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Fu EL. Target Trial Emulation to Improve Causal Inference from Observational Data: What, Why, and How? J Am Soc Nephrol 2023; 34:1305-1314. [PMID: 37131279 PMCID: PMC10400102 DOI: 10.1681/asn.0000000000000152] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 04/17/2023] [Indexed: 05/04/2023] Open
Abstract
ABSTRACT Target trial emulation has drastically improved the quality of observational studies investigating the effects of interventions. Its ability to prevent avoidable biases that have plagued many observational analyses has contributed to its recent popularity. This review explains what target trial emulation is, why it should be the standard approach for causal observational studies that investigate interventions, and how to do a target trial emulation analysis. We discuss the merits of target trial emulation compared with often used, but biased analyses, as well as potential caveats, and provide clinicians and researchers with the tools to better interpret results from observational studies investigating the effects of interventions.
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Affiliation(s)
- Edouard L Fu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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2
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Guerra-Alejos BC, Kurz M, Min JE, Dale LM, Piske M, Bach P, Bruneau J, Gustafson P, Hu XJ, Kampman K, Korthuis PT, Loughin T, Maclure M, Platt RW, Siebert U, Socías ME, Wood E, Nosyk B. Comparative effectiveness of urine drug screening strategies alongside opioid agonist treatment in British Columbia, Canada: a population-based observational study protocol. BMJ Open 2023; 13:e068729. [PMID: 37258082 PMCID: PMC10255039 DOI: 10.1136/bmjopen-2022-068729] [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: 09/29/2022] [Accepted: 04/26/2023] [Indexed: 06/02/2023] Open
Abstract
INTRODUCTION Urine drug tests (UDTs) are commonly used for monitoring opioid agonist treatment (OAT) responses, supporting the clinical decision for take-home doses and monitoring potential diversion. However, there is limited evidence supporting the utility of mandatory UDTs-particularly the impact of UDT frequency on OAT retention. Real-world evidence can inform patient-centred approaches to OAT and improve current strategies to address the ongoing opioid public health emergency. Our objective is to determine the safety and comparative effectiveness of alternative UDT monitoring strategies as observed in clinical practice among OAT clients in British Columbia, Canada from 2010 to 2020. METHODS AND ANALYSIS We propose a population-level retrospective cohort study of all individuals 18 years of age or older who initiated OAT from 1 January 2010 to 17 March 2020. The study will draw on eight linked health administrative databases from British Columbia. Our primary outcomes include OAT discontinuation and all-cause mortality. To determine the effectiveness of the intervention, we will emulate a 'per-protocol' target trial using a clone censoring approach to compare fixed and dynamic UDT monitoring strategies. A range of sensitivity analyses will be executed to determine the robustness of our results. ETHICS AND DISSEMINATION The protocol, cohort creation and analysis plan have been classified and approved as a quality improvement initiative by Providence Health Care Research Ethics Board and the Simon Fraser University Office of Research Ethics. Results will be disseminated to local advocacy groups and decision-makers, national and international clinical guideline developers, presented at international conferences and published in peer-reviewed journals electronically and in print.
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Affiliation(s)
- B Carolina Guerra-Alejos
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Megan Kurz
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Jeong Eun Min
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Laura M Dale
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Micah Piske
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Paxton Bach
- Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Julie Bruneau
- Department of Family Medicine and Emergency Medicine, University of Montreal, Montreal, Québec, Canada
- Research Center, Centre hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - Paul Gustafson
- Department of Statistics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - X Joan Hu
- Department of Statistics and Actuarial Science, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Kyle Kampman
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - P Todd Korthuis
- School of Public Health, OHSU-PSU, Portland, Oregon, USA
- Section of Addiction Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Tom Loughin
- Department of Statistics and Actuarial Science, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Malcolm Maclure
- Department of Anesthesiology, Pharmacology and Therapeutics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert W Platt
- Departments of Epidemiology, Biostatistics, and Occupational Health and of Pediatrics, McGill University, Montreal, Québec, Canada
| | - U Siebert
- Center for Health Decision Science, Department of Health Policy and Management, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- Department of Public Health, Health Services Research and Health Technology Assessment, Private University of Health Sciences Medical Informatics and Technology Hall/Tyrol Institute for Health Information Systems, Hall in Tirol, Austria
| | - M Eugenia Socías
- Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Evan Wood
- Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Bohdan Nosyk
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
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Kuehne F, Arvandi M, Hess LM, Faries DE, Matteucci Gothe R, Gothe H, Beyrer J, Zeimet AG, Stojkov I, Mühlberger N, Oberaigner W, Marth C, Siebert U. Causal analyses with target trial emulation for real-world evidence removed large self-inflicted biases: systematic bias assessment of ovarian cancer treatment effectiveness. J Clin Epidemiol 2022; 152:269-280. [PMID: 36252741 DOI: 10.1016/j.jclinepi.2022.10.005] [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: 06/13/2022] [Revised: 08/17/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND AND OBJECTIVES Drawing causal conclusions from real-world data (RWD) poses methodological challenges and risk of bias. We aimed to systematically assess the type and impact of potential biases that may occur when analyzing RWD using the case of progressive ovarian cancer. METHODS We retrospectively compared overall survival with and without second-line chemotherapy (LOT2) using electronic medical records. Potential biases were determined using directed acyclic graphs. We followed a stepwise analytic approach ranging from crude analysis and multivariable-adjusted Cox model up to a full causal analysis using a marginal structural Cox model with replicates emulating a reference randomized controlled trial (RCT). To assess biases, we compared effect estimates (hazard ratios [HRs]) of each approach to the HR of the reference trial. RESULTS The reference trial showed an HR for second line vs. delayed therapy of 1.01 (95% confidence interval [95% CI]: 0.82-1.25). The corresponding HRs from the RWD analysis ranged from 0.51 for simple baseline adjustments to 1.41 (95% CI: 1.22-1.64) accounting for immortal time bias with time-varying covariates. Causal trial emulation yielded an HR of 1.12 (95% CI: 0.96-1.28). CONCLUSION Our study, using ovarian cancer as an example, shows the importance of a thorough causal design and analysis if one is expecting RWD to emulate clinical trial results.
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Affiliation(s)
- Felicitas Kuehne
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT TIROL - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Marjan Arvandi
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT TIROL - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Lisa M Hess
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | - Raffaella Matteucci Gothe
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT TIROL - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Holger Gothe
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT TIROL - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria; Chair of Health Sciences/Public Health, Medical Faculty "Carl Gustav Carus", Technical University Dresden, Dresden, Germany
| | | | - Alain Gustave Zeimet
- Department of Obstetrics and Gynecology, Innsbruck Medical University, Innsbruck, Austria
| | - Igor Stojkov
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT TIROL - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Nikolai Mühlberger
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT TIROL - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria
| | - Willi Oberaigner
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT TIROL - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria; Institute for Clinical Epidemiology, Cancer Registry Tyrol, Tirol Kliniken, Innsbruck, Austria
| | - Christian Marth
- Department of Obstetrics and Gynecology, Innsbruck Medical University, Innsbruck, Austria
| | - Uwe Siebert
- Department of Public Health, Health Services Research and Health Technology Assessment, Institute of Public Health, Medical Decision Making and Health Technology Assessment, UMIT TIROL - University for Health Sciences, Medical Informatics and Technology, Hall i.T., Austria; Center for Health Decision Science and Departments of Epidemiology and Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Mitra N, Roy J, Small D. The Future of Causal Inference. Am J Epidemiol 2022; 191:1671-1676. [PMID: 35762132 PMCID: PMC9991894 DOI: 10.1093/aje/kwac108] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/16/2022] [Accepted: 06/17/2022] [Indexed: 01/29/2023] Open
Abstract
The past several decades have seen exponential growth in causal inference approaches and their applications. In this commentary, we provide our top-10 list of emerging and exciting areas of research in causal inference. These include methods for high-dimensional data and precision medicine, causal machine learning, causal discovery, and others. These methods are not meant to be an exhaustive list; instead, we hope that this list will serve as a springboard for stimulating the development of new research.
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Affiliation(s)
- Nandita Mitra
- Correspondence to Dr. Nandita Mitra, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA (e-mail: )
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Edwards JK, Donastorg Y, Zadrozny S, Hileman S, Gómez H, Seamans MJ, Herce ME, Ramírez E, Barrington C, Weir S. A Two-stage Approach for Rapid Assessment of the Proportion Achieving Viral Suppression Using Routine Clinical Data. Epidemiology 2022; 33:642-649. [PMID: 35648416 PMCID: PMC9378579 DOI: 10.1097/ede.0000000000001513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Improving viral suppression among people with HIV reduces morbidity, mortality, and transmission. Accordingly, monitoring the proportion of patients with a suppressed viral load is important to optimizing HIV care and treatment programs. But viral load data are often incomplete in clinical records. We illustrate a two-stage approach to estimate the proportion of treated people with HIV who have a suppressed viral load in the Dominican Republic. METHODS Routinely collected data on viral load and patient characteristics were recorded in a national database, but 74% of patients on treatment at the time of the study did not have a recent viral load measurement. We recruited a subset of these patients for a rapid assessment that obtained additional viral load measurements. We combined results from the rapid assessment and main database using a two-stage weighting approach and compared results to estimates obtained using standard approaches to account for missing data. RESULTS Of patients with recent routinely collected viral load data, 60% had a suppressed viral load. Results were similar after applying standard approaches to account for missing data. Using the two-stage approach, we estimated that 77% (95% confidence interval [CI] = 74, 80) of those on treatment had a suppressed viral load. CONCLUSIONS When assessing the proportion of people on treatment with a suppressed viral load using routinely collected data, applying standard approaches to handle missing data may be inadequate. In these settings, augmenting routinely collected data with data collected through sampling-based approaches could allow more accurate and efficient monitoring of HIV treatment program effectiveness.
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Affiliation(s)
- Jessie K. Edwards
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Yeycy Donastorg
- Instituto Dermatológico y Cirugia de Piel, Santo Domingo, Dominican Republic
| | - Sabrina Zadrozny
- Frank Porter Graham Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Hoisex Gómez
- Instituto Dermatológico y Cirugia de Piel, Santo Domingo, Dominican Republic
| | | | - Michael E. Herce
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Edwin Ramírez
- Servicio Nacional de Salud, Santo Domingo, Dominican Republic
| | - Clare Barrington
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sharon Weir
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Larochelle MR, Lodi S, Yan S, Clothier BA, Goldsmith ES, Bohnert ASB. Comparative Effectiveness of Opioid Tapering or Abrupt Discontinuation vs No Dosage Change for Opioid Overdose or Suicide for Patients Receiving Stable Long-term Opioid Therapy. JAMA Netw Open 2022; 5:e2226523. [PMID: 35960518 PMCID: PMC9375167 DOI: 10.1001/jamanetworkopen.2022.26523] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Opioid dosage tapering has emerged as a strategy to reduce harms associated with long-term opioid therapy; however, evidence supporting this approach is limited. OBJECTIVE To identify the association of opioid tapering or abrupt discontinuation with opioid overdose and suicide events among patients receiving stable long-term opioid therapy without evidence of opioid misuse. DESIGN, SETTING, AND PARTICIPANTS This comparative effectiveness study with a trial emulation approach used a large US claims data set of individuals with commercial insurance or Medicare Advantage who were aged 18 years or older and receiving stable long-term opioid therapy without evidence of opioid misuse between January 1, 2010, and December 31, 2018. Statistical analysis was performed from January 17, 2020, through November 12, 2021. INTERVENTIONS Three opioid dosage strategies: stable dosage, tapering (dosage reduction ≥15%), or abrupt discontinuation. MAIN OUTCOMES AND MEASURES Time to opioid overdose or suicide event identified from International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes in medical claims over 11 months of follow-up. Inverse probability weighting was used to adjust for baseline confounders. The primary analysis used an intention-to-treat approach; follow-up after assignment regardless of changes in opioid dose was included. A per-protocol analysis was also conducted, in which episodes were censored for lack of adherence to assigned treatment. RESULTS A cohort of 199 836 individuals (45.1% men; mean [SD] age, 56.9 [12.4] years; and 57.6% aged 45-64 years) had 415 123 qualifying, long-term opioid therapy episodes; 87.1% of episodes were considered stable, 11.1% were considered a taper, and 1.8% were considered abrupt discontinuation. The adjusted cumulative incidence of opioid overdose or suicide events 11 months after baseline was 0.96% (95% CI, 0.92%-0.99%) with a stable dosage strategy, 1.10% (95% CI, 0.99%-1.22%) with a tapered dosage strategy, and 1.28% (95% CI, 0.93%-1.38%) with an abrupt discontinuation strategy. The risk difference between a taper and a stable dosage was 0.15% (95% CI, 0.03%-0.26%), and the risk difference between abrupt discontinuation and a stable dosage was 0.33% (95% CI, -0.03% to 0.74%). Results were similar using the per-protocol approach. CONCLUSIONS AND RELEVANCE This study identified a small absolute increase in risk of harms associated with opioid tapering compared with a stable opioid dosage. These results do not suggest that policies of mandatory dosage tapering for individuals receiving a stable long-term opioid dosage without evidence of opioid misuse will reduce short-term harm via suicide and overdose.
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Affiliation(s)
- Marc R. Larochelle
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Sara Lodi
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Shapei Yan
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Barbara A. Clothier
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
| | - Elizabeth S. Goldsmith
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota Medical School, Minneapolis
| | - Amy S. B. Bohnert
- Department of Anesthesiology, University of Michigan, Veterans Affairs Center for Clinical Management Research, Ann Arbor
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Mukonda E, Lesosky M. A comparative analysis and review of how national guidelines for chronic disease monitoring are made in low- and middle-income compared to high-income countries. J Glob Health 2021; 11:04055. [PMID: 34552724 PMCID: PMC8442582 DOI: 10.7189/jogh.11.04055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Understanding how clinical practice guidelines and recommendations are adopted in high-income and low-income settings will help contextualise the value and validity of recommendations in different settings. We investigate how major guidelines and recommendations are developed for management and monitoring of post-diagnosis treatment for three important chronic diseases: HIV, hypertension and type 2 diabetes mellitus (T2DM). Methods Eligible guidelines were searched for using PubMed, Google, and health ministry websites for all three conditions. Only guidelines published from 2010 to 2020 were included. The source of the guidelines, year of most recent guideline, and basis of the guidelines were assessed. Additionally, recommendations, the strength of the recommendation and the quality of the evidence for treatment goals of non-pregnant adults and the frequency of monitoring were also extracted and assessed. Results Of the 42 countries searched 90%, 71% and 60% had T2DM, hypertension and HIV guidelines outlining targets for long-term management, respectively. Most T2DM guidelines recommend an HbA1c target of ≤7.0% (68%) or ≤6.5% (24%) as the ideal glycaemic target for most non-pregnant adults, while hypertension guidelines recommend blood pressure (systolic blood pressure/diastolic blood pressure) targets of <140/90 mm Hg (94%) and <130/80 mm Hg (6%). Of the identified HIV guidelines, 67% define virological failure as a viral load >1000 copies/mL, with 26%, mostly HICs, defining virological failure as a viral load >200 copies/mL. Recommendations for the frequency of monitoring for any diagnosed patients were available in 18 (55%) of the hypertension guidelines, 25 (93%) of HIV guidelines, and 27 (73%) of the T2DM guidelines. Only a few of the guidelines provide the strength of the recommendation and the quality of the evidence. Conclusions Most guidelines from LMICs are adopted or adapted from existing HIC guidelines or international and regional organisation guidelines with little consideration for resource availability, contextual factors, logistical issues and general feasibility.
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Affiliation(s)
- Elton Mukonda
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Maia Lesosky
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
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Zhao SS, Lyu H, Yoshida K. Versatility of the clone-censor-weight approach: response to "trial emulation in the presence of immortal-time bias". Int J Epidemiol 2021; 50:694-695. [PMID: 33349843 DOI: 10.1093/ije/dyaa223] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- Sizheng Steven Zhao
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Houchen Lyu
- National Clinical Research Center for Musculoskeletal Diseases, General Hospital of Chinese PLA, Beijing, China.,Department of Orthopedics, General Hospital of Chinese PLA, Beijing, China
| | - Kazuki Yoshida
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, MA, USA
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9
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Kreif N, Sofrygin O, Schmittdiel JA, Adams AS, Grant RW, Zhu Z, van der Laan MJ, Neugebauer R. Exploiting nonsystematic covariate monitoring to broaden the scope of evidence about the causal effects of adaptive treatment strategies. Biometrics 2020; 77:329-342. [PMID: 32297311 DOI: 10.1111/biom.13271] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 01/31/2020] [Accepted: 03/16/2020] [Indexed: 12/25/2022]
Abstract
In studies based on electronic health records (EHR), the frequency of covariate monitoring can vary by covariate type, across patients, and over time, which can limit the generalizability of inferences about the effects of adaptive treatment strategies. In addition, monitoring is a health intervention in itself with costs and benefits, and stakeholders may be interested in the effect of monitoring when adopting adaptive treatment strategies. This paper demonstrates how to exploit nonsystematic covariate monitoring in EHR-based studies to both improve the generalizability of causal inferences and to evaluate the health impact of monitoring when evaluating adaptive treatment strategies. Using a real world, EHR-based, comparative effectiveness research (CER) study of patients with type II diabetes mellitus, we illustrate how the evaluation of joint dynamic treatment and static monitoring interventions can improve CER evidence and describe two alternate estimation approaches based on inverse probability weighting (IPW). First, we demonstrate the poor performance of the standard estimator of the effects of joint treatment-monitoring interventions, due to a large decrease in data support and concerns over finite-sample bias from near-violations of the positivity assumption (PA) for the monitoring process. Second, we detail an alternate IPW estimator using a no direct effect assumption. We demonstrate that this estimator can improve efficiency but at the potential cost of increase in bias from violations of the PA for the treatment process.
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Affiliation(s)
- Noémi Kreif
- Centre for Health Economics, University of York, York, UK
| | - Oleg Sofrygin
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Julie A Schmittdiel
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Alyce S Adams
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Richard W Grant
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Zheng Zhu
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Mark J van der Laan
- Division of Biostatistics, School of Public Health, University of California, Berkeley, California
| | - Romain Neugebauer
- Division of Research, Kaiser Permanente Northern California, Oakland, California
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10
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Mukosha M, Chiyesu G, Vwalika B. Adherence to antiretroviral therapy among HIV infected pregnant women in public health sectors: a pilot of Chilenje level one Hospital Lusaka, Zambia. Pan Afr Med J 2020; 35:49. [PMID: 32537054 PMCID: PMC7250199 DOI: 10.11604/pamj.2020.35.49.20078] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 08/24/2019] [Indexed: 12/22/2022] Open
Abstract
Introduction regular use of Antiretroviral Therapy (ART) in pregnancy and breastfeeding reduces the odds of Mother-to-Child HIV Transmission (MTCT). However, adherence to ART is critical for MTCT to be successful. The present study investigated factors that influence adherence to ART among HIV infected pregnant women in Zambia. Methods a cross-sectional study design was conducted involving 71 HIV infected pregnant women who were advised to join the Prevention of Mother-to-Child HIV Transmission (PMTCT) program during their routine Antenatal clinic (ANC) visit and were on ART for more than six months. We used the Medication Possession Ratio (MPR) to quantify adherence levels. We used logistic regression to establish factors that influence adherence to ART. Results a total of 71 HIV infected pregnant women with a median age of 27years (IQR, 25-30) were enrolled in the study. There was evidence of a difference in adherence levels between pregnant women above 30 years and ones between 15 years and 30 years (P<0.001). Median adherence levels in this group were found to be at 96%(IQR 89-97). The main predictor of adherence in this population was marital status (being on separation) and age. The women who were on separation were 0.14 times less likely to adhere to option B+ compared to married women. Conclusion adherence to option B+ among pregnant women is low. Adherence was significantly influenced by marital status (being on separation) and age. Efforts to improve adherence should be directed towards women on separation and young adults (< 30 years of age).
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Affiliation(s)
- Moses Mukosha
- Department of Pharmacy, University of Zambia, Lusaka, Zambia.,Mosi-o-Tunya University of Science and Technology, Lusaka, Zambia
| | - Grace Chiyesu
- Faculty of Pharmacy Nutrition and Dietetics, Apex Medical University, Lusaka, Zambia
| | - Bellington Vwalika
- Department of Obstetrics and Gynecology, University of Zambia, Lusaka, Zambia
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11
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Stirrup OT, Sabin CA, Phillips AN, Williams I, Churchill D, Tostevin A, Hill T, Dunn DT. Associations between baseline characteristics, CD4 cell count response and virological failure on first-line efavirenz + tenofovir + emtricitabine for HIV. J Virus Erad 2019; 5:204-211. [PMID: 31754443 PMCID: PMC6844404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES The aim of this study was to investigate associations between baseline characteristics and CD4 cell count response on first-line antiretroviral therapy and risk of virological failure (VF) with or without drug resistance. METHODS We conducted an analysis of UK Collaborative HIV Cohort data linked to the UK HIV Drug Resistance Database. Inclusion criteria were viral sequence showing no resistance prior to initiation of first-line efavirenz + tenofovir disoproxil fumarate + emtricitabine and virological suppression within 6 months. Outcomes of VF (≥200 copies/mL) with or without drug resistance were assessed using a competing risks approach fitted jointly with a model for CD4 cell count recovery. Hazard ratios for each VF outcome were estimated for baseline CD4 cell count and viral load and characteristics of CD4 cell count response using latent variables on a standard normal scale. RESULTS A total of 3640 people were included with 338 VF events; corresponding viral sequences were available in 134 with ≥1 resistance mutation in 36. VF with resistance was associated with lower baseline CD4 (0.30, 0.09-0.62), lower CD4 recovery (0.04, 0.00-0.17) and higher CD4 variability (4.40, 1.22-12.68). A different pattern of associations was observed for VF without resistance, but the strength of these results was less consistent across sensitivity analyses. Cumulative incidence of VF with resistance was estimated to be <2% at 3 years for baseline CD4 ≥350 cells/μL. CONCLUSION Lower baseline CD4 cell count and suboptimal CD4 recovery are associated with VF with drug resistance. People with low CD4 cell count before ART or with suboptimal CD4 recovery on treatment should be a priority for regimens with high genetic barrier to resistance.
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Affiliation(s)
- Oliver T Stirrup
- Institute for Global Health, University College London, London, UK
| | - Caroline A Sabin
- Institute for Global Health, University College London, London, UK
| | | | - Ian Williams
- Institute for Global Health, University College London, London, UK
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK
| | | | - Anna Tostevin
- Institute for Global Health, University College London, London, UK
| | - Teresa Hill
- Institute for Global Health, University College London, London, UK
| | - David T Dunn
- Institute for Global Health, University College London, London, UK
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12
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Lodi S, Günthard HF, Gill J, Phillips AN, Dunn D, Vu Q, Siemieniuk R, Garcia F, Logan R, Jose S, Bucher HC, Scherrer AU, Reiss P, van Sighem A, Boender TS, Porter K, Gilson R, Paraskevis D, Simeon M, Vourli G, Moreno S, Jarrin I, Sabin C, Hernán MA. Effectiveness of Transmitted Drug Resistance Testing Before Initiation of Antiretroviral Therapy in HIV-Positive Individuals. J Acquir Immune Defic Syndr 2019; 82:314-320. [PMID: 31609929 PMCID: PMC7830777 DOI: 10.1097/qai.0000000000002135] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND For people living with HIV, major guidelines in high-income countries recommend testing for transmitted drug resistance (TDR) to guide the choice of first-line antiretroviral therapy (ART). However, individuals who fail a first-line regimen can now be switched to one of several effective regimens. Therefore, the virological and clinical benefit of TDR testing needs to be evaluated. METHODS We included individuals from the HIV-CAUSAL Collaboration who enrolled <6 months of HIV diagnosis between 2006 and 2015, were ART-naive, and had measured CD4 count and HIV-RNA. Follow-up started at the date when all inclusion criteria were first met (baseline). We compared 2 strategies: (1) TDR testing within 3 months of baseline versus (2) no TDR testing. We used inverse probability weighting to estimate the 5-year proportion and hazard ratios (HRs) of virological suppression (confirmed HIV-RNA <50 copies/mL), and of AIDS or death under both strategies. RESULTS Of 25,672 eligible individuals (82% males, 52% diagnosed in 2010 or later), 17,189 (67%) were tested for TDR within 3 months of baseline. Of these, 6% had intermediate- or high-level TDR to any antiretroviral drug. The estimated 5-year proportion virologically suppressed was 77% under TDR testing and 74% under no TDR testing; HR 1.06 (95% confidence interval: 1.03 to 1.19). The estimated 5-year risk of AIDS or death was 6% under both strategies; HR 1.03 (95% confidence interval: 0.95 to 1.12). CONCLUSIONS TDR prevalence was low. Although TDR testing improved virological response, we found no evidence that it reduced the incidence of AIDS or death in first 5 years after diagnosis.
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Affiliation(s)
- Sara Lodi
- Boston University School of Public Health, Boston, MA
| | - Huldrych F Günthard
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Zürich, Switzerland
| | - John Gill
- University of Calgary, Calgary, Alberta, Canada
- Southern Alberta Clinic, Calgary, Alberta, Canada
| | - Andrew N Phillips
- Institute for Global Health, University College London, London, United Kingdom
| | - David Dunn
- Institute for Global Health, University College London, London, United Kingdom
| | - Quang Vu
- University of Calgary, Calgary, Alberta, Canada
| | - Reed Siemieniuk
- Southern Alberta Clinic, Calgary, Alberta, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Roger Logan
- Harvard T.H. Chan School of Public Health, Boston, MA
| | - Sophie Jose
- Institute for Global Health, University College London, London, United Kingdom
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Alexandra U Scherrer
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland
- Institute of Medical Virology, University of Zurich, Zurich, Zürich, Switzerland
| | - Peter Reiss
- Stichting HIV Monitoring, Amsterdam, the Netherlands
- Division of Infectious Diseases, Department of Global Health, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
| | | | | | - Kholoud Porter
- Institute for Global Health, University College London, London, United Kingdom
| | - Richard Gilson
- Institute for Global Health, University College London, London, United Kingdom
| | | | | | - Georgia Vourli
- National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Santiago Moreno
- Ramón y Cajal Hospital, IRYCIS, Madrid, Spain
- University of Alcalá de Henares, Madrid, Spain
| | - Inmaculada Jarrin
- Centro Nacional de Epidemiologia, Instituto de Salud Carlos III, Madrid, Spain
| | - Caroline Sabin
- Institute for Global Health, University College London, London, United Kingdom
| | - Miguel A Hernán
- Harvard T.H. Chan School of Public Health, Boston, MA
- Harvard-MIT Division of Health Sciences and Technology, Boston, MA
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13
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Is it Safe and Cost Saving to Defer the CD4+ Cell Count Monitoring in Stable Patients on Art with More than 350 or 500 cells/μl? Mediterr J Hematol Infect Dis 2019; 11:e2019063. [PMID: 31700588 PMCID: PMC6827605 DOI: 10.4084/mjhid.2019.063] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 10/10/2019] [Indexed: 11/19/2022] Open
Abstract
Background CD4+ lymphocyte cell count represents the main immunological marker used to monitor HIV infection. However, frequent monitoring may be unnecessary, could cause anxiety to the patient as well as burdening healthcare with extra expenses. Objectives and methods A two-step retrospective (safety and cost-saving) analysis was performed to evaluate the probability of maintaining a safe number of more than 350 CD4+ cells/μl in HIV-positive subjects under treatment during a three-year follow up and secondarily to estimate in real life the cost of the CD4+ determinations in a 3 years period, speculating on possible cost-saving strategies. The safety analyses was conducted with Kaplan-Meyer method considering: 1) all patients independently from their viral load (VL); 2) patients with 500 > CD4+ ≥ 350 cells/μl versus (vs) CD4+ ≥ 500 cells/μl at baseline; 3) patients with VL < 20 copies/ml vs VL > 20 copies/ml. The cost-saving analysis measuring the costs of CD4+ determinations was calculated from April 1, 2013, to March 31, 2016. Results In the safety analysis, 253 subjects were enrolled. The median CD4+ count was 623 (489–805) cells/μl. Subjects maintaining ≥ 350 cells/μl in the first, second, and third year were respectively 238 (94.1%), 229 (90.5%), and 226 (89.3%), independently from VL. Within subjects with ≥ 350 CD4+/μl vs. ≥ 500 CD4+/μl at baseline, those who maintained ≥ 350 cells/μl until the third year were respectively 241 (95.3%) and 158 (98.1%). The probability of maintaining these values in the third year was 89.3% for those who had CD4+ ≥ 350/μl at baseline and 98.1% for those who had CD4+ ≥ 500/μl. This probability was around 90% vs. 99% for subjects with HIV-RNA above or below 20 copies/ml. In the real-life cost saving analysis, we evaluated subjects with a stable value or more than 500 CD4+ (respectively 343, 364 and 383 in the first, second and third period). We observed mean value of about two determinations patient/year (2.41 in 2013/2014; 2.32 in 2014/2015; 2.18 in 2015/2016), with a significant decrease between the first and the last period (p<0.001). The mean cost patient/year was €101.51 in the first year, €97.61 in the second, €92.00 in the third (p<0,001). Assuming to extend these procedures to all our patients with stable CD4+ cells/μl and monitoring CD4+ cell count once in a year, we were able to obtain an overall saving of €19,152/year. Conclusions A very high percentage of subjects maintained a high and safe number of CD4+ cells (>350 cells/μl) during a three-year follow-up. It could be possible to save up to 66% of the costs by reducing the number of CD4+ count determinations in a year, to have other favorable consequences as well, releasing new resources for patient management.
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14
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Stirrup OT, Sabin CA, Phillips AN, Williams I, Churchill D, Tostevin A, Hill T, Dunn DT, Asboe D, Pozniak A, Cane P, Chadwick D, Churchill D, Clark D, Collins S, Delpech V, Douthwaite S, Dunn D, Fearnhill E, Porter K, Tostevin A, Stirrup O, Fraser C, Geretti AM, Gunson R, Hale A, Hué S, Lazarus L, Leigh-Brown A, Mbisa T, Mackie N, Orkin C, Nastouli E, Pillay D, Phillips A, Sabin C, Smit E, Templeton K, Tilston P, Volz E, Williams I, Zhang H, Fairbrother K, Dawkins J, O’Shea S, Mullen J, Cox A, Tandy R, Fawcett T, Hopkins M, Booth C, Renwick L, Renwick L, Schmid ML, Payne B, Hubb J, Dustan S, Kirk S, Bradley-Stewart A, Hill T, Jose S, Thornton A, Huntington S, Glabay A, Shidfar S, Lynch J, Hand J, de Souza C, Perry N, Tilbury S, Youssef E, Gazzard B, Nelson M, Mabika T, Mandalia S, Anderson J, Munshi S, Post F, Adefisan A, Taylor C, Gleisner Z, Ibrahim F, Campbell L, Baillie K, Gilson R, Brima N, Ainsworth J, Schwenk A, Miller S, Wood C, Johnson M, Youle M, Lampe F, Smith C, Tsintas R, Chaloner C, Hutchinson S, Walsh J, Mackie N, Winston A, Weber J, Ramzan F, Carder M, Leen C, Wilson A, Morris S, Gompels M, Allan S, Palfreeman A, Lewszuk A, Kegg S, Faleye A, Ogunbiyi V, Mitchell S, Hay P, Kemble C, Martin F, Russell-Sharpe S, Gravely J, Allan S, Harte A, Tariq A, Spencer H, Jones R, Pritchard J, Cumming S, Atkinson C, Mital D, Edgell V, Allen J, Ustianowski A, Murphy C, Gunder I, Trevelion R, Babiker A. Associations between baseline characteristics, CD4 cell count response and virological failure on first-line efavirenz + tenofovir + emtricitabine for HIV. J Virus Erad 2019. [DOI: 10.1016/s2055-6640(20)30037-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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15
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Caniglia EC, Robins JM, Cain LE, Sabin C, Logan R, Abgrall S, Mugavero MJ, Hernández-Díaz S, Meyer L, Seng R, Drozd DR, Seage Iii GR, Bonnet F, Le Marec F, Moore RD, Reiss P, van Sighem A, Mathews WC, Jarrín I, Alejos B, Deeks SG, Muga R, Boswell SL, Ferrer E, Eron JJ, Gill J, Pacheco A, Grinsztejn B, Napravnik S, Jose S, Phillips A, Justice A, Tate J, Bucher HC, Egger M, Furrer H, Miro JM, Casabona J, Porter K, Touloumi G, Crane H, Costagliola D, Saag M, Hernán MA. Emulating a trial of joint dynamic strategies: An application to monitoring and treatment of HIV-positive individuals. Stat Med 2019; 38:2428-2446. [PMID: 30883859 DOI: 10.1002/sim.8120] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 01/18/2019] [Accepted: 01/19/2019] [Indexed: 12/13/2022]
Abstract
Decisions about when to start or switch a therapy often depend on the frequency with which individuals are monitored or tested. For example, the optimal time to switch antiretroviral therapy depends on the frequency with which HIV-positive individuals have HIV RNA measured. This paper describes an approach to use observational data for the comparison of joint monitoring and treatment strategies and applies the method to a clinically relevant question in HIV research: when can monitoring frequency be decreased and when should individuals switch from a first-line treatment regimen to a new regimen? We outline the target trial that would compare the dynamic strategies of interest and then describe how to emulate it using data from HIV-positive individuals included in the HIV-CAUSAL Collaboration and the Centers for AIDS Research Network of Integrated Clinical Systems. When, as in our example, few individuals follow the dynamic strategies of interest over long periods of follow-up, we describe how to leverage an additional assumption: no direct effect of monitoring on the outcome of interest. We compare our results with and without the "no direct effect" assumption. We found little differences on survival and AIDS-free survival between strategies where monitoring frequency was decreased at a CD4 threshold of 350 cells/μl compared with 500 cells/μl and where treatment was switched at an HIV-RNA threshold of 1000 copies/ml compared with 200 copies/ml. The "no direct effect" assumption resulted in efficiency improvements for the risk difference estimates ranging from an 7- to 53-fold increase in the effective sample size.
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Affiliation(s)
- Ellen C Caniglia
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Department of Population Health, School of Medicine, New York University, New York, New York
| | - James M Robins
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Lauren E Cain
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | - Roger Logan
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | - Michael J Mugavero
- School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Sonia Hernández-Díaz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | | | | | - George R Seage Iii
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Fabrice Bonnet
- Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Fabien Le Marec
- Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Richard D Moore
- School of Medicine, The Johns Hopkins University, Baltimore, Maryland
| | - Peter Reiss
- Academisch Medisch Centrum Geneeskunde, Amsterdam, The Netherlands
| | - Ard van Sighem
- Academisch Medisch Centrum Geneeskunde, Amsterdam, The Netherlands
| | - William C Mathews
- Department of Medicine, University of California San Diego Health, San Diego, California
| | - Inma Jarrín
- National Center of Epidemiology, Instituto de Salud Carlos III, Madrid, Spain
| | - Belén Alejos
- National Center of Epidemiology, Instituto de Salud Carlos III, Madrid, Spain
| | - Steven G Deeks
- School of Medicine, University of California, San Francisco, San Francisco, California
| | | | | | - Elena Ferrer
- Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Joseph J Eron
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - John Gill
- Southern Alberta HIV Program, Calgary, Canada
| | | | | | - Sonia Napravnik
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | | | - Amy Justice
- School of Public Health, Yale University, New Haven, Connecticut
| | - Janet Tate
- School of Public Health, Yale University, New Haven, Connecticut
| | | | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Hansjakob Furrer
- Division of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | | | | | - Giota Touloumi
- Department of Hygiene, Epidemiology and Medical Statistics, Athens University Medical School, Athens, Greece
| | - Heidi Crane
- University of Washington, Seattle, Washington
| | | | - Michael Saag
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Miguel A Hernán
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Harvard-MIT Division of Health Sciences and Technology, Boston, Massachusetts
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16
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Brief Report: Drop in CD4+ Counts Below 200 Cells/μL After Reaching (or Starting From) Values Higher than 350 Cells/μL in HIV-Infected Patients With Virological Suppression. J Acquir Immune Defic Syndr 2018; 76:417-422. [PMID: 28816721 DOI: 10.1097/qai.0000000000001522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The aim of the study was to quantify the risk of a drop in CD4 counts below 200 cells/μL after reaching values >350 cells/μL on antiretroviral therapy (ART) (or after starting ART with CD4 count >350 cells/μL) in the absence of virological failure. SETTING Ambulatory care services, Italy. METHODS Prospective cohort study of patients enrolled in the ICONA Foundation Study cohort who started ART with >350 CD4/μL or with ≤350 CD4/μL and reached values >350 cells/μL after virological suppression (VS, defined by 2 consecutive viral loads ≤50 copies/mL). The date of CD4 count >350 was the baseline for the analysis and those with ≥1 viral load and CD4 count after baseline were included. The primary end point was the cumulative risk (estimated using the Kaplan-Meier method) of a CD4 drop below 200 cells/μL over follow-up, which was censored at the date of virological failure (confirmed HIV-RNA >50 copies/mL), death, or last visit. RESULTS Six thousand six hundred sixty-three patients were included. A confirmed CD4 drop below 200 cells/μL was never observed over a median follow-up of 45 (Q1: 21, Q3: 89) months, as long as VS was maintained. Upper limits of the 97.5% confidence interval of rates of confirmed CD4 drop below 200 cells/μL were 0.28 and 0.38/1000 person-years of follow-up for patients with ≤350 and >350 CD4 cells/μL at starting ART. CONCLUSIONS In patients who started ART in Italy with >350 CD4 cells/μL or reached >350 CD4 cells/μL after VS, the risk of a CD4 drop below 200 cells/μL in those maintaining VS was negligible.
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17
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Herbert S. Clinical round-up. Br J Vener Dis 2018. [DOI: 10.1136/sextrans-2017-053299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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18
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Caniglia EC, Cain LE, Sabin CA, Robins JM, Logan R, Abgrall S, Mugavero MJ, Hernández-Díaz S, Meyer L, Seng R, Drozd DR, Seage GR, Bonnet F, Dabis F, Moore RD, Reiss P, van Sighem A, Mathews WC, Del Amo J, Moreno S, Deeks SG, Muga R, Boswell SL, Ferrer E, Eron JJ, Napravnik S, Jose S, Phillips A, Justice AC, Tate JP, Gill J, Pacheco A, Veloso VG, Bucher HC, Egger M, Furrer H, Porter K, Touloumi G, Crane H, Miro JM, Sterne JA, Costagliola D, Saag M, Hernán MA. Comparison of dynamic monitoring strategies based on CD4 cell counts in virally suppressed, HIV-positive individuals on combination antiretroviral therapy in high-income countries: a prospective, observational study. Lancet HIV 2017; 4:e251-e259. [PMID: 28411091 PMCID: PMC5492888 DOI: 10.1016/s2352-3018(17)30043-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 01/14/2017] [Accepted: 01/19/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Clinical guidelines vary with respect to the optimal monitoring frequency of HIV-positive individuals. We compared dynamic monitoring strategies based on time-varying CD4 cell counts in virologically suppressed HIV-positive individuals. METHODS In this observational study, we used data from prospective studies of HIV-positive individuals in Europe (France, Greece, the Netherlands, Spain, Switzerland, and the UK) and North and South America (Brazil, Canada, and the USA) in The HIV-CAUSAL Collaboration and The Centers for AIDS Research Network of Integrated Clinical Systems. We compared three monitoring strategies that differ in the threshold used to measure CD4 cell count and HIV RNA viral load every 3-6 months (when below the threshold) or every 9-12 months (when above the threshold). The strategies were defined by the threshold CD4 counts of 200 cells per μL, 350 cells per μL, and 500 cells per μL. Using inverse probability weighting to adjust for baseline and time-varying confounders, we estimated hazard ratios (HRs) of death and of AIDS-defining illness or death, risk ratios of virological failure, and mean differences in CD4 cell count. FINDINGS 47 635 individuals initiated an antiretroviral therapy regimen between Jan 1, 2000, and Jan 9, 2015, and met the eligibility criteria for inclusion in our study. During follow-up, CD4 cell count was measured on average every 4·0 months and viral load every 3·8 months. 464 individuals died (107 in threshold 200 strategy, 157 in threshold 350, and 200 in threshold 500) and 1091 had AIDS-defining illnesses or died (267 in threshold 200 strategy, 365 in threshold 350, and 459 in threshold 500). Compared with threshold 500, the mortality HR was 1·05 (95% CI 0·86-1·29) for threshold 200 and 1·02 (0·91·1·14) for threshold 350. Corresponding estimates for death or AIDS-defining illness were 1·08 (0·95-1·22) for threshold 200 and 1·03 (0·96-1·12) for threshold 350. Compared with threshold 500, the 24 month risk ratios of virological failure (viral load more than 200 copies per mL) were 2·01 (1·17-3·43) for threshold 200 and 1·24 (0·89-1·73) for threshold 350, and 24 month mean CD4 cell count differences were 0·4 (-25·5 to 26·3) cells per μL for threshold 200 and -3·5 (-16·0 to 8·9) cells per μL for threshold 350. INTERPRETATION Decreasing monitoring to annually when CD4 count is higher than 200 cells per μL compared with higher than 500 cells per μL does not worsen the short-term clinical and immunological outcomes of virally suppressed HIV-positive individuals. However, more frequent virological monitoring might be necessary to reduce the risk of virological failure. Further follow-up studies are needed to establish the long-term safety of these strategies. FUNDING National Institutes of Health.
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Affiliation(s)
- Ellen C Caniglia
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA.
| | - Lauren E Cain
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | | | - James M Robins
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA; Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Roger Logan
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Sophie Abgrall
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France; Assistance Publique-Hopitaux de Paris (AP-HP), Hopital Antoine Béclère, Service de Médecine Interne, Clamart, France
| | - Michael J Mugavero
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; UAB Center for AIDS Research, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sonia Hernández-Díaz
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Laurence Meyer
- Université Paris Sud, INSERM CESP U1018, Paris, France; AP-HP, Hopital de Bicêtre, Service de Santé Publique, le Kremlin Bicêtre, France
| | - Remonie Seng
- Université Paris Sud, INSERM CESP U1018, Paris, France; AP-HP, Hopital de Bicêtre, Service de Santé Publique, le Kremlin Bicêtre, France
| | - Daniel R Drozd
- School of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - George R Seage
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Fabrice Bonnet
- Institut de Santé Publique, d'Epidémiologie et de Développement, Université de Bordeaux, Bordeaux, France; Department of Internal Medicine, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Francois Dabis
- INSERM U897, Centre INSERM Epidémiologie et Biostatistique, Université de Bordeaux, Bordeaux, France; Department of Internal Medicine, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Richard D Moore
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Peter Reiss
- Stichting HIV Monitoring, Amsterdam, Netherlands; Academic Medical Center, Department of Global Health and Division of Infectious Diseases, University of Amsterdam, Amsterdam, Netherlands; Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
| | | | | | - Julia Del Amo
- National Centre of Epidemiology, Instituto de Salud Carlos III, Madrid, Spain; Consorcio de Investigación Biomédica de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Santiago Moreno
- Ramón y Cajal Hospital, IRYCIS, Madrid, Spain; University of Alcalá de Henares, Madrid, Spain
| | - Steven G Deeks
- Positive Health Program, San Francisco General Hospital, San Francisco, CA, USA
| | - Roberto Muga
- Servei de Medicina Interna, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Elena Ferrer
- Hospital Universitari de Bellvitge-Bellvitge Institute for Biomedical Research, Hospitalet de Llobregat, Barcelona, Spain
| | - Joseph J Eron
- Division of Infectious Diseases, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sonia Napravnik
- Division of Infectious Diseases, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | - Amy C Justice
- Yale School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
| | - Janet P Tate
- Yale School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
| | - John Gill
- Southern Alberta HIV Clinic, University of Calgary, Calgary, AB, Canada
| | - Antonio Pacheco
- Programa de Computação Científica, FIOCRUZ, Rio de Janeiro, Brazil
| | | | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Matthias Egger
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; University of Bern, Institute for Social and Preventive Medicine, Bern, Switzerland
| | - Hansjakob Furrer
- Department of Infectious Diseases, Bern University Hospital and University of Bern, Bern, Switzerland
| | | | - Giota Touloumi
- Department of Hygiene, Epidemiology and Medical Statistics, Athens University Medical School, Athens, Greece
| | - Heidi Crane
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jose M Miro
- Infectious Diseases, Hospital Clinic-IDIBAPS, Barcelona, Spain
| | - Jonathan A Sterne
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Dominique Costagliola
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France
| | - Michael Saag
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Miguel A Hernán
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA; Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA, USA; Harvard-MIT Division of Health Sciences and Technology, Boston, MA, USA
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