USA
| | - Timothy L Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Cancer Prevention and Control Program, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Geoffrey Liu
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Universal Health Network, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Applied Molecular Profiling Pharmacogenomic Epidemiologic Laboratory, Princess Margaret Cancer Centre, Universal Health Network, Toronto, Ontario, Canada
| | - Tzuyung Doug Kou
- Global Patient Safety, BeiGene, Ridgefield Park, New Jersey, USA
| | - Donna R Rivera
- Oncology Center of Excellence, United States Food & Drug Administration, Silver Spring, Maryland, USA
| | - Jaclyn Bosco
- Epidemiology and Database Studies, Real World Solutions, IQVIA, Boston, Massachusetts, USA
- Department of Epidemiology, Boston University, Boston, Massachusetts, USA
| | - Kim Van Naarden Braun
- Translational Epidemiology, Informatics and Predictive Sciences, BMS, Summit, New Jersey, USA
| | - Fiona Grimson
- Health Data Science, London School of Hygiene and Tropical Medicine, London, UK
- Biometrics and Quantitative Sciences, UCB Pharma, Slough, UK
| | - Deborah Layton
- PEPI Consultancy Limited, Southampton, UK
- School of Life & Medical Sciences, University of Hertfordshire, Hatfield, UK
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Banack HR, Smith SN, Bodnar LM. Application of a Web-based Tool for Quantitative Bias Analysis: The Example of Misclassification Due to Self-reported Body Mass Index. Epidemiology 2024; 35:359-367. [PMID: 38300118 PMCID: PMC11022994 DOI: 10.1097/ede.0000000000001726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 01/28/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND We describe the use of Apisensr, a web-based application that can be used to implement quantitative bias analysis for misclassification, selection bias, and unmeasured confounding. We apply Apisensr using an example of exposure misclassification bias due to use of self-reported body mass index (BMI) to define obesity status in an analysis of the relationship between obesity and diabetes. METHODS We used publicly available data from the National Health and Nutrition Examination Survey. The analysis consisted of: (1) estimating bias parameter values (sensitivity, specificity, negative predictive value, and positive predictive value) for self-reported obesity by sex, age, and race-ethnicity compared to obesity defined by measured BMI, and (2) using Apisensr to adjust for exposure misclassification. RESULTS The discrepancy between self-reported and measured obesity varied by demographic group (sensitivity range: 75%-89%; specificity range: 91%-99%). Using Apisensr for quantitative bias analysis, there was a clear pattern in the results: the relationship between obesity and diabetes was underestimated using self-report in all age, sex, and race-ethnicity categories compared to measured obesity. For example, in non-Hispanic White men aged 40-59 years, prevalence odds ratios for diabetes were 3.06 (95% confidence inerval = 1.78, 5.30) using self-reported BMI and 4.11 (95% confidence interval = 2.56, 6.75) after bias analysis adjusting for misclassification. CONCLUSION Apisensr is an easy-to-use, web-based Shiny app designed to facilitate quantitative bias analysis. Our results also provide estimates of bias parameter values that can be used by other researchers interested in examining obesity defined by self-reported BMI.
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Affiliation(s)
- Hailey R. Banack
- From the Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Samantha N. Smith
- Department of Epidemiology and Environmental Health, State University of New York at Buffalo, Buffalo, NY
| | - Lisa M. Bodnar
- School of Public Health, University of Pittsburgh, Pittsburgh, PA
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Angriman F, Saoraya J, Lawler PR, Shah BR, Martin CM, Scales DC. Preexisting Diabetes Mellitus and All-Cause Mortality in Adult Patients With Sepsis: A Population-Based Cohort Study. Crit Care Explor 2024; 6:e1085. [PMID: 38709081 DOI: 10.1097/cce.0000000000001085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Abstract
OBJECTIVES We assessed the association of preexisting diabetes mellitus with all-cause mortality and organ support receipt in adult patients with sepsis. DESIGN Population-based cohort study. SETTING Ontario, Canada (2008-2019). POPULATION Adult patients (18 yr old or older) with a first sepsis-related hospitalization episode. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The main exposure of interest was preexisting diabetes (either type 1 or 2). The primary outcome was all-cause mortality by 90 days; secondary outcomes included receipt of invasive mechanical ventilation and new renal replacement therapy. We report adjusted (for baseline characteristics using standardization) risk ratios (RRs) alongside 95% CIs. A main secondary analysis evaluated the potential mediation by prior metformin use of the association between preexisting diabetes and all-cause mortality following sepsis. Overall, 503,455 adults with a first sepsis-related hospitalization episode were included; 36% had preexisting diabetes. Mean age was 73 years, and 54% of the cohort were females. Preexisting diabetes was associated with a lower adjusted risk of all-cause mortality at 90 days (RR, 0.81; 95% CI, 0.80-0.82). Preexisting diabetes was associated with an increased risk of new renal replacement therapy (RR, 1.53; 95% CI, 1.46-1.60) but not invasive mechanical ventilation (RR, 1.03; 95% CI, 1.00-1.05). Overall, 21% (95% CI, 19-28) of the association between preexisting diabetes and reduced risk of all-cause mortality was mediated by prior metformin use. CONCLUSIONS Preexisting diabetes is associated with a lower risk of all-cause mortality and higher risk of new renal replacement therapy among adult patients with sepsis. Future studies should evaluate the underlying mechanisms of these associations.
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Affiliation(s)
- Federico Angriman
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Jutamas Saoraya
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Faculty of Medicine, Chulalongkorn University, Pathum Wan, Bangkok, Thailand
- McGill University Health Centre, Montreal, QC, Canada
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
| | - Patrick R Lawler
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- McGill University Health Centre, Montreal, QC, Canada
| | - Baiju R Shah
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Faculty of Medicine, Chulalongkorn University, Pathum Wan, Bangkok, Thailand
- McGill University Health Centre, Montreal, QC, Canada
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
| | - Claudio M Martin
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Lawson Health Research Institute, London, ON, Canada
| | - Damon C Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Yamada R, Sachdev D, Lee R, Sauer MV, Ananth CV. Infertility treatment is associated with increased risk of postpartum hospitalization due to heart disease. J Intern Med 2024; 295:668-678. [PMID: 38403886 DOI: 10.1111/joim.13773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
BACKGROUND Cardiovascular disease is a major cause of maternal mortality, but the extent to which infertility treatment is implicated in heart disease remains unclear. OBJECTIVE To evaluate the association between infertility treatment and postpartum heart disease. METHODS We designed a retrospective cohort study of patients who delivered in the United States between 2010 and 2018. The primary outcome was hospitalization within 12-month post-delivery due to heart disease (including ischemic heart disease, atherosclerotic heart disease, cardiomyopathy, hypertensive disease, heart failure, and cardiac dysrhythmias). We estimated the rate difference (RD) of hospitalizations among patients who conceived with infertility treatment and those who conceived spontaneously. Associations were expressed as hazard ratios (HRs) and 95% confidence intervals (CIs), derived from Cox proportional hazards regression after adjustment for potential confounders. RESULTS Infertility treatment was recorded in 0.9% (n = 287,813) of 31,339,991 deliveries. Rates of heart disease hospitalizations with infertility treatment and with spontaneous conception were 550 and 355 per 100,000, respectively (RD 195, 95% CI: 143-247; adjusted HR 1.99, 95% CI: 1.80-2.20). The most important increase in risk was observed for hypertensive disease (adjusted HR 2.16, 95% CI: 1.92-2.42). This increased risk was apparent as early as 30-day post-delivery (HR 1.61, 95% CI: 1.39-1.86), with progressively increasing risk up to a year. CONCLUSIONS Although the absolute risk of postpartum heart disease hospitalization is low, infertility treatment is associated with an increased risk, especially for hypertensive disease. These findings highlight the importance of timely postpartum follow-ups in patients who received infertility treatment.
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Affiliation(s)
- Rei Yamada
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Devika Sachdev
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Rachel Lee
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Mark V Sauer
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Cande V Ananth
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
- Cardiovascular Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey, USA
- Environmental and Occupational Health Sciences Institute, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
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Mussa J, Rahme E, Dahhou M, Nakhla M, Dasgupta K. Incident Diabetes in Women With Patterns of Gestational Diabetes Occurrences Across 2 Pregnancies. JAMA Netw Open 2024; 7:e2410279. [PMID: 38722629 PMCID: PMC11082690 DOI: 10.1001/jamanetworkopen.2024.10279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 03/07/2024] [Indexed: 05/12/2024] Open
Abstract
Importance Gestational diabetes is a type 2 diabetes risk indicator, and recurrence further augments risk. In women with a single occurrence across 2 pregnancies, it is unclear whether first- vs second-pregnancy gestational diabetes differ in terms of risk. Objective To compare the hazards of incident diabetes among those with gestational diabetes in the first, in the second, and in both pregnancies with women without gestational diabetes in either. Design, Setting, and Participants This was a retrospective cohort study with cohort inception from April 1, 1990, to December 31, 2012. Follow-up was April 1, 1990, to April 1, 2019. Participants were mothers with 2 singleton deliveries between April 1, 1990, and December 31, 2012, without diabetes before or between pregnancies, who were listed in public health care insurance administrative databases and birth, stillbirth, and death registries in Quebec, Canada. Data were analyzed from July to December 2023. Exposure Gestational diabetes occurrence(s) across 2 pregnancies. Main outcomes and measures Incident diabetes from the second delivery until a third pregnancy, death, or the end of the follow-up period, whichever occurred first. Results The 431 980 women with 2 singleton deliveries studied had a mean (SD) age of 30.1 (4.5) years at second delivery, with a mean (SD) of 2.8 (1.5) years elapsed between deliveries; 373 415 (86.4%) were of European background, and 78 770 (18.2%) were at the highest quintile of material deprivation. Overall, 10 920 women (2.5%) had gestational diabetes in their first pregnancy, 16 145 (3.7%) in their second, and 8255 (1.9%) in both (12 205 incident diabetes events; median [IQR] follow-up 11.5 [5.3-19.4] years). First pregnancy-only gestational diabetes increased hazards 4.35-fold (95% CI, 4.06-4.67), second pregnancy-only increased hazards 7.68-fold (95% CI, 7.31-8.07), and gestational diabetes in both pregnancies increased hazards 15.8-fold (95% CI, 15.0-16.6). Compared with first pregnancy-only gestational diabetes, second pregnancy-only gestational diabetes increased hazards by 76% (95% CI, 1.63-1.91), while gestational diabetes in both pregnancies increased it 3.63-fold (95% CI, 3.36-3.93). Conclusions and relevance In this retrospective cohort study of nearly half a million women with 2 singleton pregnancies, both the number and ordinal pregnancy of any gestational diabetes occurrence increased diabetes risk. These considerations offer greater nuance than an ever or never gestational diabetes dichotomy.
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Affiliation(s)
- Joseph Mussa
- Department of Medicine, McGill University, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre (RI-MUHC), Montreal, Quebec, Canada
| | - Elham Rahme
- Department of Medicine, McGill University, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre (RI-MUHC), Montreal, Quebec, Canada
| | - Mourad Dahhou
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre (RI-MUHC), Montreal, Quebec, Canada
| | - Meranda Nakhla
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre (RI-MUHC), Montreal, Quebec, Canada
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Kaberi Dasgupta
- Department of Medicine, McGill University, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre (RI-MUHC), Montreal, Quebec, Canada
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11
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Marinescu DC, Wong AW. Epidemiology of idiopathic pulmonary fibrosis: opportunities and hurdles for population-level studies of rare disease. Thorax 2024:thorax-2024-221581. [PMID: 38688707 DOI: 10.1136/thorax-2024-221581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2024] [Indexed: 05/02/2024]
Affiliation(s)
- Daniel-Costin Marinescu
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Lung Health, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Alyson W Wong
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Advancing Health Outcomes, St. Paul's Hospital, Vancouver, British Columbia, Canada
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12
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Ogilvie RP, Layton JB, Lloyd PC, Jiao Y, Djibo DA, Wong HL, Gruber JF, Parambi R, Deng J, Miller M, Song J, Weatherby LB, Peetluk L, Lo AC, Matuska K, Wernecke M, Bui CL, Clarke TC, Cho S, Bell EJ, Yang G, Amend KL, Forshee RA, Anderson SA, McMahill-Walraven CN, Chillarige Y, Anthony MS, Seeger JD, Shoaibi A. Effectiveness of BNT162b2 COVID-19 primary series vaccination in children aged 5-17 years in the United States: a cohort study. BMC Pediatr 2024; 24:276. [PMID: 38671379 PMCID: PMC11047006 DOI: 10.1186/s12887-024-04756-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND COVID-19 vaccines are authorized for use in children in the United States; real-world assessment of vaccine effectiveness in children is needed. This study's objective was to estimate the effectiveness of receiving a complete primary series of monovalent BNT162b2 (Pfizer-BioNTech) COVID-19 vaccine in US children. METHODS This cohort study identified children aged 5-17 years vaccinated with BNT162b2 matched with unvaccinated children. Participants and BNT162b2 vaccinations were identified in Optum and CVS Health insurance administrative claims databases linked with Immunization Information System (IIS) COVID-19 vaccination records from 16 US jurisdictions between December 11, 2020, and May 31, 2022 (end date varied by database and IIS). Vaccinated children were followed from their first BNT162b2 dose and matched to unvaccinated children on calendar date, US county of residence, and demographic and clinical factors. Censoring occurred if vaccinated children failed to receive a timely dose 2 or if unvaccinated children received any dose. Two COVID-19 outcome definitions were evaluated: COVID-19 diagnosis in any medical setting and COVID-19 diagnosis in hospitals/emergency departments (EDs). Propensity score-weighted hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated with Cox proportional hazards models, and vaccine effectiveness (VE) was estimated as 1 minus HR. VE was estimated overall, within age subgroups, and within variant-specific eras. Sensitivity, negative control, and quantitative bias analyses evaluated various potential biases. RESULTS There were 453,655 eligible vaccinated children one-to-one matched to unvaccinated comparators (mean age 12 years; 50% female). COVID-19 hospitalizations/ED visits were rare in children, regardless of vaccination status (Optum, 41.2 per 10,000 person-years; CVS Health, 44.1 per 10,000 person-years). Overall, vaccination was associated with reduced incidence of any medically diagnosed COVID-19 (meta-analyzed VE = 38% [95% CI, 36-40%]) and hospital/ED-diagnosed COVID-19 (meta-analyzed VE = 61% [95% CI, 56-65%]). VE estimates were lowest among children 5-11 years and during the Omicron-variant era. CONCLUSIONS Receipt of a complete BNT162b2 vaccine primary series was associated with overall reduced medically diagnosed COVID-19 and hospital/ED-diagnosed COVID-19 in children; observed VE estimates differed by age group and variant era. REGISTRATION The study protocol was publicly posted on the BEST Initiative website ( https://bestinitiative.org/wp-content/uploads/2022/03/C19-VX-Effectiveness-Protocol_2022_508.pdf ).
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Affiliation(s)
| | - J Bradley Layton
- RTI Health Solutions, 3040 East Cornwallis Rd, PO Box 12194, Research Triangle Park, NC, 27709, USA.
| | | | | | | | - Hui Lee Wong
- US Food and Drug Administration, Silver Spring, MD, USA
| | | | | | - Jie Deng
- Optum Epidemiology, Boston, MA, USA
| | | | | | | | | | | | | | | | - Christine L Bui
- RTI Health Solutions, 3040 East Cornwallis Rd, PO Box 12194, Research Triangle Park, NC, 27709, USA
| | | | - Sylvia Cho
- US Food and Drug Administration, Silver Spring, MD, USA
| | | | | | | | | | | | | | | | - Mary S Anthony
- RTI Health Solutions, 3040 East Cornwallis Rd, PO Box 12194, Research Triangle Park, NC, 27709, USA
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Shiroshita A, Tochitani K, Maki Y, Terayama T, Kataoka Y. Association between Empirical Anti-Pseudomonal Antibiotics and Progression to Thoracic Surgery and Death in Empyema: Database Research. Antibiotics (Basel) 2024; 13:383. [PMID: 38786112 PMCID: PMC11117277 DOI: 10.3390/antibiotics13050383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/18/2024] [Accepted: 04/22/2024] [Indexed: 05/25/2024] Open
Abstract
Evidence on the optimal antibiotic strategy for empyema is lacking. Our database study aimed to evaluate the effectiveness of empirical anti-pseudomonal antibiotics in patients with empyema. We utilised a Japanese real-world data database, focusing on patients aged ≥40 diagnosed with empyema, who underwent thoracostomy and received intravenous antibiotics either upon admission or the following day. Patients administered intravenous vasopressors were excluded. We compared thoracic surgery and death within 90 days after admission between patients treated with empirical anti-pseudomonal and non-anti-pseudomonal antibiotics. Cause-specific hazard ratios for thoracic surgery and death were estimated using Cox proportional hazards models, with adjustment for clinically important confounders. Subgroup analyses entailed the same procedures for patients exhibiting at least one risk factor for multidrug-resistant organisms. Between March 2014 and March 2023, 855 patients with empyema meeting the inclusion criteria were enrolled. Among them, 271 (31.7%) patients received anti-pseudomonal antibiotics. The Cox proportional hazards models indicated that compared to empirical non-anti-pseudomonal antibiotics, empirical anti-pseudomonal antibiotics were associated with higher HRs for thoracic surgery and death within 90 days, respectively. Thus, regardless of the risks of multidrug-resistant organisms, empirical anti-pseudomonal antibiotics did not extend the time to thoracic surgery or death within 90 days.
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Affiliation(s)
- Akihiro Shiroshita
- Division of Epidemiology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN 37203, USA
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka 541-0043, Japan
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Kentaro Tochitani
- Department of Infectious Diseases, Kyoto City Hospital, Kyoto 604-8845, Japan
| | - Yohei Maki
- Division of Infectious Diseases and Respiratory Medicine, National Defense Medical College, Saitama 359-8513, Japan
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Takero Terayama
- Department of Emergency, Self-Defense Forces Central Hospital, Tokyo 154-8532, Japan
| | - Yuki Kataoka
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka 541-0043, Japan
- Department of Internal Medicine, Kyoto Min-Iren Asukai Hospital, Kyoto 616-8147, Japan
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Kyoto 606-8507, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine/Public Health, Kyoto 606-8501, Japan
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14
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Tartour AI, Chivese T, Eltayeb S, Elamin FM, Fthenou E, Seed Ahmed M, Babu GR. Prenatal psychological distress and 11β-HSD2 gene expression in human placentas: Systematic review and meta-analysis. Psychoneuroendocrinology 2024; 166:107060. [PMID: 38677195 DOI: 10.1016/j.psyneuen.2024.107060] [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: 11/03/2023] [Revised: 03/10/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND The placenta acts as a buffer to regulate the degree of fetal exposure to maternal cortisol through the 11-Beta Hydroxysteroid Dehydrogenase isoenzyme type 2 (11-β HSD2) enzyme. We conducted a systematic review and meta-analysis to assess the effect of prenatal psychological distress (PPD) on placental 11-β HSD2 gene expression and explore the related mechanistic pathways involved in fetal neurodevelopment. METHODS We searched PubMed, Embase, Scopus, APA PsycInfo®, and ProQuest Dissertations for observational studies assessing the association between PPD and 11-β HSD2 expression in human placentas. Adjusted regression coefficients (β) and corresponding 95% confidence intervals (CIs) were pooled based on three contextual PPD exposure groups: prenatal depression, anxiety symptoms, and perceived stress. RESULTS Of 3159 retrieved records, sixteen longitudinal studies involving 1869 participants across seven countries were included. Overall, exposure to PPD disorders showed weak negative associations with the placental 11-β HSD2 gene expression as follows: prenatal depression (β -0.01, 95% CI 0.05-0.02, I2=0%), anxiety symptoms (β -0.02, 95% CI 0.06-0.01, I2=0%), and perceived stress (β -0.01 95% CI 0.06-0.04, I2=62.8%). Third-trimester PPD exposure was more frequently associated with lower placental 11-β HSD2 levels. PPD and placental 11-β HSD2 were associated with changes in cortisol reactivity and the development of adverse health outcomes in mothers and children. Female-offspring were more vulnerable to PPD exposures. CONCLUSION The study presents evidence of a modest role of prenatal psychological distress in regulating placental 11-β HSD2 gene expression. Future prospective cohorts utilizing larger sample sizes or advanced statistical methods to enhance the detection of small effect sizes should be planned. Additionally, controlling for key predictors such as the mother's ethnicity, trimester of PPD exposure, mode of delivery, and infant sex is crucial for valid exploration of PPD effects on fetal programming.
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Affiliation(s)
- Angham Ibrahim Tartour
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, P. O. Box:2713, Doha, Qatar.
| | - Tawanda Chivese
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, P. O. Box:2713, Doha, Qatar
| | - Safa Eltayeb
- Qatar Biobank for Medical Research, Qatar Foundation, Doha, Qatar
| | - Fatima M Elamin
- Office of Research Ethics and Integrity, Qatar University, P. O. Box:2713, Doha, Qatar
| | - Eleni Fthenou
- Qatar Biobank for Medical Research, Qatar Foundation, Doha, Qatar
| | - Mohammed Seed Ahmed
- Department of Basic Medical Sciences, College of Medicine, QU Health, Qatar University, P. O. Box:2713, Doha, Qatar
| | - Giridhara Rathnaiah Babu
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, P. O. Box:2713, Doha, Qatar
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15
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Craik R, Volvert ML, Koech A, Jah H, Pickerill K, Abubakar A, D’Alessandro U, Barratt B, Blencowe H, Bone JN, Chandna J, Gladstone MJ, Khalil A, Li L, Magee LA, Makacha L, Mistry HD, Moore SE, Roca A, Salisbury TT, Temmerman M, Toudup D, Vidler M, von Dadelszen P. The PRECISE-DYAD protocol: linking maternal and infant health trajectories in sub-Saharan Africa. Wellcome Open Res 2024; 7:281. [PMID: 38779418 PMCID: PMC11109552 DOI: 10.12688/wellcomeopenres.18465.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2024] [Indexed: 05/25/2024] Open
Abstract
Background PRECISE-DYAD is an observational cohort study of mother-child dyads running in urban and rural communities in The Gambia and Kenya. The cohort is being followed for two years and includes uncomplicated pregnancies and those that suffered pregnancy hypertension, fetal growth restriction, preterm birth, and/or stillbirth. Methods The PRECISE-DYAD study will follow up ~4200 women and their children recruited into the original PRECISE study. The study will add to the detailed pregnancy information and samples in PRECISE, collecting additional biological samples and clinical information on both the maternal and child health.Women will be asked about both their and their child's health, their diets as well as undertaking a basic cardiology assessment. Using a case-control approach, some mothers will be asked about their mental health, their experiences of care during labour in the healthcare facility. In a sub-group, data on financial expenditure during antenatal, intrapartum, and postnatal periods will also be collected. Child development will be assessed using a range of tools, including neurodevelopment assessments, and evaluating their home environment and quality of life. In the event developmental milestones are not met, additional assessments to assess vision and their risk of autism spectrum disorders will be conducted. Finally, a personal environmental exposure model for the full cohort will be created based on air and water quality data, combined with geographical, demographic, and behavioural variables. Conclusions The PRECISE-DYAD study will provide a greater epidemiological and mechanistic understanding of health and disease pathways in two sub-Saharan African countries, following healthy and complicated pregnancies. We are seeking additional funding to maintain this cohort and to gain an understanding of the effects of pregnancies outcome on longer-term health trajectories in mothers and their children.
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Affiliation(s)
- Rachel Craik
- Department of Women and Children’s Health, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Marie-Laure Volvert
- Department of Women and Children’s Health, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Angela Koech
- Centre of Excellence Women and Child Health, Aga Khan University, Nairobi, Kenya
| | - Hawanatu Jah
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Kelly Pickerill
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada
| | - Amina Abubakar
- Institute for Human Development, Aga Khan University, Nairobi, Kenya
| | - Umberto D’Alessandro
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Benjamin Barratt
- MRC Centre for Environment and Health, Imperial College London, London, UK
| | | | - Jeffrey N Bone
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada
| | - Jaya Chandna
- London School of Hygiene and Tropical Medicine, London, UK
| | - Melissa J. Gladstone
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Asma Khalil
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St. George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Larry Li
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada
| | - Laura A Magee
- Department of Women and Children’s Health, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Liberty Makacha
- Department of Women and Children’s Health, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
- MRC Centre for Environment and Health, Imperial College London, London, UK
- Department of Surveying and Geomatics, Midlands State University, Gweru, Zimbabwe
| | - Hiten D Mistry
- Department of Women and Children’s Health, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Sophie E. Moore
- Department of Women and Children’s Health, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Anna Roca
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Tatiana T Salisbury
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Marleen Temmerman
- Centre of Excellence Women and Child Health, Aga Khan University, Nairobi, Kenya
| | | | - Marianne Vidler
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada
| | - Peter von Dadelszen
- Department of Women and Children’s Health, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - and The PRECISE-DYAD Network
- Department of Women and Children’s Health, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
- Centre of Excellence Women and Child Health, Aga Khan University, Nairobi, Kenya
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada
- Institute for Human Development, Aga Khan University, Nairobi, Kenya
- MRC Centre for Environment and Health, Imperial College London, London, UK
- London School of Hygiene and Tropical Medicine, London, UK
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St. George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Department of Surveying and Geomatics, Midlands State University, Gweru, Zimbabwe
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Medical School, University of Sheffield, Sheffield, UK
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16
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Brown JP, Hunnicutt JN, Ali MS, Bhaskaran K, Cole A, Langan SM, Nitsch D, Rentsch CT, Galwey NW, Wing K, Douglas IJ. Quantifying possible bias in clinical and epidemiological studies with quantitative bias analysis: common approaches and limitations. BMJ 2024; 385:e076365. [PMID: 38565248 DOI: 10.1136/bmj-2023-076365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2024] [Indexed: 04/04/2024]
Affiliation(s)
- Jeremy P Brown
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Jacob N Hunnicutt
- Epidemiology, Value Evidence and Outcomes, R&D Global Medical, GSK, Collegeville, PA, USA
| | - M Sanni Ali
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Krishnan Bhaskaran
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Ashley Cole
- Real World Analytics, Value Evidence and Outcomes, R&D Global Medical, GSK, Collegeville, PA, USA
| | - Sinead M Langan
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Dorothea Nitsch
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Christopher T Rentsch
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Kevin Wing
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Ian J Douglas
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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17
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Höfler M, Giesche A. Avoidance of causality outside experiments: Hypotheses from cognitive dissonance reduction. Sci Prog 2024; 107:368504241235505. [PMID: 38567445 PMCID: PMC10993686 DOI: 10.1177/00368504241235505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
The avoidance of causality in the design, analysis and interpretation of non-experimental studies has often been criticised as an untenable scientific stance, because theories are based on causal relations (and not associations) and a rich set of methodological tools for causal analysis has been developed in recent decades. Psychology researchers (n = 106 with complete data) participated in an online study presenting a causal statement about the results of a fictitious paper on the potential effect of drinking clear water for years on the risk of dementia. Two randomised groups of participants were then asked to reflect on the conflict between the goal of approaching a causal answer and the prevailing norm of avoiding doing so. One of the two groups was also instructed to think about possible benefits of addressing causality. Both groups then responded to a list of 19 items about attitudes to causal questions in science. A control group did this without reflecting on conflict or benefits. Free-text assessments were also collected during reflection, giving some indication of how and why causality is avoided. We condense the exploratory findings of this study into five new hypotheses about the how and why, filtered through what can be explained by cognitive dissonance reduction theory. These concern the cost of addressing causality, the variety of ways in which dissonance can be reduced, the need for profound intervention through teaching and social aspects. Predictions are derived from the hypotheses for confirmation trials in future studies and recommendations for teaching causality. Open data are provided for researchers' own analyses.
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Affiliation(s)
- Michael Höfler
- Clinical Psychology and Behavioural Neuroscience, Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
| | - Alexander Giesche
- Clinical Psychology and Behavioural Neuroscience, Institute of Clinical Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
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18
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Kim MK, Rouphael C, McMichael J, Welch N, Dasarathy S. Challenges in and Opportunities for Electronic Health Record-Based Data Analysis and Interpretation. Gut Liver 2024; 18:201-208. [PMID: 37905424 PMCID: PMC10938158 DOI: 10.5009/gnl230272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 08/15/2023] [Indexed: 11/02/2023] Open
Abstract
Electronic health records (EHRs) have been increasingly adopted in clinical practices across the United States, providing a primary source of data for clinical research, particularly observational cohort studies. EHRs are a high-yield, low-maintenance source of longitudinal real-world data for large patient populations and provide a wealth of information and clinical contexts that are useful for clinical research and translation into practice. Despite these strengths, it is important to recognize the multiple limitations and challenges related to the use of EHR data in clinical research. Missing data are a major source of error and biases and can affect the representativeness of the cohort of interest, as well as the accuracy of the outcomes and exposures. Here, we aim to provide a critical understanding of the types of data available in EHRs and describe the impact of data heterogeneity, quality, and generalizability, which should be evaluated prior to and during the analysis of EHR data. We also identify challenges pertaining to data quality, including errors and biases, and examine potential sources of such biases and errors. Finally, we discuss approaches to mitigate and remediate these limitations. A proactive approach to addressing these issues can help ensure the integrity and quality of EHR data and the appropriateness of their use in clinical studies.
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Affiliation(s)
- Michelle Kang Kim
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Carol Rouphael
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John McMichael
- Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Nicole Welch
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Srinivasan Dasarathy
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
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Sachdev D, Sauer MV, Ananth CV. Gestational diabetes mellitus in pregnancies conceived after infertility treatment: a population-based study in the United States, 2015-2020. F S Rep 2024; 5:102-110. [PMID: 38524205 PMCID: PMC10958713 DOI: 10.1016/j.xfre.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 11/13/2023] [Accepted: 11/14/2023] [Indexed: 03/26/2024] Open
Abstract
Objective To evaluate the risk of gestational diabetes mellitus (GDM) in singleton pregnancies conceived using infertility treatment and examine the influence of race and ethnicity as well as prepregnancy body mass index (BMI). Design Cross-sectional study using the US vital records data of women that delivered singleton births. Setting United States, 2015-2020. Interventions Any infertility treatment was divided into two groups: those that used fertility-enhancing drugs, artificial insemination, or intrauterine insemination, and those that used assisted reproductive technology (ART). Main Outcome Measuress Gestational diabetes mellitus, defined as a diagnosis of diabetes mellitus during pregnancy, includes both diet-controlled GDM and medication-controlled GDM in singleton pregnancies conceived with infertility treatment or spontaneously and delivered between 20- and 44-weeks' gestation. We also examined whether the infertility treatment-GDM association was modified by maternal race and ethnicity as well as prepregnancy BMI. Associations were expressed as a rate ratio (RR) and 95% confidence interval (CI), derived from log-linear models after adjustment for potential confounders. Results A total of 21,943,384 singleton births were included, with 1.5% (n = 318,086) undergoing infertility treatment. Rates of GDM among women undergoing infertility treatment and those who conceived spontaneously were 11.0% (n = 34,946) and 6.5% (n = 1,398,613), respectively (adjusted RR 1.24, 95% CI 1.23, 1.26). The RRs were adjusted for maternal age, parity, education, race and ethnicity, smoking, BMI, chronic hypertension, and year of delivery. The risk of GDM was modestly increased for those using fertility-enhancing drugs (adjusted RR 1.28, 95% CI 1.27, 1.30) compared with ART (adjusted RR 1.18, 95% CI 1.17, 1.20), and this risk was especially apparent for non-Hispanic White women (adjusted RR 1.29, 95% CI 1.26, 1.31) and Hispanic women (adjusted RR 1.35, 95% CI 1.29, 1.41). The number of women who needed to be exposed to infertility treatment to diagnose one case of GDM was 46. Prepregnancy BMI did not modify the infertility treatment-GDM association overall and within strata of race and ethnicity. These general patterns were stronger after potential corrections for misclassification of infertility treatment and unmeasured confounding. Conclusions Infertility treatment, among those who received fertility-enhancing drugs, is associated with an increased GDM risk. The persistently higher risk of GDM among women who seek infertility treatment, irrespective of prepregnancy weight classification, deserves attention. Infertility specialists must be vigilant with preconception counseling and ensure that all patients, regardless of race and ethnicity or BMI, are adequately tested for GDM early in pregnancy using a fasting blood glucose level or a traditional 50-g oral glucose tolerance test. Testing may be completed by the infertility specialist or deferred to the primary prenatal care provider at the first prenatal visit.
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Affiliation(s)
- Devika Sachdev
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Mark V. Sauer
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Cande V. Ananth
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
- Cardiovascular Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey
- Environmental and Occupational Health Sciences Institute, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey
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20
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Johnston A, Smith GN, Tanuseputro P, Coutinho T, Edwards JD. Assessing cardiovascular disease risk in women with a history of hypertensive disorders of pregnancy: A guidance paper for studies using administrative data. Paediatr Perinat Epidemiol 2024; 38:254-267. [PMID: 38220144 DOI: 10.1111/ppe.13043] [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: 05/15/2023] [Revised: 12/29/2023] [Accepted: 01/03/2024] [Indexed: 01/16/2024]
Abstract
BACKGROUND Hypertensive disorders of pregnancy (HDP) are a major cause of maternal morbidity and mortality, and their association with increased cardiovascular disease (CVD) risk represents a major public health concern. However, assessing CVD risk in women with a history of these conditions presents unique challenges, especially when studies are carried out using routinely collected data. OBJECTIVES To summarise and describe key challenges related to the design and conduct of administrative studies assessing CVD risk in women with a history of HDP and provide concrete recommendations for addressing them in future research. METHODS This is a methodological guidance paper. RESULTS Several conceptual and methodological factors related to the data-generating mechanism and study conceptualisation, design/data management and analysis, as well as the interpretation and reporting of study findings should be considered and addressed when designing and carrying out administrative studies on this topic. Researchers should develop an a priori conceptual framework within which the research question is articulated, important study variables are identified and their interrelationships are carefully considered. CONCLUSIONS To advance our understanding of CVD risk in women with a history of HDP, future studies should carefully consider and address the conceptual and methodological considerations outlined in this guidance paper. In highlighting these challenges, and providing specific recommendations for how to address them, our goal is to improve the quality of research carried out on this topic.
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Affiliation(s)
- Amy Johnston
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Brain and Heart Nexus Research Program, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Graeme N Smith
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Kingston Health Sciences Centre, Queens University, Kingston, Ontario, Canada
| | - Peter Tanuseputro
- ICES, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Thais Coutinho
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jodi D Edwards
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Brain and Heart Nexus Research Program, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- ICES, Ottawa, Ontario, Canada
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21
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Thorlund K, Duffield S, Popat S, Ramagopalan S, Gupta A, Hsu G, Arora P, Subbiah V. Quantitative bias analysis for external control arms using real-world data in clinical trials: a primer for clinical researchers. J Comp Eff Res 2024; 13:e230147. [PMID: 38205741 PMCID: PMC10945419 DOI: 10.57264/cer-2023-0147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 12/14/2023] [Indexed: 01/12/2024] Open
Abstract
Development of medicines in rare oncologic patient populations are growing, but well-powered randomized controlled trials are typically extremely challenging or unethical to conduct in such settings. External control arms using real-world data are increasingly used to supplement clinical trial evidence where no or little control arm data exists. The construction of an external control arm should always aim to match the population, treatment settings and outcome measurements of the corresponding treatment arm. Yet, external real-world data is typically fraught with limitations including missing data, measurement error and the potential for unmeasured confounding given a nonrandomized comparison. Quantitative bias analysis (QBA) comprises a collection of approaches for modelling the magnitude of systematic errors in data which cannot be addressed with conventional statistical adjustment. Their applications can range from simple deterministic equations to complex hierarchical models. QBA applied to external control arm represent an opportunity for evaluating the validity of the corresponding comparative efficacy estimates. We provide a brief overview of available QBA approaches and explore their application in practice. Using a motivating example of a comparison between pralsetinib single-arm trial data versus pembrolizumab alone or combined with chemotherapy real-world data for RET fusion-positive advanced non-small cell lung cancer (aNSCLC) patients (1-2% among all NSCLC), we illustrate how QBA can be applied to external control arms. We illustrate how QBA is used to ascertain robustness of results despite a large proportion of missing data on baseline ECOG performance status and suspicion of unknown confounding. The robustness of findings is illustrated by showing that no meaningful change to the comparative effect was observed across several 'tipping-point' scenario analyses, and by showing that suspicion of unknown confounding was ruled out by use of E-values. Full R code is also provided.
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Affiliation(s)
- Kristian Thorlund
- Dept. Health Research Methods, Evidence, & Impact, McMaster University, ON, Canada
| | | | - Sanjay Popat
- Royal Marsden Hospital, Imperial College, London, UK
| | | | | | | | - Paul Arora
- Dalla Lana School of Public Health, University of Toronto, ON, Canada
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22
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Chen J, Li XN, Lu CC, Yuan S, Yung G, Ye J, Tian H, Lin J. Considerations for master protocols using external controls. J Biopharm Stat 2024:1-23. [PMID: 38363805 DOI: 10.1080/10543406.2024.2311248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 01/24/2024] [Indexed: 02/18/2024]
Abstract
There has been an increasing use of master protocols in oncology clinical trials because of its efficiency to accelerate cancer drug development and flexibility to accommodate multiple substudies. Depending on the study objective and design, a master protocol trial can be a basket trial, an umbrella trial, a platform trial, or any other form of trials in which multiple investigational products and/or subpopulations are studied under a single protocol. Master protocols can use external data and evidence (e.g. external controls) for treatment effect estimation, which can further improve efficiency of master protocol trials. This paper provides an overview of different types of external controls and their unique features when used in master protocols. Some key considerations in master protocols with external controls are discussed including construction of estimands, assessment of fit-for-use real-world data, and considerations for different types of master protocols. Similarities and differences between regular randomized controlled trials and master protocols when using external controls are discussed. A targeted learning-based causal roadmap is presented which constitutes three key steps: (1) define a target statistical estimand that aligns with the causal estimand for the study objective, (2) use an efficient estimator to estimate the target statistical estimand and its uncertainty, and (3) evaluate the impact of causal assumptions on the study conclusion by performing sensitivity analyses. Two illustrative examples for master protocols using external controls are discussed for their merits and possible improvement in causal effect estimation.
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Affiliation(s)
- Jie Chen
- Data Sciences, ECR Global, Shanghai, China
| | | | | | - Sammy Yuan
- Oncology Statistics, GlaxoSmithKline, Collegeville, Pennsylvania, USA
| | - Godwin Yung
- Product Development Data and Statistical Sciences, Genentech/Roche, South San Francisco, Cambridge, USA
| | - Jingjing Ye
- Global Statistics and Data Sciences, BeiGene, Fulton, Maryland, USA
| | - Hong Tian
- Global Statistics, BeiGene, Ridgefield Park, New Jersy, USA
| | - Jianchang Lin
- Statistical & Quantitative Sciences, Takeda, Cambridge, Massachusetts, USA
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23
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Salvatore M, Kundu R, Shi X, Friese CR, Lee S, Fritsche LG, Mondul AM, Hanauer D, Pearce CL, Mukherjee B. To weight or not to weight? Studying the effect of selection bias in three large EHR-linked biobanks. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.02.12.24302710. [PMID: 38405832 PMCID: PMC10888982 DOI: 10.1101/2024.02.12.24302710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Objective To explore the role of selection bias adjustment by weighting electronic health record (EHR)-linked biobank data for commonly performed analyses. Materials and methods We mapped diagnosis (ICD code) data to standardized phecodes from three EHR-linked biobanks with varying recruitment strategies: All of Us (AOU; n=244,071), Michigan Genomics Initiative (MGI; n=81,243), and UK Biobank (UKB; n=401,167). Using 2019 National Health Interview Survey data, we constructed selection weights for AOU and MGI to be more representative of the US adult population. We used weights previously developed for UKB to represent the UKB-eligible population. We conducted four common descriptive and analytic tasks comparing unweighted and weighted results. Results For AOU and MGI, estimated phecode prevalences decreased after weighting (weighted-unweighted median phecode prevalence ratio [MPR]: 0.82 and 0.61), while UKB's estimates increased (MPR: 1.06). Weighting minimally impacted latent phenome dimensionality estimation. Comparing weighted versus unweighted PheWAS for colorectal cancer, the strongest associations remained unaltered and there was large overlap in significant hits. Weighting affected the estimated log-odds ratio for sex and colorectal cancer to align more closely with national registry-based estimates. Discussion Weighting had limited impact on dimensionality estimation and large-scale hypothesis testing but impacted prevalence and association estimation more. Results from untargeted association analyses should be followed by weighted analysis when effect size estimation is of interest for specific signals. Conclusion EHR-linked biobanks should report recruitment and selection mechanisms and provide selection weights with defined target populations. Researchers should consider their intended estimands, specify source and target populations, and weight EHR-linked biobank analyses accordingly.
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Affiliation(s)
- Maxwell Salvatore
- Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA
- Center for Precision Health Data Science, University of Michigan, Ann Arbor, MI, USA
| | - Ritoban Kundu
- Center for Precision Health Data Science, University of Michigan, Ann Arbor, MI, USA
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Xu Shi
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Christopher R Friese
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
- Center for Improving Patient and Population Health, School of Nursing, University of Michigan, Ann Arbor, MI, USA
- Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Seunggeun Lee
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
- Graduate School of Data Science, Seoul National University, Seoul, Republic of Korea
| | - Lars G Fritsche
- Center for Precision Health Data Science, University of Michigan, Ann Arbor, MI, USA
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - Alison M Mondul
- Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - David Hanauer
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Celeste Leigh Pearce
- Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, USA
| | - Bhramar Mukherjee
- Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA
- Center for Precision Health Data Science, University of Michigan, Ann Arbor, MI, USA
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
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24
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Desai RJ, Wang SV, Sreedhara SK, Zabotka L, Khosrow-Khavar F, Nelson JC, Shi X, Toh S, Wyss R, Patorno E, Dutcher S, Li J, Lee H, Ball R, Dal Pan G, Segal JB, Suissa S, Rothman KJ, Greenland S, Hernán MA, Heagerty PJ, Schneeweiss S. Process guide for inferential studies using healthcare data from routine clinical practice to evaluate causal effects of drugs (PRINCIPLED): considerations from the FDA Sentinel Innovation Center. BMJ 2024; 384:e076460. [PMID: 38346815 DOI: 10.1136/bmj-2023-076460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Affiliation(s)
- Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02120, USA
| | - Shirley V Wang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02120, USA
| | - Sushama Kattinakere Sreedhara
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02120, USA
| | - Luke Zabotka
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02120, USA
| | - Farzin Khosrow-Khavar
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02120, USA
| | - Jennifer C Nelson
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Xu Shi
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Sengwee Toh
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Richard Wyss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02120, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02120, USA
| | - Sarah Dutcher
- US Food and Drug Administration, Silver Spring, MD, USA
| | - Jie Li
- US Food and Drug Administration, Silver Spring, MD, USA
| | - Hana Lee
- US Food and Drug Administration, Silver Spring, MD, USA
| | - Robert Ball
- US Food and Drug Administration, Silver Spring, MD, USA
| | | | - Jodi B Segal
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Samy Suissa
- Departments of Epidemiology and Biostatistics, and Medicine, McGill University, Montreal, QC, Canada
| | | | - Sander Greenland
- Department of Epidemiology and Department of Statistics, University of California, Los Angeles, CA, USA
| | - Miguel A Hernán
- CAUSALab and Departments of Epidemiology and Biostatistics, Harvard T H Chan School of Public Health, Boston, MA, USA
| | | | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02120, USA
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25
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Côté P, Negrini S, Donzelli S, Kiekens C, Arienti C, Ceravolo MG, Gross DP, Battel I, Ferriero G, Lazzarini SG, Dan B, Shearer HM, Wong JJ. Introduction to target trial emulation in rehabilitation: a systematic approach to emulate a randomized controlled trial using observational data. Eur J Phys Rehabil Med 2024; 60:145-153. [PMID: 38420907 PMCID: PMC10938938 DOI: 10.23736/s1973-9087.24.08435-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 01/26/2024] [Indexed: 03/02/2024]
Abstract
Rehabilitation providers and policymakers need valid evidence to make informed decisions about the healthcare needs of the population. Whenever possible, these decisions should be informed by randomized controlled trials (RCTs). However, there are circumstances when evidence needs to be generated rapidly, or when RCTs are not ethical or feasible. These situations apply to studying the effects of complex interventions, including rehabilitation as defined by Cochrane Rehabilitation. Therefore, we explore using the target trial emulation framework by Hernán and colleagues to obtain valid estimates of the causal effects of rehabilitation when RCTs cannot be conducted. Target trial emulation is a framework guiding the design and analysis of non-randomized comparative effectiveness studies using observational data, by emulating a hypothetical RCT. In the context of rehabilitation, we outline steps for applying the target trial emulation framework using real world data, highlighting methodological considerations, limitations, potential mitigating strategies, and causal inference and counterfactual theory as foundational principles to estimating causal effects. Overall, we aim to strengthen methodological approaches used to estimate causal effects of rehabilitation when RCTs cannot be conducted.
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Affiliation(s)
- Pierre Côté
- Institute for Disability and Rehabilitation Research, Faculty of Health Sciences, Ontario Tech University, Oshawa, ON, Canada
| | - Stefano Negrini
- Department of Biomedical, Surgical and Dentals Sciences, University "La Statale", Milan, Italy
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Sabrina Donzelli
- Department of Orthopedics, University Medical Center, Utrecht, the Netherlands
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | | | - Maria G Ceravolo
- Department of Experimental and Clinical Medicine, Polytechnic University of Marche University, Ancona, Italy
| | - Douglas P Gross
- Department of Physical Therapy, University of Alberta, Edmonton, AB, Canada
| | - Irene Battel
- Department of Biomedical, Surgical and Dentals Sciences, University "La Statale", Milan, Italy -
| | - Giorgio Ferriero
- Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
- Physical Rehabilitation Medicine Unit, Scientific Institute of Tradate IRCCS, Istituti Clinici Scientifici Maugeri, Tradate, Varese, Italy
| | | | - Bernard Dan
- Faculty of Psychology and Educational Sciences, Université Libre de Bruxelles, Brussels, Belgium
- Inkendaal Rehabilitation Hospital, Vlezenbeek, Belgium
| | - Heather M Shearer
- Institute for Disability and Rehabilitation Research, Faculty of Health Sciences, Ontario Tech University, Oshawa, ON, Canada
- Division of Research, Canadian Memorial Chiropractic College, Toronto, ON, Canada
| | - Jessica J Wong
- Institute for Disability and Rehabilitation Research, Faculty of Health Sciences, Ontario Tech University, Oshawa, ON, Canada
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26
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van Zwieten A, Blyth FM, Wong G, Khalatbari-Soltani S. Consideration of overadjustment bias in guidelines and tools for systematic reviews and meta-analyses of observational studies is long overdue. Int J Epidemiol 2024; 53:dyad174. [PMID: 38129959 PMCID: PMC10859154 DOI: 10.1093/ije/dyad174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023] Open
Affiliation(s)
- Anita van Zwieten
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, Children’s Hospital at Westmead, Westmead, NSW, Australia
| | - Fiona M Blyth
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- ARC Centre of Excellence in Population Ageing Research (CEPAR), University of Sydney, Sydney, NSW, Australia
| | - Germaine Wong
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, Children’s Hospital at Westmead, Westmead, NSW, Australia
- Centre for Transplant and Renal Research, Westmead Hospital, Westmead, NSW, Australia
| | - Saman Khalatbari-Soltani
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- ARC Centre of Excellence in Population Ageing Research (CEPAR), University of Sydney, Sydney, NSW, Australia
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Allen NE, Lacey B, Lawlor DA, Pell JP, Gallacher J, Smeeth L, Elliott P, Matthews PM, Lyons RA, Whetton AD, Lucassen A, Hurles ME, Chapman M, Roddam AW, Fitzpatrick NK, Hansell AL, Hardy R, Marioni RE, O’Donnell VB, Williams J, Lindgren CM, Effingham M, Sellors J, Danesh J, Collins R. Prospective study design and data analysis in UK Biobank. Sci Transl Med 2024; 16:eadf4428. [PMID: 38198570 PMCID: PMC11127744 DOI: 10.1126/scitranslmed.adf4428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 12/13/2023] [Indexed: 01/12/2024]
Abstract
Population-based prospective studies, such as UK Biobank, are valuable for generating and testing hypotheses about the potential causes of human disease. We describe how UK Biobank's study design, data access policies, and approaches to statistical analysis can help to minimize error and improve the interpretability of research findings, with implications for other population-based prospective studies being established worldwide.
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Affiliation(s)
- Naomi E Allen
- UK Biobank Ltd, Stockport, UK
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Ben Lacey
- UK Biobank Ltd, Stockport, UK
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Deborah A Lawlor
- Population Health Science, Bristol Medical School University of Bristol, Bristol, UK
- Medical Research Council Integrative Epidemiology Unit at the University of Bristol, Bristol, UK
| | - Jill P Pell
- School of Health and Wellbeing, University of Glasgow, Scotland
| | - John Gallacher
- Department of Psychiatry, University of Oxford, Oxford, UK
- Dementias Platform UK, Department of Psychiatry, University of Oxford, Oxford, UK
| | - Liam Smeeth
- London School of Hygiene and Tropical Medicine, London, UK
| | - Paul Elliott
- MRC Centre for Environment and Health, School of Public Health, Imperial College London, London, UK
- NIHR Health Protection Research Unit in Chemical Radiation Threats and Hazards, Imperial College London, UK
| | - Paul M Matthews
- UK Dementia Research Centre Institute and Department of Brain Sciences, Imperial College London, London, UK
| | - Ronan A Lyons
- Population Data Science, Swansea University Medical School, Swansea, Wales
| | - Anthony D Whetton
- Veterinary Health Innovation Engine, University of Surrey, Guildford, UK
| | - Anneke Lucassen
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Faculty of Medicine, Southampton University, Southampton, UK
| | - Matthew E Hurles
- Wellcome Trust Sanger Institute, Wellcome Genome Campus, Cambridge, UK
| | | | | | | | - Anna L Hansell
- Centre for Environmental Health and Sustainability, University of Leicester, Leicester, UK
| | - Rebecca Hardy
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Riccardo E Marioni
- Centre for Genomic and Experimental Medicine, University of Edinburgh, Edinburgh, Scotland
| | | | - Julie Williams
- UK Dementia Research Institute, Cardiff University, Cardiff, Wales
| | - Cecilia M Lindgren
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
| | | | | | - John Danesh
- British Heart Foundation Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Health Data Research UK Cambridge, Wellcome Genome Campus and University of Cambridge, Cambridge, UK
- National Institute for Health Research Cambridge Biomedical Research Centre, University of Cambridge and Cambridge University Hospitals, Cambridge, UK
| | - Rory Collins
- UK Biobank Ltd, Stockport, UK
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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28
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L'Espérance K, Abrahamowicz M, O'Loughlin J, Koushik A. Childhood body fatness and the risk of epithelial ovarian cancer: A population-based case-control study in Montreal, Canada. Prev Med 2024; 178:107794. [PMID: 38072312 DOI: 10.1016/j.ypmed.2023.107794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 11/14/2023] [Accepted: 12/01/2023] [Indexed: 12/17/2023]
Abstract
OBJECTIVE To assess the association between childhood body fatness and epithelial ovarian cancer (EOC), and whether this association differs by type of EOC. METHODS Using data from a population-based case-control study (497 cases and 902 controls) in Montreal, Canada conducted 2011-2016, we examined the association between childhood body fatness and EOC, overall and separately for invasive vs. borderline EOCs. A figure rating scale was used to measure body fatness at ages 5 and 10. Multivariable logistic regression was used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (95% CI). Quantitative bias analyses were conducted to assess the impact of exposure misclassification and non-participation. RESULTS The aOR (95% CI) of overall EOC for high vs. low body fatness was 1.07 (0.85-1.34) at age 5 and 1.28 (0.98-1.68) at age 10. The associations were stronger for invasive EOC, specifically the endometrioid histological type. For borderline cancers, the aORs were below the null value with wide confidence intervals. Bias analyses did not reveal a strong influence of non-participation. Non-differential exposure misclassification may have biased aORs towards the null for invasive cancers but did not appear to have an appreciable influence on the aORs for borderline cancers. CONCLUSIONS Childhood body fatness may be a risk factor for invasive EOC in later adult life. Our study highlights the potential importance of examining early life factors for a comprehensive understanding of EOC development.
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Affiliation(s)
- Kevin L'Espérance
- Université de Montréal Hospital Research Centre (CRCHUM), 850, rue Saint-Denis, Montréal, Québec H2X 0A9, Canada; Department of Social and Preventive Medicine, Université de Montréal, 7101, avenue du Parc, Montréal, Québec H3N 1X9, Canada
| | - Michal Abrahamowicz
- Centre for Outcomes Research and Evaluation and Division of Clinical Epidemiology, 1001, boulevard Décarie, Montréal, Québec H4A 3J1, Canada; Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine and Health Sciences, McGill University, 2001, avenue McGill College, Montréal, Québec H3A 1Y7, Canada
| | - Jennifer O'Loughlin
- Université de Montréal Hospital Research Centre (CRCHUM), 850, rue Saint-Denis, Montréal, Québec H2X 0A9, Canada; Department of Social and Preventive Medicine, Université de Montréal, 7101, avenue du Parc, Montréal, Québec H3N 1X9, Canada
| | - Anita Koushik
- Université de Montréal Hospital Research Centre (CRCHUM), 850, rue Saint-Denis, Montréal, Québec H2X 0A9, Canada; Department of Social and Preventive Medicine, Université de Montréal, 7101, avenue du Parc, Montréal, Québec H3N 1X9, Canada; Gerald Bronfman Department of Oncology, Faculty of Medicine and Health Sciences, McGill University, 5100 de Maisonneuve Blvd. West, Suite 720, Montréal, Québec H4A 3T2, Canada; St. Mary's Research Centre, 3830 Lacombe Ave, Montréal, Québec, H3T 1M5, Canada.
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29
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Layton JB, Peetluk L, Wong HL, Jiao Y, Djibo DA, Bui C, Lloyd PC, Gruber JF, Miller M, Ogilvie RP, Deng J, Parambi R, Song J, Weatherby LB, Lo AC, Matuska K, Wernecke M, Clarke TC, Cho S, Bell EJ, Seeger JD, Yang GW, Illei D, Forshee RA, Anderson SA, McMahill-Walraven CN, Chillarige Y, Amend KL, Anthony MS, Shoaibi A. Effectiveness of monovalent COVID-19 booster/additional vaccine doses in the United States. Vaccine X 2024; 16:100447. [PMID: 38318230 PMCID: PMC10840109 DOI: 10.1016/j.jvacx.2024.100447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/18/2024] [Accepted: 01/19/2024] [Indexed: 02/07/2024] Open
Abstract
Background Monovalent booster/additional doses of COVID-19 vaccines were first authorized in August 2021 in the United States. We evaluated the real-world effectiveness of receipt of a monovalent booster/additional dose of COVID-19 vaccine compared with receiving a primary vaccine series without a booster/additional dose. Methods Cohorts of individuals receiving a COVID-19 booster/additional dose after receipt of a complete primary vaccine series were identified in 2 administrative insurance claims databases (Optum, CVS Health) supplemented with state immunization information system data between August 2021 and March 2022. Individuals with a complete primary series but without a booster/additional dose were one-to-one matched to boosted individuals on calendar date, geography, and clinical factors. COVID-19 diagnoses were identified in any medical setting, or specifically in hospitals/emergency departments (EDs). Propensity score-weighted hazards ratios (HRs) and 95% confidence intervals (CI) were estimated with Cox proportional hazards models; vaccine effectiveness (VE) was estimated as 1 minus the HR by vaccine brand overall and within subgroups of variant-specific eras, immunocompromised status, and homologous/heterologous booster status. Results Across both data sources, we identified 752,165 matched pairs for BNT162b2, 410,501 for mRNA-1273, and 11,398 for JNJ-7836735. For any medically diagnosed COVID-19, meta-analyzed VE estimates for BNT162b2, mRNA-1273, and JNJ-7836735, respectively, were: BNT162b2, 54% (95% CI, 53%-56%); mRNA-1273, 58% (95% CI, 56%-59%); JNJ-7836735, 34% (95% CI, 23%-44%). For hospital/ED-diagnosed COVID-19, VE estimates ranged from 70% to 76%. VE was generally lower during the Omicron era than the Delta era and for immunocompromised individuals. There was little difference observed by homologous or heterologous booster status. Conclusion The original, monovalent booster/additional doses were reasonably effective in real-world use among the populations for which they were indicated during the study period. Additional studies may be informative in the future as new variants emerge and new vaccines become available.Registration: The study protocol was publicly posted on the BEST Initiative website (https://bestinitiative.org/wp-content/uploads/2022/03/C19-VX-Effectiveness-Protocol_2022_508.pdf).
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Affiliation(s)
| | | | - Hui Lee Wong
- US Food and Drug Administration, Center for Biologics Evaluation and Research, Silver Spring, MD, USA
| | | | | | - Christine Bui
- RTI Health Solutions, Research Triangle Park, NC, USA
| | - Patricia C. Lloyd
- US Food and Drug Administration, Center for Biologics Evaluation and Research, Silver Spring, MD, USA
| | - Joann F. Gruber
- US Food and Drug Administration, Center for Biologics Evaluation and Research, Silver Spring, MD, USA
| | | | | | - Jie Deng
- Optum Epidemiology, Boston, MA, USA
| | | | | | | | | | | | | | - Tainya C. Clarke
- US Food and Drug Administration, Center for Biologics Evaluation and Research, Silver Spring, MD, USA
| | - Sylvia Cho
- US Food and Drug Administration, Center for Biologics Evaluation and Research, Silver Spring, MD, USA
| | | | | | | | | | - Richard A. Forshee
- US Food and Drug Administration, Center for Biologics Evaluation and Research, Silver Spring, MD, USA
| | - Steven A. Anderson
- US Food and Drug Administration, Center for Biologics Evaluation and Research, Silver Spring, MD, USA
| | | | | | | | | | - Azadeh Shoaibi
- US Food and Drug Administration, Center for Biologics Evaluation and Research, Silver Spring, MD, USA
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Xiao J, Jain A, Bellia G, Nyhan K, Liew Z. A scoping review of multigenerational impacts of grandparental exposures on mental health in grandchildren. Curr Environ Health Rep 2023; 10:369-382. [PMID: 38008881 DOI: 10.1007/s40572-023-00413-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2023] [Indexed: 11/28/2023]
Abstract
PURPOSE OF REVIEW The multigenerational effects of grandparental exposures on their grandchildren's mental health and neurodevelopment are gaining research attention. We conducted a scoping review to summarize the current epidemiological studies investigating pregnancy-related and environmental factors that affected grandparental pregnancies and mental health outcomes in their grandchildren. We also identified methodological challenges that affect these multigenerational health studies and discuss opportunities for future research. RECENT FINDINGS We performed a literature search using PubMed and Embase and included 18 articles for this review. The most investigated grandparental pregnancy-related factors were the grandparental age of pregnancy (N = 6), smoking during pregnancy (N = 4), and medication intake (N = 3). The most frequently examined grandchild outcomes were autism spectrum disorder (N = 6) and attention-deficit/hyperactivity disorder (N = 4). Among these studies, grandparental smoking and the use of diethylstilbestrol were more consistently reported to be associated with neurodevelopmental disorders, while the findings for grandparental age vary across the maternal or paternal line. Grandmaternal weight, adverse delivery outcomes, and other spatial-temporal markers of physical and social environmental stressors require further scrutiny. The current body of literature has suggested that mental and neurodevelopmental disorders may be outcomes of unfavorable exposures originating from the grandparental generation during their pregnancies. To advance the field, we recommend research efforts into setting up multigenerational studies with prospectively collected data that span through at least three generations, incorporating spatial, environmental, and biological markers for exposure assessment, expanding the outcome phenotypes evaluated, and developing a causal analytical framework including mediation analyses specific for multigenerational research.
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Affiliation(s)
- Jingyuan Xiao
- Department of Environmental Health Sciences, Yale School of Public Health, New Haven, USA
- Yale Center for Perinatal, Pediatric, and Environmental Epidemiology, Yale School of Public Health, New Haven, USA
| | - Anushka Jain
- Department of Social Behavioral Sciences, Yale School of Public Health, New Haven, USA
| | - Giselle Bellia
- Yale Center for Perinatal, Pediatric, and Environmental Epidemiology, Yale School of Public Health, New Haven, USA
| | - Kate Nyhan
- Department of Environmental Health Sciences, Yale School of Public Health, New Haven, USA
| | - Zeyan Liew
- Department of Environmental Health Sciences, Yale School of Public Health, New Haven, USA.
- Yale Center for Perinatal, Pediatric, and Environmental Epidemiology, Yale School of Public Health, New Haven, USA.
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Resende V, Tsilimigras DI, Endo Y, Guglielmi A, Ratti F, Aldrighetti L, Marques HP, Soubrane O, Lam V, Poultsides GA, Popescu I, Alexandrescu S, Gleisner A, Martel G, Hugh T, Endo I, Shen F, Pawlik TM. Machine-Based Learning Hierarchical Cluster Analysis: Sex-Based Differences in Prognosis Following Resection of Hepatocellular Carcinoma. World J Surg 2023; 47:3319-3327. [PMID: 37777670 DOI: 10.1007/s00268-023-07194-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Patients with hepatocellular carcinoma (HCC) may have a heterogeneous presentation, as well as different long-term outcomes following surgical resection. We sought to use machine learning to cluster patients into different prognostic groups based on preoperative characteristics. METHODS Patients who underwent curative-intent liver resection for HCC between 2000 and 2020 were identified from a large international multi-institutional database. A hierarchical cluster analysis was performed based on preoperative factors to characterize patterns of presentation and define disease-free survival (DFS). RESULTS Among 966 with HCC, 3 distinct clusters were identified: Cluster 1 (n = 160, 16.5%), Cluster 2 (n = 537, 55.6%) and Cluster 3 (n = 269, 27.8%). Cluster 1 (n = 160, 16.5%) consisted of female patients (n = 160, 100%), low inflammation-based scores, intermediate tumor burden score (TBS) (median: 4.71) and high alpha-fetoprotein (AFP) levels (median 41.3 ng/mL); Cluster 2 consisted of male individuals (n = 537, 100%), mainly with a history of HBV infection (n = 429, 79.9%), low inflammation-based scores, intermediate AFP levels (median 26.0 ng/mL) and lower TBS (median 4.49); Cluster 3 was comprised of older patients (median age 68 years) predominantly male (n = 248, 92.2%) who had low incidence of HBV/HCV infection (7.1% and 8.2%, respectively), intermediate AFP levels (median 16.8 ng/mL), high inflammation-based scores and high TBS (median 6.58). Median DFS worsened incrementally among the three different clusters with Cluster 3 having the lowest DFS (Cluster 1: median not reached; Cluster 2: 34 months, 95% CI 23.0-48.0, Cluster 3: 19 months, 95% CI 15.0-29.0, p < 0.05). CONCLUSION Cluster analysis classified HCC patients into three distinct prognostic groups. Cluster assignment predicted DFS following resection of HCC with the female cluster having the most favorable prognosis following HCC resection.
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Affiliation(s)
- Vivian Resende
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
- Federal University of Minas Gerais School of Medicine, Belo Horizonte, Brazil
| | - Diamantis I Tsilimigras
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | - Yutaka Endo
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, 395 W. 12th Ave., Suite 670, Columbus, OH, USA
| | | | | | | | - Hugo P Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | - Olivier Soubrane
- Department of Hepatobiliopancreatic Surgery, APHP, Beaujon Hospital, Clichy, France
| | - Vincent Lam
- Department of Surgery, Westmead Hospital, Sydney, Australia
| | | | - Irinel Popescu
- Department of Surgery, Fundeni Clinical Institute, Bucharest, Romania
| | | | - Ana Gleisner
- Department of Surgery, University of Colorado, Denver, CO, USA
| | | | - Tom Hugh
- Department of Surgery, School of Medicine, The University of Sydney, Sydney, Australia
| | - Itaru Endo
- Yokohama City University School of Medicine, Yokohama, Japan
| | - Feng Shen
- Eastern Hepatobiliary Surgery Hospital Second Military Medical University, Shanghai, China
| | - Timothy M Pawlik
- Department of Surgery, Wexner Medical Center and James Comprehensive Cancer Center, The Ohio State University, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Rosen EM, Ritchey ME, Girman CJ. Can Weight of Evidence, Quantitative Bias, and Bounding Methods Evaluate Robustness of Real-world Evidence for Regulator and Health Technology Assessment Decisions on Medical Interventions? Clin Ther 2023; 45:1266-1276. [PMID: 37798219 DOI: 10.1016/j.clinthera.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 06/07/2023] [Accepted: 09/12/2023] [Indexed: 10/07/2023]
Abstract
PURPOSE High-quality evidence is crucial for health care intervention decision-making. These decisions frequently use nonrandomized data, which can be more vulnerable to biases than randomized trials. Accordingly, methods to quantify biases and weigh available evidence could elucidate the robustness of findings, giving regulators more confidence in making approval and reimbursement decisions. METHODS We conducted an integrative literature review to identify methods for determining probability of causation, evaluating weight of evidence, and conducting quantitative bias analysis as related to health care interventions. Eligible studies were published from 2012 to 2021, applicable to pharmacoepidemiology, and presented a method that met our objective. FINDINGS Twenty-two eligible studies were classified into 4 categories: (1) quantitative bias analysis; (2) weight of evidence methods; (3) Bayesian networks; and (4) miscellaneous. All of the methods have strengths, limitations, and situations in which they are more well suited than others. Some methods seem to lend themselves more to applications of health care evidence on medical interventions than others. IMPLICATIONS To provide robust evidence for and improve confidence in regulatory or reimbursement decisions, we recommend applying multiple methods to triangulate associations of medical interventions, accounting for biases in different ways. This approach could lead to well-defined robustness assessments of study findings and appropriate science-driven decisions by regulators and payers for public health.
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Affiliation(s)
- Emma M Rosen
- Department of Epidemiology, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA; CERobs Consulting, LLC, Wrightsville Beach, North Carolina, USA
| | - Mary E Ritchey
- CERobs Consulting, LLC, Wrightsville Beach, North Carolina, USA; Med Tech Epi, LLC; Philadelphia, Pennsylvania, USA; Center for Pharmacoepidemiology & Treatment Science, Rutgers University, New Brunswick, New Jersey, USA
| | - Cynthia J Girman
- Department of Epidemiology, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA; CERobs Consulting, LLC, Wrightsville Beach, North Carolina, USA.
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Rosenfeld EB, Brandt JS, Fields JC, Lee R, Graham HL, Sharma R, Ananth CV. Chronic Hypertension and the Risk of Readmission for Postpartum Cardiovascular Complications. Obstet Gynecol 2023; 142:1431-1439. [PMID: 37917949 PMCID: PMC10662390 DOI: 10.1097/aog.0000000000005424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/14/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVE Preeclampsia is an important risk factor for cardiovascular disease (CVD, including heart disease and stroke) along the life course. However, whether exposure to chronic hypertension in pregnancy, in the absence of preeclampsia, is implicated in CVD risk during the immediate postpartum period remains poorly understood. Our objective was to estimate the risk of readmission for CVD complications within the calendar year after delivery for people with chronic hypertension. METHODS The Healthcare Cost and Utilization Project's Nationwide Readmission Database (2010-2018) was used to conduct a retrospective cohort study of patients aged 15-54 years. International Classification of Diseases codes were used to identify patients with chronic hypertension and postpartum readmission for CVD complications within 1 year of delivery. People with CVD diagnosed during pregnancy or delivery admission, multiple births, or preeclampsia or eclampsia were excluded. Excess rates of CVD readmission among patients with and without chronic hypertension were estimated. Associations between chronic hypertension and CVD complications were determined from Cox proportional hazards regression models. RESULTS Of 27,395,346 delivery hospitalizations that resulted in singleton births, 2.0% of individuals had chronic hypertension (n=544,639). The CVD hospitalization rate among patients with chronic hypertension and normotensive patients was 645 (n=3,791) per 100,000 delivery hospitalizations and 136 (n=37,664) per 100,000 delivery hospitalizations, respectively (rate difference 508, 95% CI 467-549; adjusted hazard ratio 4.11, 95% CI 3.64-4.66). The risk of CVD readmission, in relation to chronic hypertension, persisted for 1 year after delivery. CONCLUSION The heightened CVD risk as early as 1 month postpartum in relation to chronic hypertension underscores the need for close monitoring and timely care after delivery to reduce blood pressure and related complications.
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Affiliation(s)
- Emily B. Rosenfeld
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Justin S. Brandt
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, New York University Langone, New York, NY
| | - Jessica C. Fields
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Rachel Lee
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Hillary L. Graham
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
- Clinical Epidemiology Division, Faculty of Medicine at Solna, Karolinska Institute, Stockholm, Sweden
| | - Ruchira Sharma
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Cande V. Ananth
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
- Cardiovascular Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
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Schneeweiss S, Schneeweiss M. Concepts of Designing and Implementing Pharmacoepidemiology Studies on the Safety of Systemic Treatments in Dermatology Practice. JID INNOVATIONS 2023; 3:100226. [PMID: 37744690 PMCID: PMC10514213 DOI: 10.1016/j.xjidi.2023.100226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 09/26/2023] Open
Abstract
The U.S. Food and Drug Administration and clinical guidelines use evidence from pharmacoepidemiology studies to inform prescribing decisions and fill evidence gaps left by randomized controlled trials (RCTs). The long-term safety and infrequent adverse reactions are not well-understood when RCTs are short and involve few patients, as is the case for most systemic immunomodulating drugs in dermatology. A better understanding of the design and implementation of pharmacoepidemiology studies will help practitioners assess the accuracy of etiologic findings and use them with confidence in clinical practice. Conducting pharmacoepidemiology studies follows a structured approach, which we discuss in this article: (i) a design layer connects the research question with the appropriate study design, and considering which hypothetical RCT one ideally would want to conduct reduces inadvertent investigator errors; (ii) a measurement layer transforms longitudinal patient-level data into variables that identify the study population, patient characteristics, treatment, and outcomes; and (iii) the analysis focuses on the causal treatment effect estimation. The review and interpretation of pharmacoepidemiology studies should consider issues beyond a typical review of RCTs, chiefly the lack of baseline randomization and the use of secondary data. Well-designed and well-conducted pharmacoepidemiologic studies complement dermatology practice with critical information on prescribing systemic medications.
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Affiliation(s)
- Sebastian Schneeweiss
- Dermato-Pharmacoepidemiology Work Group, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Maria Schneeweiss
- Dermato-Pharmacoepidemiology Work Group, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Bond JC, Fox MP, Wise LA, Heaton B. Quantitative Assessment of Systematic Bias: A Guide for Researchers. J Dent Res 2023; 102:1288-1292. [PMID: 37786916 DOI: 10.1177/00220345231193314] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023] Open
Abstract
Observational research provides valuable opportunities to advance oral health science but is limited by vulnerabilities to systematic bias, including unmeasured confounding, errors in variable measurement, or bias in the creation of study populations and/or analytic samples. The potential influence of systematic biases on observed results is often only briefly mentioned among the discussion of limitations of a given study, despite existing methods that support detailed assessments of their potential effects. Quantitative bias analysis is a set of methodological techniques that, when applied to observational data, can provide important context to aid in the interpretation and integration of observational research findings into the broader body of oral health research. Specifically, these methods were developed to provide quantitative estimates of the potential magnitude and direction of the influence of systematic biases on observed results. We aim to encourage and facilitate the broad adoption of quantitative bias analyses into observational oral health research. To this end, we provide an overview of quantitative bias analysis techniques, including a step-by-step implementation guide. We also provide a detailed appendix that guides readers through an applied example using real data obtained from a prospective observational cohort study of preconception periodontitis in relation to time to pregnancy. Quantitative bias analysis methods are available to all investigators. When appropriately applied to observational studies, findings from such studies can have a greater impact in the broader research context.
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Affiliation(s)
- J C Bond
- Department of Health Policy and Health Services Research, Boston University Henry M. Goldman School of Dental Medicine, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - M P Fox
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - L A Wise
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - B Heaton
- Department of Health Policy and Health Services Research, Boston University Henry M. Goldman School of Dental Medicine, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
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Fox MP, MacLehose RF, Lash TL. SAS and R code for probabilistic quantitative bias analysis for misclassified binary variables and binary unmeasured confounders. Int J Epidemiol 2023; 52:1624-1633. [PMID: 37141446 PMCID: PMC10555728 DOI: 10.1093/ije/dyad053] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 04/18/2023] [Indexed: 05/06/2023] Open
Abstract
Systematic error from selection bias, uncontrolled confounding, and misclassification is ubiquitous in epidemiologic research but is rarely quantified using quantitative bias analysis (QBA). This gap may in part be due to the lack of readily modifiable software to implement these methods. Our objective is to provide computing code that can be tailored to an analyst's dataset. We briefly describe the methods for implementing QBA for misclassification and uncontrolled confounding and present the reader with example code for how such bias analyses, using both summary-level data and individual record-level data, can be implemented in both SAS and R. Our examples show how adjustment for uncontrolled confounding and misclassification can be implemented. Resulting bias-adjusted point estimates can then be compared to conventional results to see the impact of this bias in terms of its direction and magnitude. Further, we show how 95% simulation intervals can be generated that can be compared to conventional 95% confidence intervals to see the impact of the bias on uncertainty. Having easy to implement code that users can apply to their own datasets will hopefully help spur more frequent use of these methods and prevent poor inferences drawn from studies that do not quantify the impact of systematic error on their results.
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Affiliation(s)
- Matthew P Fox
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Richard F MacLehose
- Department of Epidemiology, University of Minnesota School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Timothy L Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Boston, MA, USA
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Velders BJJ, Boltje JWT, Vriesendorp MD, Klautz RJM, Le Cessie S, Groenwold RHH. Confounding adjustment in observational studies on cardiothoracic interventions: a systematic review of methodological practice. Eur J Cardiothorac Surg 2023; 64:ezad271. [PMID: 37505476 PMCID: PMC10597584 DOI: 10.1093/ejcts/ezad271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/03/2023] [Accepted: 07/27/2023] [Indexed: 07/29/2023] Open
Abstract
OBJECTIVES It is unknown which confounding adjustment methods are currently used in the field of cardiothoracic surgery and whether these are appropriately applied. The aim of this study was to systematically evaluate the quality of conduct and reporting of confounding adjustment methods in observational studies on cardiothoracic interventions. METHODS A systematic review was performed, which included all observational studies that compared different interventions and were published between 1 January and 1 July 2022, in 3 European and American cardiothoracic surgery journals. Detailed information on confounding adjustment methods was extracted and subsequently described. RESULTS Ninety-two articles were included in the analysis. Outcome regression (n = 49, 53%) and propensity score (PS) matching (n = 44, 48%) were most popular (sometimes used in combination), whereas 11 (12%) studies applied no method at all. The way of selecting confounders was not reported in 42 (46%) of the studies, solely based on previous literature or clinical knowledge in 14 (16%), and (partly) data-driven in 25 (27%). For the studies that applied PS matching, the matched cohorts comprised on average 46% of the entire study population (range 9-82%). CONCLUSIONS Current reporting of confounding adjustment methods is insufficient in a large part of observational studies on cardiothoracic interventions, which makes quality judgement difficult. Appropriate application of confounding adjustment methods is crucial for causal inference on optimal treatment strategies for clinical practice. Reporting on these methods is an important aspect of this, which can be improved.
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Affiliation(s)
- Bart J J Velders
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - J W Taco Boltje
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Michiel D Vriesendorp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Robert J M Klautz
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Saskia Le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
- Department of Biomedical Data Science, Leiden University Medical Center, Leiden, Netherlands
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
- Department of Biomedical Data Science, Leiden University Medical Center, Leiden, Netherlands
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Schleimer JP, Mustafa A, Ross R, Bowen A, Gallagher A, Bowen D, Rowhani-Rahbar A. Misclassification of firearm-related violent crime in criminal legal system records: challenges and opportunities. Inj Epidemiol 2023; 10:46. [PMID: 37784128 PMCID: PMC10544360 DOI: 10.1186/s40621-023-00458-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 09/19/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND Criminal legal system data are one source for measuring some types of firearm-related harms, including those that do not necessarily result in injury or death, but measurement can be hampered by imprecise criminal code statutes. We quantified the degree of misclassification in Washington state criminal codes for measuring firearm-related crime. FINDINGS In this study of individuals aged 18 years and older who were convicted of a misdemeanor in Washington Superior Courts from 1/1/2015 through 12/31/2019, we compared firearm-related charges as measured with criminal codes and with manual review of probable cause documents, considered the gold standard. The sample included 5,390 criminal cases. Of these, 77 (1.4%) were firearm-related as measured with criminal codes and 437 (8.1%) were firearm-related as measured via manual record review. In the sample overall, the sensitivity of criminal codes was 17.6% (95% CI 14.2-21.5%), and negative predictive value (NPV) was 93.2% (95% CI 92.5-93.9%). Sensitivity and NPV were higher for cases with exclusively non-violent charges. For all cases and for cases with any violent crime charge, firearm-related crimes described in probable cause documents most often involved explicit verbal threats, firearm possession, and pointing a firearm at or touching a firearm to someone; almost 10% of all cases involved shooting/discharging a firearm. For cases with exclusively non-violent charges, the most common firearm-related crime was unlawful possession. CONCLUSIONS Criminal records can be used for large-scale policy-relevant studies of firearm-related harms, but this study suggests Washington state criminal codes substantially undercount firearm-related crime, especially firearm-related violent crime.
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Affiliation(s)
- Julia P Schleimer
- Department of Epidemiology, School of Public Health, University of Washington, 3980 15th Ave NE, Seattle, WA, 98195, USA.
- Firearm Injury and Policy Research Program, University of Washington, Seattle, WA, USA.
| | - Ayah Mustafa
- Firearm Injury and Policy Research Program, University of Washington, Seattle, WA, USA
| | - Rachel Ross
- Firearm Injury and Policy Research Program, University of Washington, Seattle, WA, USA
| | - Andrew Bowen
- Firearm Injury and Policy Research Program, University of Washington, Seattle, WA, USA
| | - Amy Gallagher
- Firearm Injury and Policy Research Program, University of Washington, Seattle, WA, USA
| | - Deirdre Bowen
- Firearm Injury and Policy Research Program, University of Washington, Seattle, WA, USA
- School of Law, Seattle University, Seattle, WA, USA
| | - Ali Rowhani-Rahbar
- Department of Epidemiology, School of Public Health, University of Washington, 3980 15th Ave NE, Seattle, WA, 98195, USA
- Firearm Injury and Policy Research Program, University of Washington, Seattle, WA, USA
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Lee AK, Lee SJ, Dublin S. Addressing the unique challenges in studies of long-term medication use and dementia risk. J Am Geriatr Soc 2023; 71:3028-3030. [PMID: 37676467 DOI: 10.1111/jgs.18583] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/08/2023] [Accepted: 08/18/2023] [Indexed: 09/08/2023]
Abstract
This editorial comments on the article by Wu et al. in this issue.
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Affiliation(s)
- Alexandra K Lee
- Division of Geriatrics, University of California San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Sei J Lee
- Division of Geriatrics, University of California San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Sascha Dublin
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
- University of Washington Department of Epidemiology, Seattle, Washington, USA
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
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Dang LE, Gruber S, Lee H, Dahabreh IJ, Stuart EA, Williamson BD, Wyss R, Díaz I, Ghosh D, Kıcıman E, Alemayehu D, Hoffman KL, Vossen CY, Huml RA, Ravn H, Kvist K, Pratley R, Shih MC, Pennello G, Martin D, Waddy SP, Barr CE, Akacha M, Buse JB, van der Laan M, Petersen M. A causal roadmap for generating high-quality real-world evidence. J Clin Transl Sci 2023; 7:e212. [PMID: 37900353 PMCID: PMC10603361 DOI: 10.1017/cts.2023.635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 09/01/2023] [Accepted: 09/17/2023] [Indexed: 10/31/2023] Open
Abstract
Increasing emphasis on the use of real-world evidence (RWE) to support clinical policy and regulatory decision-making has led to a proliferation of guidance, advice, and frameworks from regulatory agencies, academia, professional societies, and industry. A broad spectrum of studies use real-world data (RWD) to produce RWE, ranging from randomized trials with outcomes assessed using RWD to fully observational studies. Yet, many proposals for generating RWE lack sufficient detail, and many analyses of RWD suffer from implausible assumptions, other methodological flaws, or inappropriate interpretations. The Causal Roadmap is an explicit, itemized, iterative process that guides investigators to prespecify study design and analysis plans; it addresses a wide range of guidance within a single framework. By supporting the transparent evaluation of causal assumptions and facilitating objective comparisons of design and analysis choices based on prespecified criteria, the Roadmap can help investigators to evaluate the quality of evidence that a given study is likely to produce, specify a study to generate high-quality RWE, and communicate effectively with regulatory agencies and other stakeholders. This paper aims to disseminate and extend the Causal Roadmap framework for use by clinical and translational researchers; three companion papers demonstrate applications of the Causal Roadmap for specific use cases.
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Affiliation(s)
- Lauren E. Dang
- Department of Biostatistics, University of California, Berkeley, CA, USA
| | | | - Hana Lee
- Office of Biostatistics, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Issa J. Dahabreh
- CAUSALab, Department of Epidemiology and Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Elizabeth A. Stuart
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Brian D. Williamson
- Biostatistics Division, Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Richard Wyss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Iván Díaz
- Division of Biostatistics, Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Debashis Ghosh
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | | | - Katherine L. Hoffman
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Carla Y. Vossen
- Syneos Health Clinical Solutions, Amsterdam, The Netherlands
| | | | | | | | - Richard Pratley
- AdventHealth Translational Research Institute, Orlando, FL, USA
| | - Mei-Chiung Shih
- Cooperative Studies Program Coordinating Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Gene Pennello
- Division of Imaging Diagnostics and Software Reliability, Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - David Martin
- Global Real World Evidence Group, Moderna, Cambridge, MA, USA
| | - Salina P. Waddy
- National Center for Advancing Translational Sciences, Bethesda, MD, USA
| | - Charles E. Barr
- Graticule Inc., Newton, MA, USA
- Adaptic Health Inc., Palo Alto, CA, USA
| | | | - John B. Buse
- Division of Endocrinology, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Mark van der Laan
- Department of Biostatistics, University of California, Berkeley, CA, USA
| | - Maya Petersen
- Department of Biostatistics, University of California, Berkeley, CA, USA
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Burstyn I, Jones RM. The chronicles of statistical methods employed in occupational hygiene. Ann Work Expo Health 2023; 67:920-925. [PMID: 37494458 DOI: 10.1093/annweh/wxad042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/04/2023] [Indexed: 07/28/2023] Open
Affiliation(s)
- Igor Burstyn
- Department of Environmental and Occupational Health, Dornsife School of Public Health, Drexel University, Nesbitt Hall Room 614, 3215 Market Street, Philadelphia, PA 19104, United States
| | - Rachael M Jones
- Department of Environmental Health Sciences, Fielding School of Public Health, University of California, Los Angeles, 650 Charles E. Young Dr S., Los Angeles, CA 90095, United States
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Agay N, Dankner R, Murad H, Olmer L, Freedman LS. Reverse causation biases weighted cumulative exposure model estimates, but can be investigated in sensitivity analyses. J Clin Epidemiol 2023; 161:46-52. [PMID: 37437786 DOI: 10.1016/j.jclinepi.2023.07.001] [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: 02/09/2023] [Revised: 06/30/2023] [Accepted: 07/02/2023] [Indexed: 07/14/2023]
Abstract
OBJECTIVES To examine the effects of reverse causation on estimates from the weighted cumulative exposure (WCE) model that is used in pharmacoepidemiology to explore drug-health outcome associations, and to identify sensitivity analyses for revealing such effects. STUDY DESIGN AND SETTING 314,099 patients with diabetes under Clalit Health Services, Israel, were followed over 2002-2012. The association between metformin and pancreatic cancer (PC) was explored using a WCE model within the framework of discrete-time Cox regression. We used computer simulations to explore the effects of reverse causation on estimates of a WCE model and to examine sensitivity analyses for revealing and adjusting for reverse causation. We then applied those sensitivity analyses to our data. RESULTS Simulation demonstrated bias in the weighted cumulative exposure model and showed that sensitivity analysis could reveal and adjust for these biases. In our data, a positive association was observed (hazard ratio (HR) = 3.24, 95% confidence interval (CI): 2.24-4.73) with metformin exposure in the previous 2 years. After applying sensitivity analysis, assuming reverse causation operated up to 4 years before cancer diagnosis, the association between metformin and PC was no longer apparent. CONCLUSION Reverse causation can cause substantial bias in the WCE model. When suspected, sensitivity analyses based on causal analysis are advocated.
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Affiliation(s)
- Nirit Agay
- Biostatistics and Biomathematics Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan 52621, Israel
| | - Rachel Dankner
- Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan 52621, Israel; Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Havi Murad
- Biostatistics and Biomathematics Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan 52621, Israel
| | - Liraz Olmer
- Biostatistics and Biomathematics Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan 52621, Israel
| | - Laurence S Freedman
- Biostatistics and Biomathematics Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Ramat Gan 52621, Israel.
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Ananth CV, Rutherford C, Rosenfeld EB, Brandt JS, Graham H, Kostis WJ, Keyes KM. Epidemiologic trends and risk factors associated with the decline in mortality from coronary heart disease in the United States, 1990-2019. Am Heart J 2023; 263:46-55. [PMID: 37178994 DOI: 10.1016/j.ahj.2023.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 05/06/2023] [Accepted: 05/08/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Despite the decline in the rate of coronary heart disease (CHD) mortality, it is unknown how the 3 strong and modifiable risk factors - alcohol, smoking, and obesity -have impacted these trends. We examine changes in CHD mortality rates in the United States and estimate the preventable fraction of CHD deaths by eliminating CHD risk factors. METHODS We performed a sequential time-series analysis to examine mortality trends among females and males aged 25 to 84 years in the United States, 1990-2019, with CHD recorded as the underlying cause of death. We also examined mortality rates from chronic ischemic heart disease (IHD), acute myocardial infarction (AMI), and atherosclerotic heart disease (AHD). All underlying causes of CHD deaths were classified based on the International Classification of Disease 9th and 10th revisions. We estimated the preventable fraction of CHD deaths attributable to alcohol, smoking, and high body-mass index (BMI) through the Global Burden of Disease. RESULTS Among females (3,452,043 CHD deaths; mean [standard deviation, SD] age 49.3 [15.7] years), the age-standardized CHD mortality rate declined from 210.5 in 1990 to 66.8 per 100,000 in 2019 (annual change -4.04%, 95% CI -4.05, -4.03; incidence rate ratio [IRR] 0.32, 95% CI, 0.41, 0.43). Among males (5,572,629 CHD deaths; mean [SD] age 47.9 [15.1] years), the age-standardized CHD mortality rate declined from 442.4 to 156.7 per 100,000 (annual change -3.74%, 95% CI, -3.75, -3.74; IRR 0.36, 95% CI, 0.35, 0.37). A slowing of the decline in CHD mortality rates among younger cohorts was evident. Correction for unmeasured confounders through a quantitative bias analysis slightly attenuated the decline. Half of all CHD deaths could have been prevented with the elimination of smoking, alcohol, and obesity, including 1,726,022 female and 2,897,767 male CHD deaths between 1990 and 2019. CONCLUSIONS The decline in CHD mortality is slowing among younger cohorts. The complex dynamics of risk factors appear to shape mortality rates, underscoring the importance of targeted strategies to reduce modifiable risk factors that contribute to CHD mortality.
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Affiliation(s)
- Cande V Ananth
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ; Cardiovascular Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ; Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ; Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ.
| | - Caroline Rutherford
- Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, New York, NY
| | - Emily B Rosenfeld
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Justin S Brandt
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Hillary Graham
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ; Clinical Epidemiology Division, Faculty of Medicine at Solna, Karolinska Institute, Stockholm, Sweden
| | - William J Kostis
- Cardiovascular Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ; Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Katherine M Keyes
- Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, New York, NY
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Brendel P, Torres A, Arah OA. Simultaneous adjustment of uncontrolled confounding, selection bias and misclassification in multiple-bias modelling. Int J Epidemiol 2023; 52:1220-1230. [PMID: 36718093 PMCID: PMC10893963 DOI: 10.1093/ije/dyad001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/23/2023] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Adjusting for multiple biases usually involves adjusting for one bias at a time, with careful attention to the order in which these biases are adjusted. A novel, alternative approach to multiple-bias adjustment involves the simultaneous adjustment of all biases via imputation and/or regression weighting. The imputed value or weight corresponds to the probability of the missing data and serves to 'reconstruct' the unbiased data that would be observed based on the provided assumptions of the degree of bias. METHODS We motivate and describe the steps necessary to implement this method. We also demonstrate the validity of this method through a simulation study with an exposure-outcome relationship that is biased by uncontrolled confounding, exposure misclassification, and selection bias. RESULTS The study revealed that a non-biased effect estimate can be obtained when correct bias parameters are applied. It also found that incorrect specification of every bias parameter by +/-25% still produced an effect estimate with less bias than the observed, biased effect. CONCLUSIONS Simultaneous multi-bias analysis is a useful way of investigating and understanding how multiple sources of bias may affect naive effect estimates. This new method can be used to enhance the validity and transparency of real-world evidence obtained from observational, longitudinal studies.
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Affiliation(s)
- Paul Brendel
- Department of Epidemiology, Fielding School of Public Health, UCLA, Los Angeles, CA, USA
- Valo Health, Boston, MA, USA
| | | | - Onyebuchi A Arah
- Department of Epidemiology, Fielding School of Public Health, UCLA, Los Angeles, CA, USA
- Department of Statistics, College of Letters and Science, UCLA, Los Angeles, CA, USA
- Department of Public Health, Section for Epidemiology, Aarhus University, Aarhus, Denmark
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Sachdev D, Yamada R, Lee R, Sauer MV, Ananth CV. Risk of Stroke Hospitalization After Infertility Treatment. JAMA Netw Open 2023; 6:e2331470. [PMID: 37647063 PMCID: PMC10469284 DOI: 10.1001/jamanetworkopen.2023.31470] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/24/2023] [Indexed: 09/01/2023] Open
Abstract
Importance Stroke accounts for 7% of pregnancy-related deaths in the US. As the use of infertility treatment is increasing, many studies have sought to characterize the association of infertility treatment with the risk of stroke with mixed results. Objective To evaluate the risk of hospitalization from hemorrhagic and ischemic strokes in patients who underwent infertility treatment. Design, Setting, and Participants This population-based, retrospective cohort study used data abstracted from the Nationwide Readmissions Database, which stores data from all-payer hospital inpatient stays from 28 states across the US, from 2010 and 2018. Eligible participants included individuals aged 15 to 54 who had a hospital delivery from January to November in a given calendar year, and any subsequent hospitalizations from January to December in the same calendar year of delivery during the study period. Statistical analysis was performed between November 2022 and April 2023. Exposure Hospital delivery after infertility treatment (ie, intrauterine insemination, assisted reproductive technology, fertility preservation procedures, or use of a gestational carrier) or after spontaneous conception. Main Outcomes and Measures The primary outcome was hospitalization for nonfatal stroke (either ischemic or hemorrhagic stroke) within the first calendar year after delivery. Secondary outcomes included risk of stroke hospitalization at less than 30 days, less than 60 days, less than 90 days, and less than 180 days post partum. Cox proportional hazards regression models were used to estimate associations, which were expressed as hazard ratios (HRs), adjusted for confounders. Effect size estimates were corrected for biases due to exposure misclassification, selection, and unmeasured confounding through a probabilistic bias analysis. Results Of 31 339 991 patients, 287 813 (0.9%; median [IQR] age, 32.1 [28.5-35.8] years) underwent infertility treatment and 31 052 178 (99.1%; median [IQR] age, 27.7 [23.1-32.0] years) delivered after spontaneous conception. The rate of stroke hospitalization within 12 months of delivery was 37 hospitalizations per 100 000 people (105 patients) among those who received infertility treatment and 29 hospitalizations per 100 000 people (9027 patients) among those who delivered after spontaneous conception (rate difference, 8 hospitalizations per 100 000 people; 95% CI, -6 to 21 hospitalizations per 100 000 people; HR, 1.66; 95% CI, 1.17 to 2.35). The risk of hospitalization for hemorrhagic stroke (adjusted HR, 2.02; 95% CI, 1.13 to 3.61) was greater than that for ischemic stroke (adjusted HR, 1.55; 95% CI, 1.01 to 2.39). The risk of stroke hospitalization increased as the time between delivery and hospitalization for stroke increased, particularly for hemorrhagic strokes. In general, these associations became larger for hemorrhagic stroke and smaller for ischemic stroke following correction for biases. Conclusions and Relevance In this cohort study, infertility treatment was associated with an increased risk of stroke-related hospitalization within 12 months of delivery; this risk was evident as early as 30 days after delivery. Timely follow-up in the immediate days post partum and continued long-term follow-up should be considered to mitigate stroke risk.
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Affiliation(s)
- Devika Sachdev
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Rei Yamada
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Rachel Lee
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Mark V. Sauer
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Cande V. Ananth
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
- Cardiovascular Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey
- Environmental and Occupational Health Sciences Institute, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey
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Angriman F, Lawler PR, Shah BR, Martin CM, Scales DC. Prevalent diabetes and long-term cardiovascular outcomes in adult sepsis survivors: a population-based cohort study. Crit Care 2023; 27:302. [PMID: 37525272 PMCID: PMC10391991 DOI: 10.1186/s13054-023-04586-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/19/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Sepsis survivors are at elevated risk for cardiovascular disease during long-term follow-up. Whether diabetes influences cardiovascular risk after sepsis survival remains unknown. We sought to describe the association of diabetes with long-term cardiovascular outcomes in adult sepsis survivors. METHODS Population-based cohort study in the province of Ontario, Canada (2008-2017). Adult survivors of a first sepsis-associated hospitalization, without pre-existing cardiovascular disease, were included. Main exposure was pre-existing diabetes (any type). The primary outcome was the composite of myocardial infarction, stroke, and cardiovascular death. Patients were followed up to 5 years from discharge date until outcome occurrence or end of study period (March 2018). We used propensity score matching (i.e., 1:1 to patients with sepsis but no pre-existing diabetes) to adjust for measured confounding at baseline. Cause-specific Cox proportional hazards models with robust standard errors were used to estimate hazard ratios (HR) alongside 95% confidence intervals (CI). A main secondary analysis evaluated the modification of the association between sepsis and cardiovascular disease by pre-existing diabetes. RESULTS 78,638 patients with pre-existing diabetes who had a sepsis-associated hospitalization were matched to patients hospitalized for sepsis but without diabetes. Mean age of patients was 71 years, and 55% were female. Median duration from diabetes diagnosis was 9.8 years; mean HbA1c was 7.1%. Adult sepsis survivors with pre-existing diabetes experienced a higher hazard of major cardiovascular disease (HR 1.25; 95% CI 1.22-1.29)-including myocardial infarction (HR 1.40; 95% CI 1.34-1.47) and stroke (HR 1.24; 95% CI 1.18-1.29)-during long-term follow-up compared to sepsis survivors without diabetes. Pre-existing diabetes modified the association between sepsis and cardiovascular disease (risk difference: 2.3%; 95% CI 2.0-2.6 and risk difference: 1.8%; 95% CI 1.6-2.0 for the effect of sepsis-compared to no sepsis-among patients with and without diabetes, respectively). CONCLUSIONS Sepsis survivors with pre-existing diabetes experience a higher long-term hazard of major cardiovascular events when compared to sepsis survivors without diabetes. Compared to patients without sepsis, the absolute risk increase of cardiovascular events after sepsis is higher in patients with diabetes (i.e., diabetes intensified the higher cardiovascular risk induced by sepsis).
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Affiliation(s)
- Federico Angriman
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
| | - Patrick R Lawler
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- McGill University Health Centre, Montreal, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| | - Baiju R Shah
- ICES, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Claudio M Martin
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Canada
- Lawson Health Research Institute, London, Canada
| | - Damon C Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Pakzad R, Nedjat S, Salehiniya H, Mansournia N, Etminan M, Nazemipour M, Pakzad I, Mansournia MA. Effect of alcohol consumption on breast cancer: probabilistic bias analysis for adjustment of exposure misclassification bias and confounders. BMC Med Res Methodol 2023; 23:157. [PMID: 37403100 DOI: 10.1186/s12874-023-01978-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 06/15/2023] [Indexed: 07/06/2023] Open
Abstract
PURPOSE This study was conducted to evaluate the effect of alcohol consumption on breast cancer, adjusting for alcohol consumption misclassification bias and confounders. METHODS This was a case-control study of 932 women with breast cancer and 1000 healthy control. Using probabilistic bias analysis method, the association between alcohol consumption and breast cancer was adjusted for the misclassification bias of alcohol consumption as well as a minimally sufficient set of adjustment of confounders derived from a causal directed acyclic graph. Population attributable fraction was estimated using the Miettinen's Formula. RESULTS Based on the conventional logistic regression model, the odds ratio estimate between alcohol consumption and breast cancer was 1.05 (95% CI: 0.57, 1.91). However, the adjusted estimates of odds ratio based on the probabilistic bias analysis ranged from 1.82 to 2.29 for non-differential and from 1.93 to 5.67 for differential misclassification. Population attributable fraction ranged from 1.51 to 2.57% using non-differential bias analysis and 1.54-3.56% based on differential bias analysis. CONCLUSION A marked measurement error was in self-reported alcohol consumption so after correcting misclassification bias, no evidence against independence between alcohol consumption and breast cancer changed to a substantial positive association.
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Affiliation(s)
- Reza Pakzad
- Department of Epidemiology, Faculty of Health, Ilam University of Medical Sciences, Ilam, Iran
- Student Research Committee, Ilam University of Medical Sciences, Ilam, Iran
| | - Saharnaz Nedjat
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, PO Box: 14155-6446, Tehran, Iran
| | - Hamid Salehiniya
- Department of Epidemiology and Biostatistics, School of Health, Birjand University of Medical Sciences, South Khorasan, Iran
| | - Nasrin Mansournia
- Department of Endocrinology, School of Medicine, AJA University of Medical Sciences, Tehran, Iran
| | - Mahyar Etminan
- Departments of Ophthalmology and Visual Sciences, Medicine and Pharmacology, University of British Columbia, Vancouver, Canada
| | - Maryam Nazemipour
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, PO Box: 14155-6446, Tehran, Iran
| | - Iraj Pakzad
- Department of Microbiology, School of Medicine, Ilam University of Medical Sciences, Ilam, Iran
| | - Mohammad Ali Mansournia
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, PO Box: 14155-6446, Tehran, Iran.
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Teijeiro-Paradis R, Grenier J, Urner M, Douflé G, Steel A, Cypel M, Keshavjee S, Herridge M, Goligher E, Granton J, Ferguson N, Fan E, Del Sorbo L. Outcomes of patients with respiratory failure declined for extracorporeal membrane oxygenation: a prospective observational study. Can J Anaesth 2023; 70:1226-1233. [PMID: 37280459 PMCID: PMC10243882 DOI: 10.1007/s12630-023-02501-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 11/28/2022] [Accepted: 11/28/2022] [Indexed: 06/08/2023] Open
Abstract
PURPOSE Descriptive information on referral patterns and short-term outcomes of patients with respiratory failure declined for extracorporeal membrane oxygenation (ECMO) is lacking. METHODS We conducted a prospective single-centre observational cohort study of ECMO referrals to Toronto General Hospital (receiving hospital) for severe respiratory failure (COVID-19 and non-COVID-19), between 1 December 2019 and 30 November 2020. Data related to the referral, the referral decision, and reasons for refusal were collected. Reasons for refusal were grouped into three mutually exclusive categories selected a priori: "too sick now," "too sick before," and "not sick enough." In declined referrals, referring physicians were surveyed to collect patient outcome on day 7 after the referral. The primary study endpoints were referral outcome (accepted/declined) and patient outcome (alive/deceased). RESULTS A total of 193 referrals were included; 73% were declined for transfer. Referral outcome was influenced by age (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.95 to 0.96; P < 0.01) and involvement of other members of the ECMO team in the discussion (OR, 4.42; 95% CI, 1.28 to 15.2; P < 0.01). Patient outcomes were missing in 46 (24%) referrals (inability to locate the referring physician or the referring physician being unable to recall the outcome). Using available data (95 declined and 52 accepted referrals; n = 147), survival to day 7 was 49% for declined referrals (35% for patients deemed "too sick now," 53% for "too sick before," 100% for "not sick enough," and 50% for reason for refusal not reported) and 98% for transferred patients. Sensitivity analysis setting missing outcomes to directional extreme values retained robustness of survival probabilities. CONCLUSION Nearly half of the patients declined for ECMO consideration were alive on day 7. More information on patient trajectory and long-term outcomes in declined referrals is needed to refine selection criteria.
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Affiliation(s)
- Ricardo Teijeiro-Paradis
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Jasmine Grenier
- Department of Critical Care, Scarborough Health Network, Scarborough, ON, Canada
| | - Martin Urner
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Ghislaine Douflé
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Andrew Steel
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Marcelo Cypel
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Shaf Keshavjee
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Margaret Herridge
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
- Division of Respirology & Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Ewan Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
- Division of Respirology & Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - John Granton
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
- Division of Respirology & Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Niall Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
- Division of Respirology & Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
- Division of Respirology & Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
- Department of Medicine, University of Toronto, Toronto, ON, Canada.
- Toronto General Hospital Research Institute, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.
- Division of Respirology & Critical Care, Department of Medicine, University Health Network, Toronto, ON, Canada.
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Major-Smith D. Exploring causality from observational data: An example assessing whether religiosity promotes cooperation. EVOLUTIONARY HUMAN SCIENCES 2023; 5:e22. [PMID: 37587927 PMCID: PMC10426067 DOI: 10.1017/ehs.2023.17] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 06/15/2023] [Accepted: 06/16/2023] [Indexed: 08/18/2023] Open
Abstract
Causal inference from observational data is notoriously difficult, and relies upon many unverifiable assumptions, including no confounding or selection bias. Here, we demonstrate how to apply a range of sensitivity analyses to examine whether a causal interpretation from observational data may be justified. These methods include: testing different confounding structures (as the assumed confounding model may be incorrect), exploring potential residual confounding and assessing the impact of selection bias due to missing data. We aim to answer the causal question 'Does religiosity promote cooperative behaviour?' as a motivating example of how these methods can be applied. We use data from the parental generation of a large-scale (n = approximately 14,000) prospective UK birth cohort (the Avon Longitudinal Study of Parents and Children), which has detailed information on religiosity and potential confounding variables, while cooperation was measured via self-reported history of blood donation. In this study, there was no association between religious belief or affiliation and blood donation. Religious attendance was positively associated with blood donation, but could plausibly be explained by unmeasured confounding. In this population, evidence that religiosity causes blood donation is suggestive, but rather weak. These analyses illustrate how sensitivity analyses can aid causal inference from observational research.
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Affiliation(s)
- Daniel Major-Smith
- Centre for Academic Child Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol BS8 2BN, UK
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Rovetta A. There is a need for more precise models to assess the determinants of health crises like COVID-19. Front Public Health 2023; 11:1179261. [PMID: 37397715 PMCID: PMC10313224 DOI: 10.3389/fpubh.2023.1179261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/31/2023] [Indexed: 07/04/2023] Open
Abstract
The COVID-19 pandemic has had a significant impact on global mortality. While the causal relationship between SARS-CoV-2 and the anomalous increase in deaths is established, more precise and complex models are needed to determine the exact weight of epidemiological factors involved. Indeed, COVID-19 behavior is influenced by a wide range of variables, including demographic characteristics, population habits and behavior, healthcare performance, and environmental and seasonal risk factors. The bidirectional causality between impacted and impacting aspects, as well as confounding variables, complicates efforts to draw clear, generalizable conclusions regarding the effectiveness and cost-benefit ratio of non-pharmaceutical health countermeasures. Thus, it is imperative that the scientific community and health authorities worldwide develop comprehensive models not only for the current pandemic but also for future health crises. These models should be implemented locally to account for micro-differences in epidemiological characteristics that may have relevant effects. It is important to note that the lack of a universal model does not imply that local decisions have been unjustified, and the request to decrease scientific uncertainty does not mean denying the evidence of the effectiveness of the countermeasures adopted. Therefore, this paper must not be exploited to denigrate either the scientific community or the health authorities.
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