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Bertsimas D, Margonis GA, Sujichantararat S, Koulouras A, Ma Y, Antonescu CR, Brennan MF, Martín-Broto J, Tang S, Rutkowski P, Kreis ME, Beyer K, Wang J, Bylina E, Sobczuk P, Gutierrez A, Jadeja B, Tap WD, Chi P, Singer S. Interpretable artificial intelligence to optimise use of imatinib after resection in patients with localised gastrointestinal stromal tumours: an observational cohort study. Lancet Oncol 2024; 25:1025-1037. [PMID: 38976997 DOI: 10.1016/s1470-2045(24)00259-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 04/29/2024] [Accepted: 05/01/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Current guidelines recommend use of adjuvant imatinib therapy for many patients with gastrointestinal stromal tumours (GISTs); however, its optimal treatment duration is unknown and some patient groups do not benefit from the therapy. We aimed to apply state-of-the-art, interpretable artificial intelligence (ie, predictions or prescription logic that can be easily understood) methods on real-world data to establish which groups of patients with GISTs should receive adjuvant imatinib, its optimal treatment duration, and the benefits conferred by this therapy. METHODS In this observational cohort study, we considered for inclusion all patients who underwent resection of primary, non-metastatic GISTs at the Memorial Sloan Kettering Cancer Center (MSKCC; New York, NY, USA) between Oct 1, 1982, and Dec 31, 2017, and who were classified as intermediate or high risk according to the Armed Forces Institute of Pathology Miettinen criteria and had complete follow-up data with no missing entries. A counterfactual random forest model, which used predictors of recurrence (mitotic count, tumour size, and tumour site) and imatinib duration to infer the probability of recurrence at 7 years for a given patient under each duration of imatinib treatment, was trained in the MSKCC cohort. Optimal policy trees (OPTs), a state-of-the-art interpretable AI-based method, were used to read the counterfactual random forest model by training a decision tree with the counterfactual predictions. The OPT recommendations were externally validated in two cohorts of patients from Poland (the Polish Clinical GIST Registry), who underwent GIST resection between Dec 1, 1981, and Dec 31, 2011, and from Spain (the Spanish Group for Research in Sarcomas), who underwent resection between Oct 1, 1987, and Jan 30, 2011. FINDINGS Among 1007 patients who underwent GIST surgery in MSKCC, 117 were included in the internal cohort; for the external cohorts, the Polish cohort comprised 363 patients and the Spanish cohort comprised 239 patients. The OPT did not recommend imatinib for patients with GISTs of gastric origin measuring less than 15·9 cm with a mitotic count of less than 11·5 mitoses per 5 mm2 or for those with small GISTs (<5·4 cm) of any site with a count of less than 11·5 mitoses per 5 mm2. In this cohort, the OPT cutoffs had a sensitivity of 92·7% (95% CI 82·4-98·0) and a specificity of 33·9% (22·3-47·0). The application of these cutoffs in the two external cohorts would have spared 38 (29%) of 131 patients in the Spanish cohort and 44 (35%) of 126 patients in the Polish cohort from unnecessary treatment with imatinib. Meanwhile, the risk of undertreating patients in these cohorts was minimal (sensitivity 95·4% [95% CI 89·5-98·5] in the Spanish cohort and 92·4% [88·3-95·4] in the Polish cohort). The OPT tested 33 different durations of imatinib treatment (<5 years) and found that 5 years of treatment conferred the most benefit. INTERPRETATION If the identified patient subgroups were applied in clinical practice, as many as a third of the current cohort of candidates who do not benefit from adjuvant imatinib would be encouraged to not receive imatinib, subsequently avoiding unnecessary toxicity on patients and financial strain on health-care systems. Our finding that 5 years is the optimal duration of imatinib treatment could be the best source of evidence to inform clinical practice until 2028, when a randomised controlled trial with the same aims is expected to report its findings. FUNDING National Cancer Institute.
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Affiliation(s)
- Dimitris Bertsimas
- Operations Research Center, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Georgios Antonios Margonis
- Operations Research Center, Massachusetts Institute of Technology, Cambridge, MA, USA; Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Angelos Koulouras
- Operations Research Center, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Yu Ma
- Operations Research Center, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Cristina R Antonescu
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Murray F Brennan
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Javier Martín-Broto
- Medical Oncology Department, Fundación Jimenez Diaz University Hospital, Madrid, Spain; Medical Oncology Department, Hospital General de Villalba, Madrid, Spain; Instituto de Investigacion Sanitaria Fundacion Jimenez Diaz, Madrid, Spain
| | - Seehanah Tang
- Operations Research Center, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Piotr Rutkowski
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Martin E Kreis
- Department of General and Visceral Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Katharina Beyer
- Department of General and Visceral Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jane Wang
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Elzbieta Bylina
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Pawel Sobczuk
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Antonio Gutierrez
- Medical Oncology Department, Fundación Jimenez Diaz University Hospital, Madrid, Spain; Medical Oncology Department, Hospital General de Villalba, Madrid, Spain; Instituto de Investigacion Sanitaria Fundacion Jimenez Diaz, Madrid, Spain
| | - Bhumika Jadeja
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - William D Tap
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ping Chi
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Samuel Singer
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Lipkovich I, Svensson D, Ratitch B, Dmitrienko A. Modern approaches for evaluating treatment effect heterogeneity from clinical trials and observational data. Stat Med 2024. [PMID: 39054669 DOI: 10.1002/sim.10167] [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: 11/20/2023] [Revised: 05/28/2024] [Accepted: 06/21/2024] [Indexed: 07/27/2024]
Abstract
In this paper, we review recent advances in statistical methods for the evaluation of the heterogeneity of treatment effects (HTE), including subgroup identification and estimation of individualized treatment regimens, from randomized clinical trials and observational studies. We identify several types of approaches using the features introduced in Lipkovich et al (Stat Med 2017;36: 136-196) that distinguish the recommended principled methods from basic methods for HTE evaluation that typically rely on rules of thumb and general guidelines (the methods are often referred to as common practices). We discuss the advantages and disadvantages of various principled methods as well as common measures for evaluating their performance. We use simulated data and a case study based on a historical clinical trial to illustrate several new approaches to HTE evaluation.
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Affiliation(s)
- Ilya Lipkovich
- Advanced Analytics and Access Capabilities, Eli Lilly and Company, Indianapolis, Indiana, USA
| | - David Svensson
- Statistical Innovation, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Bohdana Ratitch
- Clinical Statistics and Analytics, Research & Development, Pharmaceuticals, Bayer Inc., Mississauga, Ontario, Canada
| | - Alex Dmitrienko
- Department of Biostatistics, Mediana, San Juan, Puerto Rico, USA
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Søndergaard L, Andreasen AS, Perner A, Niemann C. Exploring heterogeneity of treatment effect in patients with sepsis: Protocol for a scoping review. Acta Anaesthesiol Scand 2024. [PMID: 38973287 DOI: 10.1111/aas.14492] [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: 06/05/2024] [Accepted: 06/20/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND The average treatment effect (ATE) reported by most randomised clinical trials provides estimates of treatment effects for the theoretical, non-existent average patient. However, ATE may not accurately reflect the outcomes for all subsets of the trial population; some individuals may benefit from the intervention, while others experience worse outcomes or no effect at all. Heterogeneity of treatment effect (HTE) is the non-random and explainable variation in the magnitude or direction of a treatment effect among individuals within a population. Predictive approaches to HTE seek to provide estimates of which treatment of choice is better suited for the individual patient, using regression and/or machine learning techniques. This scoping review aims to investigate the extent to which such predictive approaches to HTE are applied to data from trials on sepsis or septic shock as well as the results of these analyses. METHODS The planned review will be conducted in accordance with the PRISMA extension for scoping reviews. We will search Medline, EMBASE, Central, Cinahl and Google Scholar for studies on sepsis or septic shock in which HTE was analysed using predictive approaches. We plan to chart data regarding trial characteristics, patient demographics, disease severity, interventions, outcomes of interest and ATEs, type of predictive approach for the HTE analysis, results from HTE analysis and whether HTE analysis would change an ATE-based trial conclusion. RESULTS Studies included in the scoping review will be presented as narrative summaries, supplemented with descriptive statistics of quantitative data. CONCLUSION The planned scoping review will systematically investigate, summarise and delineate the existing evidence of analysis of HTE in trials on sepsis or septic shock patients as well as their findings, when performed using predictive approaches.
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Affiliation(s)
- Lise Søndergaard
- Department of Oncology, Zealand University Hospital, Roskilde, Denmark
| | - Anne Sofie Andreasen
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital - Herlev, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Carsten Niemann
- Department of Haematology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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Shao Y, Kay NE, Gale RP, Liang Y. Challenges in analyzing clinical trials testing Bruton tyrosine-kinase-inhibitora in chronic lymphocytic leukaemia. Leukemia 2024; 38:1469-1473. [PMID: 38824147 DOI: 10.1038/s41375-024-02294-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 05/16/2024] [Accepted: 05/20/2024] [Indexed: 06/03/2024]
Affiliation(s)
- Yingqi Shao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.
| | - Neil E Kay
- Division of Hematology, and Department of Immunology, Mayo Clinic, Rochester, MN, USA
| | - Robert Peter Gale
- Department of Hematologic Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation, Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College of Science, Technology & Medicine, London, London, UK
| | - Yang Liang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.
- Department of Hematologic Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation, Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China.
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Tang W, Yao W, Wang W, Lv Q, Ding W, He R. Common hematological and biochemical parameters for predicting urinary tract infections in geriatric patients with hip fractures. Front Med (Lausanne) 2024; 11:1333472. [PMID: 38873209 PMCID: PMC11169829 DOI: 10.3389/fmed.2024.1333472] [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: 11/10/2023] [Accepted: 03/14/2024] [Indexed: 06/15/2024] Open
Abstract
Background This study aims to discern the significance of common hematological and biochemical parameters for predicting urinary tract infections in geriatric patients with hip fractures. Methods Multivariable logistic regression and propensity score-matched analyses were conducted to calculate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for UTIs. The abilities of these parameters to predict UTIs were evaluated by receiver operating characteristic (ROC) curves. Dose-response relationships were assessed by categorizing hematological and biochemical parameters into quartiles. Subgroup analyses were further explored to investigate the relationship between these parameters and urinary tract infections. Results Out of the 1,231 participants, 23.2% were diagnosed with UTIs. Hyperglycemia, hypoproteinemia and hyperglobulinemia were risk factors for UTIs in multivariate analysis. After propensity score matching, hyperglycemia (OR 2.14, 95% CI 1.50-3.05, p < 0.001), hypoproteinemia (OR 1.75, 95% CI 1.18-2.63, p = 0.006), and hyperglobulinemia (OR 1.38, 95% CI 0.97-1.97, p = 0.074) remained significantly associated with increased odds of urinary tract infections. ROC curve analyses showed moderate predictive accuracy of blood glucose, albumin and globulin for UTIs, with areas under the curves of 0.714, 0.633, and 0.596, respectively. Significant dose-response relationships were observed between these parameters and UTIs. The associations were consistent in subgroup analyses. Conclusion Blood glucose, albumin and globulin levels can facilitate early identification of geriatric hip fracture patients at high risk of UTIs. These easily obtainable hematological and biochemical parameters provide a practical clinical prediction tool for individualized UTI prevention in this population.
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Affiliation(s)
- Wanyun Tang
- Department of Orthopedics, Zigong First People’s Hospital, Zigong, China
- Department of Orthopedics, Dandong Central Hospital, China Medical University, Dandong, China
| | - Wei Yao
- Department of Orthopedics, Dandong Central Hospital, China Medical University, Dandong, China
| | - Wei Wang
- Department of Orthopedics, Dandong Central Hospital, China Medical University, Dandong, China
| | - Qiaomei Lv
- Department of Oncology, Dandong Central Hospital, China Medical University, Dandong, China
| | - Wenbo Ding
- Department of Orthopedics, Dandong Central Hospital, China Medical University, Dandong, China
| | - RenJian He
- Department of Orthopedics, Zigong First People’s Hospital, Zigong, China
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Sherry AD, Hahn AW, McCaw ZR, Abi Jaoude J, Kouzy R, Lin TA, Minsky B, Fuller CD, Meirson T, Msaouel P, Ludmir EB. Differential Treatment Effects of Subgroup Analyses in Phase 3 Oncology Trials From 2004 to 2020. JAMA Netw Open 2024; 7:e243379. [PMID: 38546648 PMCID: PMC10979321 DOI: 10.1001/jamanetworkopen.2024.3379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/04/2024] [Indexed: 04/01/2024] Open
Abstract
Importance Subgroup analyses are often performed in oncology to investigate differential treatment effects and may even constitute the basis for regulatory approvals. Current understanding of the features, results, and quality of subgroup analyses is limited. Objective To evaluate forest plot interpretability and credibility of differential treatment effect claims among oncology trials. Design, Setting, and Participants This cross-sectional study included randomized phase 3 clinical oncology trials published prior to 2021. Trials were screened from ClinicalTrials.gov. Main Outcomes and Measures Missing visual elements in forest plots were defined as a missing point estimate or use of a linear x-axis scale for hazard and odds ratios. Multiplicity of testing control was recorded. Differential treatment effect claims were rated using the Instrument for Assessing the Credibility of Effect Modification Analyses. Linear and logistic regressions evaluated associations with outcomes. Results Among 785 trials, 379 studies (48%) enrolling 331 653 patients reported a subgroup analysis. The forest plots of 43% of trials (156 of 363) were missing visual elements impeding interpretability. While 4148 subgroup effects were evaluated, only 1 trial (0.3%) controlled for multiple testing. On average, trials that did not meet the primary end point conducted 2 more subgroup effect tests compared with trials meeting the primary end point (95% CI, 0.59-3.43 tests; P = .006). A total of 101 differential treatment effects were claimed across 15% of trials (55 of 379). Interaction testing was missing in 53% of trials (29 of 55) claiming differential treatment effects. Trials not meeting the primary end point were associated with greater odds of no interaction testing (odds ratio, 4.47; 95% CI, 1.42-15.55, P = .01). The credibility of differential treatment effect claims was rated as low or very low in 93% of cases (94 of 101). Conclusions and Relevance In this cross-sectional study of phase 3 oncology trials, nearly half of trials presented a subgroup analysis in their primary publication. However, forest plots of these subgroup analyses largely lacked essential features for interpretation, and most differential treatment effect claims were not supported. Oncology subgroup analyses should be interpreted with caution, and improvements to the quality of subgroup analyses are needed.
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Affiliation(s)
- Alexander D. Sherry
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Andrew W. Hahn
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Zachary R. McCaw
- Insitro, South San Francisco, San Francisco, California
- Department of Biostatistics, University of North Carolina at Chapel Hill
| | - Joseph Abi Jaoude
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Ramez Kouzy
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Timothy A. Lin
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bruce Minsky
- Department of Gastrointestinal Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - C. David Fuller
- Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
| | - Tomer Meirson
- Davidoff Cancer Center, Rabin Medical Center, Petach Tikva, Israel
| | - Pavlos Msaouel
- Department of Genitourinary Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston
- Department of Translational Molecular Pathology, Division of Pathology/Lab Medicine, The University of Texas MD Anderson Cancer Center, Houston
| | - Ethan B. Ludmir
- Department of Gastrointestinal Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston
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AbdulMajeed J, Khatib M, Dulli M, Sioufi S, Al-Khulaifi A, Stone J, Furuya-Kanamori L, Onitilo AA, Doi SAR. Use of conditional estimates of effect in cancer epidemiology: An application to lung cancer treatment. Cancer Epidemiol 2024; 88:102521. [PMID: 38160570 DOI: 10.1016/j.canep.2023.102521] [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: 08/22/2023] [Revised: 12/06/2023] [Accepted: 12/22/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND In oncology clinical trials, there is the assumption that randomization sufficiently balances confounding covariates and therefore average treatment effects are usually reported. This paper explores the wider benefits provided by conditioning on covariates for reasons other than mitigation of confounding. METHODS We reanalyzed the data from primary randomized controlled trials listed in two meta-analyses to explore the significance of conditioning on smoking status in terms of the effect magnitude of treatment on progression free survival in non-small cell lung cancer. RESULTS The reanalysis revealed that conditioning on smoking status using sub-group analyses provided the closest empiric estimate of individual treatment effect based on smoking status and significantly reduced the heterogeneity of treatment effect observed across studies. In addition, smoking status was determined to be a modifier of the effect of treatment. CONCLUSION Conditioning on prognostic covariates in randomized trials in oncology helps generate the closest empiric estimates of individual treatment benefit, addresses heterogeneity due to varying covariate distributions across trials and facilitates future decision making as well as evidence synthesis. Conditioning using sub-group analyses also allows examination for effect modification in meta-analysis.
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Affiliation(s)
- Jazeel AbdulMajeed
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Malkan Khatib
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Mohamad Dulli
- Department of Medicine, Hamad General Hospital, Doha, Qatar
| | | | - Azhar Al-Khulaifi
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - Jennifer Stone
- Joanna Briggs Institute, Faculty of Health and Medical Sciences, University of Adelaide, Australia
| | - Luis Furuya-Kanamori
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Herston 4029, Australia
| | - Adedayo A Onitilo
- Department of Oncology, Marshfield Clinic Health System, Marshfield, WI, USA
| | - Suhail A R Doi
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar.
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Karagiannis T, Tsapas A, Bekiari E, Toulis KA, Nauck MA. A Methodological Framework for Meta-analysis and Clinical Interpretation of Subgroup Data: The Case of Major Adverse Cardiovascular Events With GLP-1 Receptor Agonists and SGLT2 Inhibitors in Type 2 Diabetes. Diabetes Care 2024; 47:184-192. [PMID: 38241493 DOI: 10.2337/dc23-0925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/13/2023] [Indexed: 01/21/2024]
Abstract
We present a methodological framework for conducting and interpreting subgroup meta-analyses. Methodological steps comprised evaluation of clinical heterogeneity regarding the definition of subpopulations, credibility assessment of subgroup meta-analysis, and translation of relative into absolute treatment effects. We used subgroup data from type 2 diabetes cardiovascular outcomes trials (CVOTs) with glucagon-like peptide 1 (GLP-1) receptor agonists and sodium-glucose cotransporter 2 (SGLT2) inhibitors for patients with established cardiovascular disease and those at high cardiovascular risk without manifest cardiovascular disease. First, we evaluated the variability in definitions of the subpopulations across CVOTs using major adverse cardiovascular events (MACE) incidence in the placebo arm as a proxy for baseline cardiovascular risk. As baseline risk did not differ considerably across CVOTs, we conducted subgroup meta-analyses of hazard ratios (HRs) for MACE and assessed the credibility of a potential effect modification. Results suggested using the same overall relative effect for each of the two subpopulations (HR 0.85, 95% CI 0.80-0.90, for GLP-1 receptor agonists and HR 0.91, 95% CI 0.85-0.97, for SGLT2 inhibitors). Finally, we calculated 5-year absolute treatment effects (number of fewer patients with event per 1,000 patients). Treatment with GLP-1 receptor agonists resulted in 30 fewer patients with event in the subpopulation with established cardiovascular disease and 14 fewer patients with event in patients without manifest cardiovascular disease. For SGLT2 inhibitors, the respective absolute effects were 18 and 8 fewer patients with event per 1,000 patients. This framework can be applied to subgroup meta-analyses regardless of outcomes or modification variables.
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Affiliation(s)
- Thomas Karagiannis
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Diabetes Centre, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Tsapas
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Diabetes Centre, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Harris Manchester College, University of Oxford, Oxford, U.K
| | - Eleni Bekiari
- Clinical Research and Evidence-Based Medicine Unit, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Diabetes Centre, Second Medical Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos A Toulis
- Department of Endocrinology, 424 Military Hospital, Thessaloniki, Greece
- Institute of Applied Health Research, University of Birmingham, Birmingham, U.K
| | - Michael A Nauck
- Diabetes, Endocrinology, and Metabolism Section, Medical Department I, Katholisches Klinikum Bochum, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
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Zarei D, Saghazadeh A, Rezaei N. Subtyping irritable bowel syndrome using cluster analysis: a systematic review. BMC Bioinformatics 2023; 24:478. [PMID: 38102564 PMCID: PMC10724977 DOI: 10.1186/s12859-023-05567-8] [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] [Received: 03/29/2023] [Accepted: 11/13/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Irritable bowel syndrome (IBS) is a common chronic functional gastrointestinal disorder associated with a wide range of clinical symptoms. Some researchers have used cluster analysis (CA), a group of non-supervised learning methods that identifies homogenous clusters within different entities based on their similarity. OBJECTIVE AND METHODS This literature review aims to identify published articles that apply CA to IBS patients. We searched relevant keywords in PubMed, Embase, Web of Science, and Scopus. We reviewed studies in terms of the selected variables, participants' characteristics, data collection, methodology, number of clusters, clusters' profiles, and results. RESULTS Among the 14 articles focused on the heterogeneity of IBS, eight of them utilized K-means Cluster Analysis (K-means CA), four employed Hierarchical Cluster Analysis, and only two studies utilized Latent Class Analysis. Seven studies focused on clinical symptoms, while four articles examined anocolorectal functions. Two studies were centered around immunological findings, and only one study explored microbial composition. The number of clusters obtained ranged from two to seven, showing variation across the studies. Males exhibited lower symptom severity and fewer psychological findings. The association between symptom severity and rectal perception suggests that altered rectal perception serves as a biological indicator of IBS. Ultra-slow waves observed in IBS patients are linked to increased activity of the anal sphincter, higher anal pressure, dystonia, and dyschezia. CONCLUSION IBS has different subgroups based on different factors. Most IBS patients have low clinical severity, good QoL, high rectal sensitivity, delayed left colon transit time, increased systemic cytokines, and changes in microbial composition, including increased Firmicutes-associated taxa and depleted Bacteroidetes-related taxa. However, the number of clusters is inconsistent across studies due to the methodological heterogeneity. CA, a valuable non-supervised learning method, is sensitive to hyperparameters like the number of clusters and random initialization of cluster centers. The random nature of these parameters leads to diverse outcomes even with the same algorithm. This has implications for future research and practical applications, necessitating further studies to improve our understanding of IBS and develop personalized treatments.
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Affiliation(s)
- Diana Zarei
- School of Medicine, Iran University of Medical Science, Tehran, Iran
- Systematic Review and Meta-Analysis Expert Group (SRMEG), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Amene Saghazadeh
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Dr. Qarib St, Keshavarz Blvd, Tehran, 14194, Iran
- Integrated Science Association (ISA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Nima Rezaei
- Research Center for Immunodeficiencies, Children's Medical Center, Tehran University of Medical Sciences, Dr. Qarib St, Keshavarz Blvd, Tehran, 14194, Iran.
- Integrated Science Association (ISA), Universal Scientific Education and Research Network (USERN), Tehran, Iran.
- Department of Immunology and Biology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
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Ademola A, Thabane L, Adekanye J, Okikiolu A, Babatunde S, Almekhlafi MA, Menon BK, Hill MD, Hildebrand KA, Sajobi TT. The credibility of subgroup analyses reported in stroke trials is low: A systematic review. Int J Stroke 2023; 18:1161-1168. [PMID: 36988330 PMCID: PMC10676048 DOI: 10.1177/17474930231168517] [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: 02/11/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Subgroup analyses are widely used to evaluate the heterogeneity of treatment effects in randomized clinical trials. However, there is a limited investigation of the quality of prespecified and reported subgroup analyses in stroke trials. This study evaluated the credibility of subgroup analyses in stroke trials. METHODS AND ANALYSIS We searched Medline/PubMed, Embase, the Cochrane Central Register of Controlled Trials, and the Web of Science from inception to 24 March 2021. Three reviewers screened, extracted, and analyzed the data from the publications. Primary publications of stroke trials that reported at least one subgroup effect and had published corresponding study protocols were included. The Instrument for Assessing the Credibility of Effect Modification Analyses (ICEMAN) was used to examine the quality of the subgroup effects reported, with each subgroup effect assigned a credibility rating ranging from very low to high. Subgroup effects with two or more "definitely no" responses received a low credibility rating. The risk of bias was assessed using the Cochrane Risk-of-Bias tool for randomized trials version 2. RESULTS Seventy-four articles met the inclusion criteria and reported a combined total of 647 subgroup effects. The median sample size was 1264 (interquartile range (IQR): 380-3876), and the median number of subgroups prespecified in the protocol was 6 (IQR: 2-10). Sixty-one (82%) studies used the univariate test of interaction. Of the total 647 subgroup effects reported in these studies, 319 (49%) were reported in acute stroke trials, while 423 (65%) had low credibility. CONCLUSION The quality of subgroup analysis reporting in stroke trials remains poor. More effort is needed to train trialists on the best methods for designing and performing subgroup analyses, and how to report the results. TRIAL REGISTRATION NUMBER We prospectively registered the review with International Prospective Register for Systematic Reviews (registration number: CRD42020223133).
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Affiliation(s)
- Ayoola Ademola
- Department of Community Health Sciences and O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Joel Adekanye
- Department of Community Health Sciences and O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Ayooluwanimi Okikiolu
- Department Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Samuel Babatunde
- Office of Institutional Analysis, University of Calgary, Calgary, AB, Canada
| | - Mohammed A Almekhlafi
- Department Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Bijoy K Menon
- Department of Community Health Sciences and O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Department Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Michael D Hill
- Department of Community Health Sciences and O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Department Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | | | - Tolulope T Sajobi
- Department of Community Health Sciences and O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
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11
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Tritschler T, Sadeghipour P, Bikdeli B. Subgroup analysis in randomized controlled trials: Useful or misleading? Thromb Res 2023; 232:160-162. [PMID: 36357215 DOI: 10.1016/j.thromres.2022.10.009] [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] [Indexed: 11/06/2022]
Affiliation(s)
- Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Parham Sadeghipour
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; YNHH/ Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA; Cardiovascular Research Foundation (CRF), New York, NY, USA.
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12
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Gale RP, Zhang MJ, Lazarus HM. The role of randomized controlled trials, registries, observational databases in evaluating new interventions. Best Pract Res Clin Haematol 2023; 36:101523. [PMID: 38092482 DOI: 10.1016/j.beha.2023.101523] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 10/17/2023] [Indexed: 12/18/2023]
Abstract
Approaches to comparing safety and efficacy of interventions include analyzing data from randomized controlled trials (RCTs), registries and observational databases (ODBs). RCTs are regarded as the gold standard but data from such trials are sometimes unavailable because a disease is uncommon, because the intervention is uncommon, because of structural limitations or because randomization cannot be done for practical or (seemingly) ethical reasons. There are many examples of an unproved intervention being so widely-believed to be effective that clinical trialists and potential subjects decline randomization. Often, when a RCT is finally done the intervention is proved ineffective or even harmful. These situations are termed medical reversals and are not uncommon [1,2]. There is also the dilemma of when seemingly similar RCTs report discordant conclisions Data from high-quality registries, especially ODBs can be used when data from RCTs are unavailable but also have limitations. Biases and confounding co-variates may be unknown, difficult or impossible to identify and/or difficult to adjust for adequately. However, ODBs sometimes have large numbers of diverse subjects and often give answers more useful to clinicians than RCTs. Side-by-side comparisons suggest analyses from high-quality ODBs often give similar conclusions from high quality RCTs. Meta-analyses combining data from RCTs, registries and ODBs are sometimes appropriate. We suggest increased use of registries and ODBs to compare efficacy of interventions.
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Affiliation(s)
- Robert Peter Gale
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College of Science, Technology and Medicine, London, UK.
| | - Mei-Jie Zhang
- Center for International Blood and Marrow Research (CIBMTR), Medical College of Wisconsin, Milwaukee, WI, USA
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13
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Alrawabdeh J, Alzu'bi M, Alzyoud M, Odeh N, Hamadneh Y, Mian H, Mohyuddin GR, Kelkar AH, Goodman AM, Chakraborty R, Russler-Germain DA, Mehra N, Baggio D, Cliff ERS, Al Hadidi S. Characteristics of post hoc subgroup analyses of oncology clinical trials: a systematic review. JNCI Cancer Spectr 2023; 7:pkad100. [PMID: 38006333 PMCID: PMC11025370 DOI: 10.1093/jncics/pkad100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 10/23/2023] [Accepted: 11/17/2023] [Indexed: 11/27/2023] Open
Abstract
BACKGROUND Subgroup analyses in clinical trials assess intervention effects on specific patient subgroups, ensuring generalizability. However, they are usually only able to generate hypotheses rather than definitive conclusions. This study examined the prevalence and characteristics of post hoc subgroup analysis in oncology. METHODS We systematically reviewed published subgroup analyses from 2000 to 2022. We included articles presenting secondary, post hoc, or subgroup analyses of interventional clinical trials in oncology, cancer survivorship, or cancer screening, published separately from the original clinical trial publication. We collected cancer type, year of publication, where and how subgroup analyses were reported, and funding. RESULTS Out of 16 487 screened publications, 1612 studies were included, primarily subgroup analyses of treatment trials for solid tumors (82%). Medical writers contributed to 31% of articles, and 58% of articles reported conflicts of interest. Subgroup analyses increased significantly over time, with 695 published between 2019 and 2022, compared to 384 from 2000 to 2014. Gastrointestinal tumors (25%) and lymphoid lineage tumors (39%) were the most frequently studied solid and hematological malignancies, respectively. Industry funding and reporting of conflicts of interest increased over time. Subgroup analyses often neglected to indicate their secondary nature in the title. Most authors were from high-income countries, most commonly North America (45%). CONCLUSIONS This study demonstrates the rapidly growing use of post hoc subgroup analysis of oncology clinical trials, revealing that the majority are supported by pharmaceutical companies, and they frequently fail to indicate their secondary nature in the title. Given the known methodological limitations of subgroup analyses, caution is recommended among authors, readers, and reviewers when conducting and interpreting these studies.
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Affiliation(s)
| | - Marah Alzu'bi
- School of Medicine, University of Jordan, Amman, Jordan
| | | | - Nada Odeh
- School of Medicine, University of Jordan, Amman, Jordan
| | | | - Hira Mian
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | | | - Amar H Kelkar
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Rajshekhar Chakraborty
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY, USA
| | - David A Russler-Germain
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Nikita Mehra
- Department of Medical Oncology, Cancer Institute (WIA), Chennai, Tamil Nadu, India
| | - Diva Baggio
- Peter MacCallum Cancer Center, Parkville, VIC, Australia
| | - Edward R Scheffer Cliff
- Harvard Medical School, Boston, MA, USA
- Program on Regulation, Therapeutics and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Samer Al Hadidi
- Myeloma Center, Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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14
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Meijer C, Uh HW, el Bouhaddani S. Digital Twins in Healthcare: Methodological Challenges and Opportunities. J Pers Med 2023; 13:1522. [PMID: 37888133 PMCID: PMC10608065 DOI: 10.3390/jpm13101522] [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: 08/16/2023] [Revised: 10/14/2023] [Accepted: 10/15/2023] [Indexed: 10/28/2023] Open
Abstract
One of the most promising advancements in healthcare is the application of digital twin technology, offering valuable applications in monitoring, diagnosis, and development of treatment strategies tailored to individual patients. Furthermore, digital twins could also be helpful in finding novel treatment targets and predicting the effects of drugs and other chemical substances in development. In this review article, we consider digital twins as virtual counterparts of real human patients. The primary aim of this narrative review is to give an in-depth look into the various data sources and methodologies that contribute to the construction of digital twins across several healthcare domains. Each data source, including blood glucose levels, heart MRI and CT scans, cardiac electrophysiology, written reports, and multi-omics data, comes with different challenges regarding standardization, integration, and interpretation. We showcase how various datasets and methods are used to overcome these obstacles and generate a digital twin. While digital twin technology has seen significant progress, there are still hurdles in the way to achieving a fully comprehensive patient digital twin. Developments in non-invasive and high-throughput data collection, as well as advancements in modeling and computational power will be crucial to improve digital twin systems. We discuss a few critical developments in light of the current state of digital twin technology. Despite challenges, digital twin research holds great promise for personalized patient care and has the potential to shape the future of healthcare innovation.
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Affiliation(s)
| | | | - Said el Bouhaddani
- Department Data Science & Biostatistics, Julius Center, UMC Utrecht, 3584 CX Utrecht, The Netherlands (H.-W.U.)
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15
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Broadley T, Higgins A, Hodgson C. Physical rehabilitation, mobilization and patient-centred outcomes: what is new? Curr Opin Crit Care 2023; 29:505-512. [PMID: 37641507 DOI: 10.1097/mcc.0000000000001081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
PURPOSE OF REVIEW Physical rehabilitation and mobilization interventions aim to reduce the incidence of intensive care unit (ICU)-acquired weakness and subsequently reduce morbidity in critically ill patients. This chapter will explore the evidence for physical rehabilitation and mobilization with an emphasis on patient-centred outcomes selected in randomized controlled trials. This is particularly pertinent at a time when clinicians are deciding how to implement physical rehabilitation and mobilization into the treatment of critically ill patients. RECENT FINDINGS Multiple trials of physical rehabilitation and mobilization were published in 2022 and 2023 with conflicting results. Analysing the complexities of physical rehabilitation research provides an insight into these results and will aid in the interpretation of trials of physical rehabilitation and mobilization. SUMMARY Patient-centred outcomes are often utilized in physical rehabilitation and mobilization research, but this does not automatically correspond to an increase in research quality. Improving consistency in trials of physical rehabilitation will aid in the interpretation and translation of physical rehabilitation research.
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Affiliation(s)
- Tessa Broadley
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre
- Alfred Health, Melbourne
| | - Alisa Higgins
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre
- The George Institute for Global Health, Sydney
| | - Carol Hodgson
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre
- Alfred Health, Melbourne
- The George Institute for Global Health, Sydney
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
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16
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Bardal EM, Sandal LF, Nilsen TIL, Nicholl BI, Mork PJ, Søgaard K. Do age, gender, and education modify the effectiveness of app-delivered and tailored self-management support among adults with low back pain?-Secondary analysis of the selfBACK randomised controlled trial. PLOS DIGITAL HEALTH 2023; 2:e0000302. [PMID: 37738237 PMCID: PMC10516425 DOI: 10.1371/journal.pdig.0000302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 06/19/2023] [Indexed: 09/24/2023]
Abstract
selfBACK is an artificial intelligence based self-management app for low back pain (LBP) recently reported to reduce LBP-related disability. The aim of this study was to examine if age, gender, or education modify the effectiveness of the selfBACK intervention using secondary analysis of the selfBACK randomized controlled trial. Persons seeking care for LBP were recruited from primary care in Denmark and Norway and an outpatient clinic (Denmark). The intervention group (n = 232) received the selfBACK app adjunct to usual care. The control group (n = 229) received usual care only. Analyses were stratified by age (18-34, 35-64, ≥65 years), gender (male, female), and education (≤12, >12 years) to investigate differences in effect at three and nine months follow-up on LBP-related disability (Roland-Morris Disability Questionnaire [RMDQ]), LBP intensity and pain self-efficacy. Overall, there was no effect modification for any of the sociodemographic factors. However, data on LBP-related disability suggest that the effect of the intervention was somewhat more beneficial in older than in younger participants. The difference between the intervention and control group due to interaction was 2.6 (95% CI: 0.4 to 4.9) RMDQ points for those aged ≥65 years as compared to those aged 35-64 years. In conclusion, age, gender, or education did not influence the effect of the selfBACK intervention on LBP-related disability. However, older participants may have an additional long-term positive effect compared to younger participants. Trial registration: ClinicalTrials.gov Identifier: NCT03798288.
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Affiliation(s)
- Ellen Marie Bardal
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Rehabilitation, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Louise Fleng Sandal
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark (UoSD), Odense M, Denmark
| | - Tom Ivar Lund Nilsen
- Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Anaesthesia and Intensive Care, St Olavs Hospital, Trondheim University Hospital,Trondheim, Norway
| | - Barbara I. Nicholl
- Institute of Health and Wellbeing, University of Glasgow (GLA), Glasgow, United Kingdom
| | - Paul Jarle Mork
- Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Karen Søgaard
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark (UoSD), Odense M, Denmark
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17
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Chu G, Valerio L, Barco S, Huisman MV, Konstantinides SV, Klok FA. External validation of AF-BLEED for predicting major bleeding and for tailoring NOAC dose in AF patients: A post hoc analysis in the ENGAGE AF-TIMI 48. Thromb Res 2023; 229:225-231. [PMID: 37566971 DOI: 10.1016/j.thromres.2023.08.001] [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: 04/26/2023] [Revised: 07/20/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023]
Abstract
OBJECTIVE AF-BLEED, a simple bleeding risk classifier, was found to predict major bleeding (MB) in patients with atrial fibrillation (AF) and identify AF patients at high risk of MB who might potentially benefit from a lower direct oral anticoagulant dose. This post hoc study aimed to externally validate these findings in the ENGAGE AF-TIMI 48 (Effective aNticoaGulation with factor Xa next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction study 48) trial. METHODS The ENGAGE AF-TIMI 48 trial randomized AF patients to higher-dose edoxaban regimen (HDER 60/30 mg) versus lower-dose edoxaban regimen (LDER 30/15 mg), with prespecified dose reduction criteria. AF-BLEED was calculated in the modified intention-to-treat cohort (n = 21,026 patients) used for primary outcome analysis. Annualized event rates and hazard ratios (HRs) were obtained for the primary composite outcome (PCO) and its single components (MB, ischemic stroke/systemic embolism and death) to compare LDER 30 mg with HDER 60 mg in both AF-BLEED classes. RESULTS AF-BLEED classified 2882 patients (13.7 %) as high-risk, characterized by a two- to three-fold higher MB risk than AF-BLEED classified low-risk patients. AF-BLEED classified high-risk patients randomized to LDER 30 mg demonstrated a 3.3 % reduction in MB at the cost of a 0.5 % increase in ischemic stroke/systemic embolism. LDER 30 mg resulted in a 3.1 % reduction of PCO compared to HDER 60 mg (HR of 0.81; 95%CI 0.65-1.01). Additional to existing dose reduction criteria, another 6 % of patients could potentially benefit of this dose adjustment strategy. CONCLUSION AF-BLEED could identify AF patients to be at high risk of major bleeding. Our findings support the hypothesis that LDER 30 mg might provide a reasonable option in AF patients with legitimate bleeding concerns.
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Affiliation(s)
- G Chu
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
| | - L Valerio
- Center for Thrombosis and Hemostasis (CTH), University Medical Centre Mainz, Mainz, Germany
| | - S Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Centre Mainz, Mainz, Germany; Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - M V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - S V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Centre Mainz, Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - F A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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18
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Sormani MP, Chataway J, Kent DM, Marrie RA. Assessing heterogeneity of treatment effect in multiple sclerosis trials. Mult Scler 2023; 29:1158-1161. [PMID: 37555493 PMCID: PMC10413777 DOI: 10.1177/13524585231189673] [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: 03/08/2023] [Revised: 05/08/2023] [Accepted: 05/10/2023] [Indexed: 08/10/2023]
Abstract
Multiple sclerosis (MS) is heterogeneous with respect to outcomes, and evaluating possible heterogeneity of treatment effect (HTE) is of high interest. HTE is non-random variation in the magnitude of a treatment effect on a clinical outcome across levels of a covariate (i.e. a patient attribute or set of attributes). Multiple statistical techniques can evaluate HTE. The simplest but most bias-prone is conventional one variable-at-a-time subgroup analysis. Recently, multivariable predictive approaches have been promoted to provide more patient-centered results, by accounting for multiple relevant attributes simultaneously. We review approaches used to estimate HTE in clinical trials of MS.
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Affiliation(s)
- Maria Pia Sormani
- Department of Health Sciences, University of Genoa, Genoa, Italy/IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Jeremy Chataway
- Queen Square Multiple Sclerosis Centre, Department of Neuroinflammation, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK/National Institute for Health Research, University College London Hospitals, Biomedical Research Centre, London, UK/Medical Research Council Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - David M Kent
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Ruth Ann Marrie
- Departments of Internal Medicine and Community Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
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19
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Sollfrank L, Linn SC, Hauptmann M, Jóźwiak K. A scoping review of statistical methods in studies of biomarker-related treatment heterogeneity for breast cancer. BMC Med Res Methodol 2023; 23:154. [PMID: 37386356 PMCID: PMC10308726 DOI: 10.1186/s12874-023-01982-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 06/19/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Many scientific papers are published each year and substantial resources are spent to develop biomarker-based tests for precision oncology. However, only a handful of tests is currently used in daily clinical practice, since development is challenging. In this situation, the application of adequate statistical methods is essential, but little is known about the scope of methods used. METHODS A PubMed search identified clinical studies among women with breast cancer comparing at least two different treatment groups, one of which chemotherapy or endocrine treatment, by levels of at least one biomarker. Studies presenting original data published in 2019 in one of 15 selected journals were eligible for this review. Clinical and statistical characteristics were extracted by three reviewers and a selection of characteristics for each study was reported. RESULTS Of 164 studies identified by the query, 31 were eligible. Over 70 different biomarkers were evaluated. Twenty-two studies (71%) evaluated multiplicative interaction between treatment and biomarker. Twenty-eight studies (90%) evaluated either the treatment effect in biomarker subgroups or the biomarker effect in treatment subgroups. Eight studies (26%) reported results for one predictive biomarker analysis, while the majority performed multiple evaluations, either for several biomarkers, outcomes and/or subpopulations. Twenty-one studies (68%) claimed to have found significant differences in treatment effects by biomarker level. Fourteen studies (45%) mentioned that the study was not designed to evaluate treatment effect heterogeneity. CONCLUSIONS Most studies evaluated treatment heterogeneity via separate analyses of biomarker-specific treatment effects and/or multiplicative interaction analysis. There is a need for the application of more efficient statistical methods to evaluate treatment heterogeneity in clinical studies.
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Affiliation(s)
- L Sollfrank
- Institute of Biostatistics and Registry Research, Brandenburg Medical School Theodor Fontane, Fehrbelliner Straße 39, Neuruppin, 16816, Germany
| | - S C Linn
- Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Medical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Pathology, University Medical Center, Utrecht, The Netherlands
| | - M Hauptmann
- Institute of Biostatistics and Registry Research, Brandenburg Medical School Theodor Fontane, Fehrbelliner Straße 39, Neuruppin, 16816, Germany
| | - K Jóźwiak
- Institute of Biostatistics and Registry Research, Brandenburg Medical School Theodor Fontane, Fehrbelliner Straße 39, Neuruppin, 16816, Germany.
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20
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Ghazi L, Shen J, Ying J, Derington CG, Cohen JB, Marcum ZA, Herrick JS, King JB, Cheung AK, Williamson JD, Pajewski NM, Bryan N, Supiano M, Sonnen J, Weintraub WS, Greene TH, Bress AP. Identifying Patients for Intensive Blood Pressure Treatment Based on Cognitive Benefit: A Secondary Analysis of the SPRINT Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2314443. [PMID: 37204788 PMCID: PMC10199351 DOI: 10.1001/jamanetworkopen.2023.14443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 03/25/2023] [Indexed: 05/20/2023] Open
Abstract
Importance Intensive vs standard treatment to lower systolic blood pressure (SBP) reduces risk of mild cognitive impairment (MCI) or dementia; however, the magnitude of cognitive benefit likely varies among patients. Objective To estimate the magnitude of cognitive benefit of intensive vs standard systolic BP (SBP) treatment. Design, Setting, and Participants In this ad hoc secondary analysis of the Systolic Blood Pressure Intervention Trial (SPRINT), 9361 randomized clinical trial participants 50 years or older with high cardiovascular risk but without a history of diabetes, stroke, or dementia were followed up. The SPRINT trial was conducted between November 1, 2010, and August 31, 2016, and the present analysis was completed on October 31, 2022. Intervention Systolic blood pressure treatment to an intensive (<120 mm Hg) vs standard (<140 mm Hg) target. Main Outcomes and Measures The primary outcome was a composite of adjudicated probable dementia or amnestic MCI. Results A total of 7918 SPRINT participants were included in the analysis; 3989 were in the intensive treatment group (mean [SD] age, 67.9 [9.2] years; 2570 [64.4%] men; 1212 [30.4%] non-Hispanic Black) and 3929 were in the standard treatment group (mean [SD] age, 67.9 [9.4] years; 2570 [65.4%] men; 1249 [31.8%] non-Hispanic Black). Over a median follow-up of 4.13 (IQR, 3.50-5.88) years, there were 765 and 828 primary outcome events in the intensive treatment group and standard treatment group, respectively. Older age (hazard ratio [HR] per 1 SD, 1.87 [95% CI, 1.78-1.96]), Medicare enrollment (HR per 1 SD, 1.42 [95% CI, 1.35-1.49]), and higher baseline serum creatinine level (HR per 1 SD, 1.24 [95% CI, 1.19-1.29]) were associated with higher risk of the primary outcome, while better baseline cognitive functioning (HR per 1 SD, 0.43 [95% CI, 0.41-0.44]) and active employment status (HR per 1 SD, 0.44 [95% CI, 0.42-0.46]) were associated with lower risk of the primary outcome. Risk of the primary outcome by treatment goal was estimated accurately based on similar projected and observed absolute risk differences (C statistic = 0.79). Higher baseline risk for the primary outcome was associated with greater benefit (ie, larger absolute reduction of probable dementia or amnestic MCI) of intensive vs standard treatment across the full range of estimated baseline risk. Conclusions and Relevance In this secondary analysis of the SPRINT trial, participants with higher baseline projected risk of probable dementia or amnestic MCI gained greater absolute cognitive benefit from intensive vs standard SBP treatment in a monotonic fashion. Trial Registration ClinicalTrials.gov Identifier: NCT01206062.
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Affiliation(s)
- Lama Ghazi
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham
| | - Jincheng Shen
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City
| | - Jian Ying
- Department of Internal Medicine, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
| | - Catherine G. Derington
- Intermountain Healthcare Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
| | - Jordana B. Cohen
- Department of Medicine, Renal-Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Zachary A. Marcum
- Department of Pharmacy, University of Washington School of Pharmacy, Seattle
| | - Jennifer S. Herrick
- Intermountain Healthcare Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah
| | - Jordan B. King
- Intermountain Healthcare Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | - Alfred K. Cheung
- Department of Internal Medicine, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah
| | - Jeff D. Williamson
- The Sticht Center for Healthy Aging and Alzheimer’s Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Nicholas M. Pajewski
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Nick Bryan
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Mark Supiano
- Division of Geriatrics, University of Utah School of Medicine, and The Center on Aging, University of Utah, Salt Lake City
| | - Josh Sonnen
- Department of Pathology and Neurology and Neurosurgery, McGill University School of Medicine, Montreal, Quebec, Canada
| | | | - Tom H. Greene
- Intermountain Healthcare Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
| | - Adam P. Bress
- Intermountain Healthcare Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah
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21
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Blette BS, Granholm A, Li F, Shankar-Hari M, Lange T, Munch MW, Møller MH, Perner A, Harhay MO. Causal Bayesian machine learning to assess treatment effect heterogeneity by dexamethasone dose for patients with COVID-19 and severe hypoxemia. Sci Rep 2023; 13:6570. [PMID: 37085591 PMCID: PMC10120498 DOI: 10.1038/s41598-023-33425-3] [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: 01/03/2023] [Accepted: 04/12/2023] [Indexed: 04/23/2023] Open
Abstract
The currently recommended dose of dexamethasone for patients with severe or critical COVID-19 is 6 mg per day (mg/d) regardless of patient features and variation. However, patients with severe or critical COVID-19 are heterogenous in many ways (e.g., age, weight, comorbidities, disease severity, and immune features). Thus, it is conceivable that a standardized dosing protocol may not be optimal. We assessed treatment effect heterogeneity in the COVID STEROID 2 trial, which compared 6 mg/d to 12 mg/d, using a causal inference framework with Bayesian Additive Regression Trees, a flexible modeling method that detects interactive effects and nonlinear relationships among multiple patient characteristics simultaneously. We found that 12 mg/d of dexamethasone, relative to 6 mg/d, was probably associated with better long-term outcomes (days alive without life support and mortality after 90 days) among the entire trial population (i.e., no signals of harm), and probably more beneficial among those without diabetes mellitus, that were older, were not using IL-6 inhibitors at baseline, weighed less, or had higher level respiratory support at baseline. This adds more evidence supporting the use of 12 mg/d in practice for most patients not receiving other immunosuppressants and that additional study of dosing could potentially optimize clinical outcomes.
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Affiliation(s)
- Bryan S Blette
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Clinical Trials Methods and Outcomes Lab, Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anders Granholm
- Department of Intensive Care, Rigshospitalet-Copenhagen University Hospital, Copenhagen, Denmark
- Collaboration for Research in Intensive Care, Copenhagen, Denmark
| | - Fan Li
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT, USA
- Center for Methods in Implementation and Prevention Science, Yale University School of Public Health, New Haven, CT, USA
| | - Manu Shankar-Hari
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Theis Lange
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Marie Warrer Munch
- Department of Intensive Care, Rigshospitalet-Copenhagen University Hospital, Copenhagen, Denmark
- Collaboration for Research in Intensive Care, Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Rigshospitalet-Copenhagen University Hospital, Copenhagen, Denmark
- Collaboration for Research in Intensive Care, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet-Copenhagen University Hospital, Copenhagen, Denmark
- Collaboration for Research in Intensive Care, Copenhagen, Denmark
| | - Michael O Harhay
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Clinical Trials Methods and Outcomes Lab, Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Division of Pulmonary and Critical Care, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 304 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104-6021, USA.
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22
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Efthimiou O, Hoogland J, Debray TP, Seo M, Furukawa TA, Egger M, White IR. Measuring the performance of prediction models to personalize treatment choice. Stat Med 2023; 42:1188-1206. [PMID: 36700492 PMCID: PMC7615726 DOI: 10.1002/sim.9665] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 11/07/2022] [Accepted: 12/31/2022] [Indexed: 01/27/2023]
Abstract
When data are available from individual patients receiving either a treatment or a control intervention in a randomized trial, various statistical and machine learning methods can be used to develop models for predicting future outcomes under the two conditions, and thus to predict treatment effect at the patient level. These predictions can subsequently guide personalized treatment choices. Although several methods for validating prediction models are available, little attention has been given to measuring the performance of predictions of personalized treatment effect. In this article, we propose a range of measures that can be used to this end. We start by defining two dimensions of model accuracy for treatment effects, for a single outcome: discrimination for benefit and calibration for benefit. We then amalgamate these two dimensions into an additional concept, decision accuracy, which quantifies the model's ability to identify patients for whom the benefit from treatment exceeds a given threshold. Subsequently, we propose a series of performance measures related to these dimensions and discuss estimating procedures, focusing on randomized data. Our methods are applicable for continuous or binary outcomes, for any type of prediction model, as long as it uses baseline covariates to predict outcomes under treatment and control. We illustrate all methods using two simulated datasets and a real dataset from a trial in depression. We implement all methods in the R package predieval. Results suggest that the proposed measures can be useful in evaluating and comparing the performance of competing models in predicting individualized treatment effect.
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Affiliation(s)
- Orestis Efthimiou
- Institute of Social and Preventive Medicine (ISPM), University of BernBernSwitzerland
- Institute of Primary Health Care (BIHAM), University of BernBernSwitzerland
- Department of PsychiatryUniversity of OxfordOxfordUK
| | - Jeroen Hoogland
- Julius Center for Health Sciences and Primary CareUniversity Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
- Department of Epidemiology and Data ScienceAmsterdam University Medical CentersAmsterdamThe Netherlands
| | - Thomas P.A. Debray
- Julius Center for Health Sciences and Primary CareUniversity Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
- Smart Data Analysis and Statistics B.V.UtrechtThe Netherlands
| | - Michael Seo
- Institute of Social and Preventive Medicine (ISPM), University of BernBernSwitzerland
- Graduate School for Health SciencesUniversity of BernBernSwitzerland
| | - Toshiaki A. Furukawa
- Departments of Health Promotion and Human Behavior and of Clinical EpidemiologyKyoto University Graduate School of Medicine/School of Public HealthKyotoJapan
| | - Matthias Egger
- Institute of Social and Preventive Medicine (ISPM), University of BernBernSwitzerland
- Centre for Infectious Disease Epidemiology and Research, Faculty of Health SciencesUniversity of Cape TownCape TownSouth Africa
- Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - Ian R. White
- MRC Clinical Trials Unit at UCLUniversity College LondonLondonUK
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23
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Dahabreh IJ, Kazi DS. Toward Personalizing Care: Assessing Heterogeneity of Treatment Effects in Randomized Trials. JAMA 2023; 329:1063-1065. [PMID: 36942555 DOI: 10.1001/jama.2023.3576] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Affiliation(s)
- Issa J Dahabreh
- CAUSALab and Departments of Epidemiology and Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Statistical Editor, JAMA
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Dhruv S Kazi
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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24
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Rabey M, Kendell M, Shea YL, Mattinson D, Koh YFN, Seow KC, Beales D. Interaction analyses: Enhancing understanding of chronic low back pain. Musculoskelet Sci Pract 2023; 64:102728. [PMID: 36804720 DOI: 10.1016/j.msksp.2023.102728] [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: 08/04/2022] [Revised: 02/02/2023] [Accepted: 02/13/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Chronic low back pain (CLBP) is complex. Statistical examination of influences of exposures (e.g. characteristics) upon outcomes (e.g. pain) facilitates understanding of complexity and personalized care. Psychological factors may be associated with higher disability following exercise in CLBP. Examining interactions of psychological variables with exercise on disability might further understanding of CLBP. OBJECTIVES Secondary analysis of data from a CLBP cohort evaluating interactions between psychological variables and exercise on disability. DESIGN Longitudinal cohort study. METHOD Variables from a published prognostic model for disability: disability (baseline/one-year follow-up), psychological principal component scores (principal component score two (PC2) - Fear-avoidance beliefs, pain catastrophizing, pain self-efficacy; principal component score three (PC3) - thought suppression, behavioral endurance), exercise (during follow-up), forward-bending time, punishing significant other responses. Differences between exercisers and non-exercisers were assessed using Chi-Squared/Mann-Whitney tests. Multivariable linear regression models for follow-up disability included a term examining interaction between principal component scores and exercise. RESULTS Exercisers had significantly different scores for PC2 (p = .02) and PC3 (p = .03), lower baseline (p = .005) and follow-up pain intensity (p < .001), follow-up disability (p < .001) and faster forward-bend times (p = .014). There was no significant interaction between exercise and PC2 (p = .92) or PC3 (p = .75). CONCLUSIONS This study showed no interaction between psychological factors and exercise on disability at follow-up. These findings suggest that the disability outcome of people with CLBP who undertake exercise as an intervention does not differ from those who do not undertake exercise, irrespective of their baseline psychological status.
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Affiliation(s)
- Martin Rabey
- Curtin enAble Institute and Curtin School of Allied Health, Curtin University, GPO Box U1987, Perth, Western Australia, Australia.
| | - Michelle Kendell
- Curtin enAble Institute and Curtin School of Allied Health, Curtin University, GPO Box U1987, Perth, Western Australia, Australia
| | - Yik Lui Shea
- Curtin enAble Institute and Curtin School of Allied Health, Curtin University, GPO Box U1987, Perth, Western Australia, Australia
| | - Deb Mattinson
- Curtin enAble Institute and Curtin School of Allied Health, Curtin University, GPO Box U1987, Perth, Western Australia, Australia
| | - Yi Fan Nathan Koh
- Curtin enAble Institute and Curtin School of Allied Health, Curtin University, GPO Box U1987, Perth, Western Australia, Australia
| | - Kuang Cheng Seow
- Curtin enAble Institute and Curtin School of Allied Health, Curtin University, GPO Box U1987, Perth, Western Australia, Australia
| | - Darren Beales
- Curtin enAble Institute and Curtin School of Allied Health, Curtin University, GPO Box U1987, Perth, Western Australia, Australia
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25
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Gil-Sierra MD, Briceño-Casado MDP, Fénix-Caballero S, Alegre-Del Rey EJ, de la Lastra-Romero CA, Sánchez-Hidalgo M. Daratumumab-based therapies in transplant-ineligible patients with untreated multiple myeloma and hepatic dysfunction: A systematic review of subgroup analyses. J Oncol Pharm Pract 2023; 29:155-161. [PMID: 34846221 DOI: 10.1177/10781552211062144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION There is subgroup analysis suggesting a lack of benefit of daratumumab use in multiple myeloma (MM) and hepatic disease (HD). The objectives of this study were to conduct a systematic review and interpretation of daratumumab-based regimen efficacy in transplant-ineligible patients with untreated MM and HD. METHODS A systematic search in Pubmed® database about randomized clinical trials (RCTs) with subgroup analysis regarding hepatic function for overall survival (OS) or progression-free survival (PFS) were developed. Two methodologies were applied. One of them considered statistical interaction, prespecification, biological support and consistency of subgroup results. Second methodology was two-part validated tool: preliminary questions to reject subset analysis without minimal relevance, and a checklist relating a recommendation for applicability in clinical practice. RESULTS It was included three records. About first methodology, statistical interaction among subgroups was found for PFS in one RCT. Subsets were prespecified in all RCTs. Biological support of efficacy differences could be reasonable. Inconsistent results were found. Second methology directly rejected applicability of subset analysis in two records. Checklist recommended "null" application of results in the remaining RCT. CONCLUSIONS No consistent heterogeneity for daratumumab-based regimen efficacy was observed among subgroups regarding hepatic function in transplant-ineligible patients with untreated MM. Patients with normal hepatic function and HD could benefit from these treatments.
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Affiliation(s)
- Manuel David Gil-Sierra
- Pharmacy Department, 16875Hospital Universitario Puerto Real, Cadiz, Spain.,Department of Pharmacology, 16778Universidad de Sevilla, Facultad de Farmacia, Sevilla, Spain
| | | | | | | | | | - Marina Sánchez-Hidalgo
- Department of Pharmacology, 16778Universidad de Sevilla, Facultad de Farmacia, Sevilla, Spain
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26
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de Jonge SW, Kaji AH, Itani KMF. Practical Guide to Statistical Considerations in Clinical Trials in Surgery. JAMA Surg 2023; 158:89-90. [PMID: 36287537 DOI: 10.1001/jamasurg.2022.4892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
This Guide to Statistics and Methods discusses key statistical considerations in the conduct of randomized clinical trials in surgery.
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Affiliation(s)
- Stijn W de Jonge
- Department of Surgery, Amsterdam UMC, location AMC, Amsterdam Gastroenterology Endocrinology and Metabolism, University of Amsterdam, Amsterdam, the Netherlands
| | - Amy H Kaji
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California.,Statistical Editor, JAMA Surgery
| | - Kamal M F Itani
- Veterans Affairs Boston Health Care System, Boston University, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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27
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Paratore C, Zichi C, Audisio M, Bungaro M, Caglio A, Di Liello R, Gamba T, Gargiulo P, Mariniello A, Reale M, Perrone F, Di Maio M. Subgroup analyses in randomized phase III trials of systemic treatments in patients with advanced solid tumours: a systematic review of trials published between 2017 and 2020. ESMO Open 2022; 7:100593. [PMID: 36228332 PMCID: PMC9808470 DOI: 10.1016/j.esmoop.2022.100593] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/25/2022] [Accepted: 08/25/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Subgroup analyses of randomized controlled trials are very common in oncology; nevertheless, the methodological approach has not been systematically evaluated. The present analysis was conducted with the aim of describing the prevalence and methodological characteristics of the subgroup analyses in randomized controlled trials in patients with advanced cancer. METHODS A systematic literature search using PubMed was carried out to identify all phase III randomized controlled trials conducted in adult patients affected by locally advanced or metastatic solid tumours, published between 2017 and 2020. RESULTS Overall, 253 publications were identified. Subgroup analyses were reported in 217 (86%) publications. A statistically significant association of presence of subgroup analysis with study sponsor was observed: subgroup analyses were reported in 157 (94%) for-profit trials compared with 60 (70%) non-profit trials (P < 0.001). Description of the methodology of subgroup analysis was completely lacking in 82 trials (38%), only cited without methodological details in 100 trials (46%) and fully described in 35 trials (16%). Forest plot of subgroup analyses for the primary endpoint was available in 195 publications (77%). Among publications with reported forest plots, the median number of subgroups for primary endpoint was 19 (range 6-78). Out of the 217 publications with subgroup analyses, authors discuss the heterogeneity of treatment effect among different subgroups in 173 publications (80%), although a formal test for interaction for subgroup analysis of primary endpoint was reported for at least one variable only in 60 publications (28%). Correction for multiplicity was explicitly carried out only in nine trials (4%). CONCLUSIONS The very high prevalence of subgroup analyses in published papers, together with their methodological weaknesses, makes advisable an adequate education about their correct presentation and correct reading. More attention about proper planning and conduction of subgroup analysis should be paid not only by readers, but also by authors, journal editors and reviewers.
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Affiliation(s)
- C. Paratore
- Department of Oncology, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy,Department of Oncology, University of Turin, Ordine Mauriziano Hospital, Turin, Italy
| | - C. Zichi
- Department of Oncology, University of Turin, Ordine Mauriziano Hospital, Turin, Italy
| | - M. Audisio
- Department of Oncology, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - M. Bungaro
- Department of Oncology, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - A. Caglio
- Department of Oncology, University of Turin, Ordine Mauriziano Hospital, Turin, Italy
| | - R. Di Liello
- Clinical Trials Unit, Istituto Nazionale Tumori – IRCCS – Fondazione Giovanni Pascale, Naples, Italy
| | - T. Gamba
- Department of Oncology, University of Turin, Ordine Mauriziano Hospital, Turin, Italy
| | - P. Gargiulo
- Clinical Trials Unit, Istituto Nazionale Tumori – IRCCS – Fondazione Giovanni Pascale, Naples, Italy
| | - A. Mariniello
- Department of Oncology, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy,Emory Vaccine Center, Emory University School of Medicine, Atlanta, USA
| | - M.L. Reale
- Department of Oncology, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - F. Perrone
- Clinical Trials Unit, Istituto Nazionale Tumori – IRCCS – Fondazione Giovanni Pascale, Naples, Italy
| | - M. Di Maio
- Department of Oncology, University of Turin, Ordine Mauriziano Hospital, Turin, Italy,Correspondence to: Prof. Massimo Di Maio, Department of Oncology, University of Turin, Division of Medical Oncology, Ordine Mauriziano Hospital, Via Magellano 1, Turin 10128, Italy. Tel: +39-011-5082032 @MassimoDiMaio75
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28
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Jian T, Zhan Y, Hu K, He L, Chen S, Hu R, Lu J. Systemic triplet therapy for metastatic hormone-sensitive prostate cancer: A systematic review and network meta-analysis. Front Pharmacol 2022; 13:955925. [PMID: 36278154 PMCID: PMC9582339 DOI: 10.3389/fphar.2022.955925] [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: 05/29/2022] [Accepted: 09/21/2022] [Indexed: 11/24/2022] Open
Abstract
Purpose: To perform a systematic review and network meta-analysis to compare the efficacy and safety of currently available docetaxel-based systemic triplet therapies for metastatic hormone-sensitive prostate cancer (mHSPC). Methods: We searched for eligible publications in PubMed, Embase, and Cochrane CENTRAL. Improvements in overall survival (OS) and radiographic progression-free time (rPFS) were compared indirectly using network meta-analysis and evaluated using the surface under the cumulative ranking curve (SUCRA). Other secondary endpoints, such as time to castration-resistant prostate cancer and/or adverse events (AEs), were also compared and evaluated. Results: Five trials were selected and analyzed using a network meta-analysis. Compared to androgen deprivation therapy (ADT) plus docetaxel, darolutamide (hazard ratio [HR]: 0.68, 95% credible interval [CrI]: 0.57–0.80) and abiraterone (HR: 0.75, 95% CrI: 0.59–0.95) triplet therapy had significantly longer OS, and darolutamide triplet therapy was the first treatment ranked. Abiraterone (HR: 0.49, 95% CrI: 0.39–0.61) and enzalutamide (HR: 0.52, 95% CrI: 0.30–0.89) had significantly better rPFS than ADT plus docetaxel; however, all three therapies, including abiraterone, apalutamide, and enzalutamide, were the best options with a similar SUCRA. At most secondary endpoints, systemic triplet therapy was superior to ADT plus docetaxel. The risk of any AEs in darolutamide or abiraterone triplet therapy was comparable with ADT plus docetaxel (odds ratio [OR]: 2.53, 95% credible interval [CrI]: 0.68–12.63; OR: 1.07, 95% CrI: 0.03–36.25). Abiraterone triplet therapy had an increased risk of grade≥3 AEs (OR: 1.56, 95% CrI: 1.15–2.11). Conclusion: Systemic triplet therapy was more effective than ADT plus docetaxel for mHSPC. Of the triplet therapy regimens, darolutamide ranked first in terms of improved OS. Abiraterone and enzalutamide triplet ranked first in terms of rFPS, however, it did not confer a statistically difference among all triplet regimens. The overall risk of AEs was comparable. More studies are required for current and potential combinations of systemic triplet therapy.
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Affiliation(s)
- Tengteng Jian
- Department of Urology, The First Hospital of Jilin University, Changchun, China
| | - Yang Zhan
- School of Life Sciences, Jilin University, Changchun, China
| | - Kebang Hu
- Department of Urology, The First Hospital of Jilin University, Changchun, China
| | - Liang He
- Department of Urology, The First Hospital of Jilin University, Changchun, China
| | - Sunmeng Chen
- Department of Urology, The First Hospital of Jilin University, Changchun, China
| | - Rui Hu
- Department of Urology, The First Hospital of Jilin University, Changchun, China
| | - Ji Lu
- Department of Urology, The First Hospital of Jilin University, Changchun, China
- *Correspondence: Ji Lu,
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29
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Hancock MJ, Kent P. Research Note: Treatment effect moderators. J Physiother 2022; 68:283-287. [PMID: 36244961 DOI: 10.1016/j.jphys.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 08/10/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Mark J Hancock
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Australia
| | - Peter Kent
- Curtin School of Allied Health, Curtin University, Australia
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30
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Montesinos P, de Botton S, Döhner H. Ivosidenib and Azacitidine in IDH1-Mutated AML. Reply. N Engl J Med 2022; 386:2536-2537. [PMID: 35767450 DOI: 10.1056/nejmc2206489] [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: 11/19/2022]
Affiliation(s)
- Pau Montesinos
- Hospital Universitari i Politècnic La Fe, València, Spain
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31
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It Hurts to Move! Intervention Effects and Assessment Methods for Movement-Evoked Pain in Patients With Musculoskeletal Pain: A Systematic Review with Meta-analysis. J Orthop Sports Phys Ther 2022; 52:345-374. [PMID: 35128943 DOI: 10.2519/jospt.2022.10527] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To estimate the effects of musculoskeletal rehabilitation interventions on movementevoked pain and to explore the assessment methods/protocols used to evaluate movement-evoked pain in adults with musculoskeletal pain. DESIGN Systematic review with meta-analysis. LITERATURE SEARCH Three electronic databases (PubMed, Web of Science, and Scopus) were searched. STUDY SELECTION CRITERIA Randomized controlled trials investigating musculoskeletal rehabilitation interventions for movement-evoked pain in adults with musculoskeletal pain were included. DATA SYNTHESIS Meta-analysis was conducted for outcomes with homogeneous data from at least 2 trials. The mean change in movementevoked pain was the primary outcome measure. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation framework. RESULTS Thirty-eight trials were included, and 60 different interventions were assessed. There was moderate-certainty evidence of a beneficial effect of exercise therapy compared to no treatment (standardized mean difference [SMD], -0.65; 95% confidence interval [CI]: -0.83, -0.47; P<.001) on movement-evoked pain in adults with musculoskeletal pain. There was low-certainty evidence of a beneficial effect of transcutaneous electrical nerve stimulation compared to no treatment (SMD, -0.46; 95% CI: -0.71, -0.21; P = .0004). There was no benefit of transcutaneous electrical nerve stimulation when compared to sham transcutaneous electrical nerve stimulation (SMD, -0.28; 95% CI: -0.60, 0.05; P = .09; moderate-certainty evidence). CONCLUSION There was moderate-certainty evidence that exercise therapy is effective for reducing movement-evoked pain in patients with musculoskeletal pain compared to no treatment. Consider exercise therapy as the first-choice treatment for movement-evoked pain in clinical practice. J Orthop Sports Phys Ther 2022;52(6):345-374. Epub: 05 Feb 2022. doi:10.2519/jospt.2022.10527.
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Reed RL, Roeger L, Kwok YH, Kaambwa B, Allison S, Osborne RH. A general practice intervention for people at risk of poor health outcomes: the Flinders QUEST cluster randomised controlled trial and economic evaluation. Med J Aust 2022; 216:469-475. [PMID: 35388512 PMCID: PMC9321612 DOI: 10.5694/mja2.51484] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 11/13/2020] [Indexed: 11/17/2022]
Abstract
Objective To determine whether a multicomponent general practice intervention cost‐effectively improves health outcomes and reduces health service use for patients at high risk of poor health outcomes. Design, setting Clustered randomised controlled trial in general practices in metropolitan Adelaide. Participants Three age‐based groups of patients identified by their general practitioners as being at high risk of poor health outcomes: children and young people (under 18 years), adults (18–64 years) with two or more chronic diseases, and older people (65 years or more). Intervention Enrolment of patients with a preferred GP, longer general practice appointments, and general practice follow‐up within seven days of emergency department and hospital care episodes. Intervention practices received payment of $1000 per enrolled participant. Main outcome measures Primary outcome: change in self‐rated health between baseline and 12‐month follow‐up for control (usual care) and intervention groups. Secondary outcomes: numbers of emergency department presentations and hospital admissions, Medicare specialist claims and Pharmaceutical Benefits Scheme (PBS) items supplied, Health Literacy Questionnaire scores, and cost‐effectiveness of the intervention (based on the number of quality‐adjusted life‐years [QALYs] gained over 12 months, derived from EQ‐5D‐5L utility scores for the two adult groups). Results Twenty practices with a total of 92 GPs were recruited, and 1044 eligible patients participated. The intervention did not improve self‐rated health (coefficient, –0.29; 95% CI, –2.32 to 1.73), nor did it have significant effects on the numbers of emergency department presentations (incidence rate ratio [IRR], 0.90; 95% CI, 0.69–1.17), hospital admissions (IRR, 0.90; 95% CI, 0.66–1.22), Medicare specialist claims (IRR, 1.00; 95% CI, 0.91–1.09), or PBS items supplied (IRR, 0.99; 95% CI, 0.96–1.03), nor on Health Literacy Questionnaire scores. The intervention was effective in terms of QALYs gained (v usual care: difference, 0.032 QALYs; 95% CI, 0.001–0.063), but the incremental cost‐effectiveness ratio was $69 585 (95% CI, $22 968–$116 201) per QALY gained, beyond the willingness‐to‐pay threshold. Conclusions Our multicomponent intervention did not improve self‐rated health, health service use, or health literacy. It achieved greater improvement in quality of life than usual care, but not cost‐effectively. Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12617001589370 (prospective).
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Affiliation(s)
- Richard L Reed
- College of Medicine and Public Health Flinders University Adelaide SA
| | - Leigh Roeger
- College of Medicine and Public Health Flinders University Adelaide SA
| | - Yuen H Kwok
- College of Medicine and Public Health Flinders University Adelaide SA
| | | | - Stephen Allison
- College of Medicine and Public Health Flinders University Adelaide SA
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Kulhánek A, Lukavska K, Gabrhelík R, Novák D, Burda V, Prokop J, Holter MTS, Brendryen H. Comparing Reminders Sent via SMS Text Messaging and Email for Improving Adherence to an Electronic Health Program: Randomized Controlled Trial. JMIR Mhealth Uhealth 2022; 10:e31040. [PMID: 35302945 PMCID: PMC8976257 DOI: 10.2196/31040] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/12/2021] [Accepted: 12/20/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND eHealth interventions can help people change behavior (eg, quit smoking). Reminders sent via SMS text messaging or email may improve the adherence to web-based programs and increase the probability of successful behavior change; however, it is unclear whether their efficiency is affected by the modality of the communication channel. OBJECTIVE A 2-armed randomized control trial was conducted to compare the effect of providing reminders via SMS text messaging versus email on the adherence to an eHealth program for smoking cessation and on the probability to initiate a quit attempt. METHODS Smokers were recruited via an internet-based advertisement. A total of 591 participants who diverted from intended use of the program (ie, failed to log on to a session) were automatically randomized to the experimental (SMS text messaging reminder, n=304) or the active comparator (email reminder, n=287) group. RESULTS Unexpectedly, we found that the mode of reminder delivery did not significantly affect either the adherence, namely the number of completed program sessions, with the SMS text messaging reminder group showing a mean of 4.30 (SD 3.24) and the email reminder group showing a mean of 4.36 (SD 3.27) (t586=0.197, P=.84, and Cohen d=0.016), or the outcome, namely the quit smoking attempt rate (34.2% in the SMS text messaging group vs 31.7% in the email group; χ21=0.4, P=.52). Secondary analyses showed that age, gender, and education had significant effects on program adherence and education on the outcome. Moreover, we found a significant interaction effect between the mode of reminder delivery and gender on program adherence, suggesting that the effectiveness of SMS text message reminders might be different for females and males. However, this particular finding should be treated with care as it was based on post hoc subgroup analysis. CONCLUSIONS This study indicates that the modality of user reminders to log on increased neither the program adherence nor the probability of quitting smoking. This suggests that program developers may save costs using emails instead of SMS text messaging reminders. TRIAL REGISTRATION ClinicalTrials.gov NCT03276767; https://clinicaltrials.gov/ct2/show/ NCT03276767.
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Affiliation(s)
- Adam Kulhánek
- Department of Addictology, General University Hospital in Prague, Prague, Czech Republic
- Department of Addictology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Katerina Lukavska
- Department of Addictology, General University Hospital in Prague, Prague, Czech Republic
- Department of Addictology, First Faculty of Medicine, Charles University, Prague, Czech Republic
- Department of Psychology, Faculty of Education, Charles University, Prague, Czech Republic
| | - Roman Gabrhelík
- Department of Addictology, General University Hospital in Prague, Prague, Czech Republic
- Department of Addictology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Daniel Novák
- Department of Cybernetics, Faculty of Electrical Engineering, Czech Technical University in Prague, Prague, Czech Republic
| | - Václav Burda
- Department of Addictology, First Faculty of Medicine, Charles University, Prague, Czech Republic
- Department of Cybernetics, Faculty of Electrical Engineering, Czech Technical University in Prague, Prague, Czech Republic
| | - Jindřich Prokop
- Department of Cybernetics, Faculty of Electrical Engineering, Czech Technical University in Prague, Prague, Czech Republic
| | - Marianne T S Holter
- The Norwegian Centre for Addiction Research (SERAF), Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway
| | - Håvar Brendryen
- The Norwegian Centre for Addiction Research (SERAF), Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway
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Costa ML, Achten J, Ooms A, Png ME, Cook J, Dritsaki M, Lamb SE, Lerner R, Draper K, Campolier M, Dakin H, McGibbon A, Parsons N, Hedley H, Dias J. Moulded cast compared with K-wire fixation after manipulation of an acute dorsally displaced distal radius fracture: the DRAFFT 2 RCT. Health Technol Assess 2022; 26:1-80. [PMID: 35152940 PMCID: PMC8883335 DOI: 10.3310/rlcf6332] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Patients with a displaced fracture of the distal radius are frequently offered surgical fixation. Manipulation of the fracture and moulded plaster casting is an alternative treatment that avoids metal implants, but evidence of its effectiveness is lacking. OBJECTIVE To compare functional outcomes, quality-of-life outcomes, complications and resource use among patients with a dorsally displaced fracture of the distal radius treated with manipulation and surgical fixation with Kirschner wires (K-wires) and those treated with manipulation and moulded cast. DESIGN Pragmatic, superiority, multicentre, randomised controlled trial with a health economic evaluation. SETTING A total of 36 orthopaedic trauma centres in the UK NHS. PARTICIPANTS Patients (aged ≥ 16 years) treated for an acute dorsally displaced fracture of the distal radius were potentially eligible. Patients were excluded if their injury had occurred > 2 weeks previously, if the fracture was open, if it extended > 3 cm from the radiocarpal joint or if it required open reduction, or if the participant was unable to complete questionnaires. INTERVENTIONS Participants were randomly assigned in theatre (1 : 1) to receive a moulded cast (i.e. the cast group) or surgical fixation with K-wires (i.e. the K-wire group) after fracture manipulation. MAIN OUTCOME MEASURES The primary outcome measure was the Patient-Rated Wrist Evaluation score at 12 months, analysed on an intention-to-treat basis. Health-related quality of life was recorded using the EuroQol-5 Dimensions, five-level version, and resource use was recorded from a health and personal social care perspective. RESULTS Between January 2017 and March 2019, 500 participants (mean age 60 years, 83% women) were randomly allocated to receive a moulded cast (n = 255) or surgical fixation with K-wire (n = 245) following a manipulation of their fracture. A total of 395 (80%) participants were included in the primary analysis at 12 months. There was no difference in the Patient-Rated Wrist Evaluation score at 1 year post randomisation [cast group: n = 200, mean score 21.2 (standard deviation 23.1); K-wire group: n = 195, mean score 20.7 (standard deviation 22.3); adjusted mean difference -0.34 (95% confidence interval -4.33 to 3.66); p = 0.87]. A total of 33 (13%) participants in the cast group required surgical fixation for loss of fracture position in the first 6 weeks, compared with one participant in the K-wire group (odds ratio 0.02, 95% confidence interval 0.001 to 0.10). The base-case cost-effectiveness analysis showed that manipulation and surgical fixation with K-wires had a higher mean cost than manipulation and a moulded cast, despite similar mean effectiveness. The use of K-wires is unlikely to be cost-effective, and sensitivity analyses found this result to be robust. LIMITATIONS Because the interventions were identifiable, neither patients nor clinicians could be blind to their treatment. CONCLUSIONS Surgical fixation with K-wires was not found to be superior to moulded casting following manipulation of a dorsally displaced fracture of the distal radius, as measured by Patient-Rated Wrist Evaluation score. However, one in eight participants treated in a moulded cast required surgery for loss of fracture reduction in the first 6 weeks. After a successful closed reduction, clinicians may consider a moulded cast as a safe and cost-effective alternative to surgical fixation with K-wires. FUTURE WORK Further research should focus on optimal techniques for immobilisation and manipulation of this type of fracture, including optimal analgesia, and for rehabilitation of the patient after immobilisation. TRIAL REGISTRATION This trial is registered as ISRCTN11980540 and UKCRN Portfolio 208830. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 11. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Matthew L Costa
- Oxford Trauma and Emergency Care, Kadoorie Research Centre, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Juul Achten
- Oxford Trauma and Emergency Care, Kadoorie Research Centre, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Alexander Ooms
- Centre for Statistics in Medicine, Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - May Ee Png
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jonathan Cook
- Centre for Statistics in Medicine, Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Melina Dritsaki
- Centre for Statistics in Medicine, Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah E Lamb
- Oxford Trauma and Emergency Care, Kadoorie Research Centre, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- College of Medicine and Health, St Luke's Campus, University of Exeter, Exeter, UK
| | - Robin Lerner
- Oxford Trauma and Emergency Care, Kadoorie Research Centre, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Blizard Institute, Queen Mary University of London, London, UK
| | - Kylea Draper
- Oxford Trauma and Emergency Care, Kadoorie Research Centre, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Marta Campolier
- Oxford Trauma and Emergency Care, Kadoorie Research Centre, Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Helen Dakin
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alwin McGibbon
- Patient and public involvement group member, Wimbourne, UK
| | - Nicholas Parsons
- Statistics and Epidemiology Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Helen Hedley
- Department of Orthopaedics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Joseph Dias
- AToMS Academic Team of Musculoskeletal Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
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Clinical and pharmacoeconomic impact of subgroup analysis in onco-hematological patients. Support Care Cancer 2022; 30:3761-3772. [PMID: 35028720 DOI: 10.1007/s00520-022-06823-y] [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: 08/18/2021] [Accepted: 01/10/2022] [Indexed: 10/19/2022]
Abstract
Subgroup analysis evaluates a health intervention in subpopulations according to a characteristic or factor. It can be useful for generating new hypotheses or conducting new studies. However, subgroup analysis presents several limitations and it should be considered cautiously. The development of new onco-hematological drugs is accelerating in recent years and the impact of subgroup analysis on clinical decision-making is increasing. The interpretation of subgroup analyses can be controversial in some cases, negatively affecting patients and healthcare systems. This work is a review of the clinical and pharmacoeconomic impact of subgroup analysis in onco-hematological patients. The study describes some illustrative examples of inadequate interpretations about subset analysis: combination of pembrolizumab plus chemotherapy in lung cancer, inhibitors of cyclin-dependent kinases in breast cancer, daratumumab-based regimens in newly diagnosed multiple myeloma, combination of nivolumab with ipilimumab in melanoma and docetaxel in prostate cancer. Subgroup analysis can have a significant impact on the data selection for the development of studies; efficacy, safety, and convenience of treatments in onco-hematological patients; efficiency of therapies in health systems; and therapeutic positioning of antineoplastic drugs. There is a strong need to establish homogeneous criteria for the assessment of subgroup analysis and to develop new tools for its consideration.
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Stuke H. Markers of muscarinic deficit for individualized treatment in schizophrenia. Front Psychiatry 2022; 13:1100030. [PMID: 36699495 PMCID: PMC9868756 DOI: 10.3389/fpsyt.2022.1100030] [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: 11/16/2022] [Accepted: 12/20/2022] [Indexed: 01/11/2023] Open
Abstract
Recent clinical studies have shown that agonists at muscarinic acetylcholine receptors effectively reduce schizophrenia symptoms. It is thus conceivable that, for the first time, a second substance class of procholinergic antipsychotics could become established alongside the usual antidopaminergic antipsychotics. In addition, various basic science studies suggest that there may be a subgroup of schizophrenia in which hypofunction of muscarinic acetylcholine receptors is of etiological importance. This could represent a major opportunity for individualized treatment of schizophrenia if markers can be identified that predict response to procholinergic vs. antidopaminergic interventions. In this perspective, non-response to antidopaminergic antipsychotics, specific symptom patterns like visual hallucinations and strong disorganization, the presence of antimuscarinic antibodies, ERP markers such as mismatch negativity, and radiotracers are presented as possible in vivo markers of muscarinic deficit and thus potentially of response to procholinergic therapeutics. Finally, open questions and further research steps are outlined.
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Affiliation(s)
- Heiner Stuke
- Department of Psychiatry and Psychotherapy, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health at Charité-Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Berlin, Germany
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Husereau D, Drummond M, Augustovski F, de Bekker-Grob E, Briggs AH, Carswell C, Caulley L, Chaiyakunapruk N, Greenberg D, Loder E, Mauskopf J, Mullins CD, Petrou S, Pwu RF, Staniszewska S. Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 Explanation and Elaboration: A Report of the ISPOR CHEERS II Good Practices Task Force. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:10-31. [PMID: 35031088 DOI: 10.1016/j.jval.2021.10.008] [Citation(s) in RCA: 283] [Impact Index Per Article: 141.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/03/2021] [Indexed: 05/22/2023]
Abstract
Health economic evaluations are comparative analyses of alternative courses of action in terms of their costs and consequences. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement, published in 2013, was created to ensure health economic evaluations are identifiable, interpretable, and useful for decision making. It was intended as guidance to help authors report accurately which health interventions were being compared and in what context, how the evaluation was undertaken, what the findings were, and other details that may aid readers and reviewers in interpretation and use of the study. The new CHEERS 2022 statement replaces the previous CHEERS reporting guidance. It reflects the need for guidance that can be more easily applied to all types of health economic evaluation, new methods and developments in the field, and the increased role of stakeholder involvement including patients and the public. It is also broadly applicable to any form of intervention intended to improve the health of individuals or the population, whether simple or complex, and without regard to context (such as healthcare, public health, education, and social care). This Explanation and Elaboration Report presents the new CHEERS 2022 28-item checklist with recommendations and explanation and examples for each item. The CHEERS 2022 statement is primarily intended for researchers reporting economic evaluations for peer-reviewed journals and the peer reviewers and editors assessing them for publication. Nevertheless, we anticipate familiarity with reporting requirements will be useful for analysts when planning studies. It may also be useful for health technology assessment bodies seeking guidance on reporting, given that there is an increasing emphasis on transparency in decision making.
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Affiliation(s)
- Don Husereau
- University of Ottawa, School of Epidemiology and Public Health, Ottawa, Ontario, Canada and Institute of Health Economics, Edmonton, Alberta, Canada (Husereau).
| | | | - Federico Augustovski
- Health Technology Assessment and Health Economics Department of the Institute for Clinical Effectiveness and Health Policy (IECS- CONICET), Buenos Aires; University of Buenos Aires, Buenos Aires; CONICET (National Scientific and Technical Research Council), Buenos Aires, Argentina
| | - Esther de Bekker-Grob
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Andrew H Briggs
- London School of Hygiene and Tropical Medicine, London, England, UK
| | | | - Lisa Caulley
- Department of Otolaryngology - Head & Neck Surgery, University of Ottawa, Ontario, Canada; Clinical Epidemiology Program and Center for Journalology, Ottawa Hospital Research Institute, Ontario, Canada; Department of Epidemiology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nathorn Chaiyakunapruk
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
| | - Dan Greenberg
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheva, Israel
| | - Elizabeth Loder
- Harvard Medical School, Boston, MA, USA; The BMJ, London, UK
| | - Josephine Mauskopf
- RTI Health Solutions, RTI International, Research Triangle Park, NC, USA
| | - C Daniel Mullins
- School of Pharmacy, University of Maryland Baltimore, Baltimore, MD, USA
| | - Stavros Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Raoh-Fang Pwu
- National Hepatitis C Program Office, Ministry of Health and Welfare, Taipei City, Taiwan
| | - Sophie Staniszewska
- Warwick Research in Nursing, University of Warwick Warwick Medical School, Warwick, UK
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Zen M, Haider R, Simmons D, Peek M, Nolan CJ, Padmanabhan S, Jesudason S, Alahakoon TI, Cheung NW, Lee VW. Aspirin for the prevention of pre-eclampsia in women with pre-existing diabetes: Systematic review. Aust N Z J Obstet Gynaecol 2021; 62:12-21. [PMID: 34806161 DOI: 10.1111/ajo.13460] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/12/2021] [Accepted: 11/03/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND There is a lack of evidence for pre-eclampsia prophylaxis with aspirin in women with pre-existing diabetes mellitus (DM). AIMS To examine the evidence for aspirin in pre-eclampsia prophylaxis in women with pre-existing DM. MATERIAL AND METHODS An electronic search using Ovid MEDLINE, Embase, CinicalTrials.gov and the Cochrane CENTRAL register of controlled trials through to February 2021 was performed. Reference lists of identified studies, previous review articles, clinical practice guidelines and government reports were manually searched. Randomised controlled trials (RCTs) of aspirin vs placebo for pre-eclampsia prophylaxis were included. Articles were manually reviewed to determine if cohorts included women with DM. The systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Data from included trials were extracted independently by two authors who also independently assessed risk of bias as per the Cochrane Handbook criteria version 5.1.0. Data were analysed using Rev-Man 5.4. RESULTS Forty RCTs were identified, of which 11 included a confirmed subset of women with DM; however, data were insufficient for meta-analysis. Meta-analysis of 930 women with DM, from individual patient data included in a systematic review and unpublished data from one of the 11 RCTs, showed a non-significant difference in the outcome of pre-eclampsia in participants treated with aspirin compared to placebo (odds ratio 0.58; 95% CI 0.20-1.71; P = 0.33). CONCLUSIONS Pre-eclampsia risk reduction with aspirin prophylaxis in women with pre-existing DM may be similar to women without pre-existing DM. However, randomised data within this meta-analysis were insufficient, warranting the need for further studies within this high-risk group of women.
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Affiliation(s)
- Monica Zen
- Westmead Institute for Maternal & Fetal Medicine, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, Faculty of Medicine and Health, Westmead Hospital, The University of Sydney, Sydney, New South Wales, Australia
| | - Rabbia Haider
- Department of Endocrinology, Nepean Hospital, Sydney, New South Wales, Australia
| | - David Simmons
- Macarthur Clinical School, Western Sydney University, Sydney, New South Wales, Australia
| | - Michael Peek
- ANU Medical School, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - Christopher J Nolan
- ANU Medical School, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - Suja Padmanabhan
- Westmead Clinical School, Faculty of Medicine and Health, Westmead Hospital, The University of Sydney, Sydney, New South Wales, Australia.,Department of Diabetes & Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Shilpa Jesudason
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Thushari I Alahakoon
- Westmead Institute for Maternal & Fetal Medicine, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, Faculty of Medicine and Health, Westmead Hospital, The University of Sydney, Sydney, New South Wales, Australia
| | - Ngai Wah Cheung
- Westmead Clinical School, Faculty of Medicine and Health, Westmead Hospital, The University of Sydney, Sydney, New South Wales, Australia.,Department of Diabetes & Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Vincent W Lee
- Westmead Clinical School, Faculty of Medicine and Health, Westmead Hospital, The University of Sydney, Sydney, New South Wales, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia.,Department of Renal Medicine, Westmead Hospital, Sydney, New South Wales, Australia
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Yuan A, Wang L, Tan MT. Set-regression with applications to subgroup analysis. Stat Med 2021; 41:180-193. [PMID: 34672000 DOI: 10.1002/sim.9229] [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: 01/21/2021] [Revised: 09/30/2021] [Accepted: 09/30/2021] [Indexed: 11/10/2022]
Abstract
Regression is a commonly used statistical model. It is the conditional mean of the response given covariates μ ( x ) = E ( Y | X = x ) . However, in some practical problems, the interest is the conditional mean of the response given the covariates belonging to some set A. Notably, in precision medicine and subgroup analysis in clinical trials, the aim is to identify subjects who benefit the most from the treatment, or identify an optimal set in the covariate space which manifests treatment favoritism if a subject's covariates fall in this set and the subject is classified to the favorable treatment subgroup. Existing methods for subgroup analysis achieve this indirectly by using classical regression. This motivates us to develop a new type of regression: set-regression, defined as μ ( A ) = E ( Y | X ∈ A ) which directly addresses the subgroup analysis problem. This extends not only the classical regression model but also improves recursive partitioning and support vector machine approaches, and is particularly suitable for objectives involving optimization of the regression over sets, such as subgroup analysis. We show that the new versatile set-regression identifies the subgroup with increased accuracy. It is easy to use. Simulation studies also show superior performance of the proposed method in finite samples.
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Affiliation(s)
- Ao Yuan
- Department of Biostatistics, Bioinformatics and Biomathematics, Georgetown University, Washington, District of Columbia, USA
| | - Lida Wang
- Department of Biostatistics, Bioinformatics and Biomathematics, Georgetown University, Washington, District of Columbia, USA
| | - Ming T Tan
- Department of Biostatistics, Bioinformatics and Biomathematics, Georgetown University, Washington, District of Columbia, USA
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Dean RL, Marquardt T, Hurducas C, Spyridi S, Barnes A, Smith R, Cowen PJ, McShane R, Hawton K, Malhi GS, Geddes J, Cipriani A. Ketamine and other glutamate receptor modulators for depression in adults with bipolar disorder. Cochrane Database Syst Rev 2021; 10:CD011611. [PMID: 34623633 PMCID: PMC8499740 DOI: 10.1002/14651858.cd011611.pub3] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Glutamergic system dysfunction has been implicated in the pathophysiology of bipolar depression. This is an update of the 2015 Cochrane Review for the use of glutamate receptor modulators for depression in bipolar disorder. OBJECTIVES 1. To assess the effects of ketamine and other glutamate receptor modulators in alleviating the acute symptoms of depression in people with bipolar disorder. 2. To review the acceptability of ketamine and other glutamate receptor modulators in people with bipolar disorder who are experiencing depressive symptoms. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase and PsycINFO all years to July 2020. We did not apply any restrictions to date, language or publication status. SELECTION CRITERIA RCTs comparing ketamine or other glutamate receptor modulators with other active psychotropic drugs or saline placebo in adults with bipolar depression. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, assessed trial quality and extracted data. Primary outcomes were response rate and adverse events. Secondary outcomes included remission rate, depression severity change scores, suicidality, cognition, quality of life, and dropout rate. The GRADE framework was used to assess the certainty of the evidence. MAIN RESULTS Ten studies (647 participants) were included in this review (an additional five studies compared to the 2015 review). There were no additional studies added to the comparisons identified in the 2015 Cochrane review on ketamine, memantine and cytidine versus placebo. However, three new comparisons were found: ketamine versus midazolam, N-acetylcysteine versus placebo, and riluzole versus placebo. The glutamate receptor modulators studied were ketamine (three trials), memantine (two), cytidine (one), N-acetylcysteine (three), and riluzole (one). Eight of these studies were placebo-controlled and two-armed. In seven trials the glutamate receptor modulators had been used as add-on drugs to mood stabilisers. Only one trial compared ketamine with an active comparator, midazolam. The treatment period ranged from a single intravenous administration (all ketamine studies), to repeated administration for riluzole, memantine, cytidine, and N-acetylcysteine (with a follow-up of eight weeks, 8 to 12 weeks, 12 weeks, and 16 to 20 weeks, respectively). Six of the studies included sites in the USA, one in Taiwan, one in Denmark, one in Australia, and in one study the location was unclear. All participants had a primary diagnosis of bipolar disorder and were experiencing an acute bipolar depressive episode, diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders fourth edition (IV) or fourth edition text revision (IV-TR). Among all glutamate receptor modulators included in this review, only ketamine appeared to be more efficacious than placebo 24 hours after infusion for response rate (odds ratio (OR) 11.61, 95% confidence interval (CI) 1.25 to 107.74; P = 0.03; participants = 33; studies = 2; I² = 0%, low-certainty evidence). Ketamine seemed to be more effective in reducing depression rating scale scores (MD -11.81, 95% CI -20.01 to -3.61; P = 0.005; participants = 32; studies = 2; I2 = 0%, very low-certainty evidence). There was no evidence of ketamine's efficacy in producing remission over placebo at 24 hours (OR 5.16, 95% CI 0.51 to 52.30; P = 0.72; participants = 33; studies = 2; I2 = 0%, very low-certainty evidence). Evidence on response, remission or depression rating scale scores between ketamine and midazolam was uncertain at 24 hours due to very low-certainty evidence (OR 3.20, 95% CI 0.23 to 45.19). In the one trial assessing ketamine and midazolam, there were no dropouts due to adverse effects or for any reason (very low-certainty evidence). Placebo may have been more effective than N-acetylcysteine in reducing depression rating scale scores at three months, although this was based on very low-certainty evidence (MD 1.28, 95% CI 0.24 to 2.31; participants = 58; studies = 2). Very uncertain evidence found no difference in response at three months (OR 0.82, 95% CI 0.32 to 2.14; participants = 69; studies = 2; very low-certainty evidence). No data were available for remission or acceptability. Extremely limited data were available for riluzole vs placebo, finding only very-low certainty evidence of no difference in dropout rates (OR 2.00, 95% CI 0.31 to 12.84; P = 0.46; participants = 19; studies = 1; I2 = 0%). AUTHORS' CONCLUSIONS It is difficult to draw reliable conclusions from this review due to the certainty of the evidence being low to very low, and the relatively small amount of data usable for analysis in bipolar disorder, which is considerably less than the information available for unipolar depression. Nevertheless, we found uncertain evidence in favour of a single intravenous dose of ketamine (as add-on therapy to mood stabilisers) over placebo in terms of response rate up to 24 hours, however ketamine did not show any better efficacy for remission in bipolar depression. Even though ketamine has the potential to have a rapid and transient antidepressant effect, the efficacy of a single intravenous dose may be limited. We did not find conclusive evidence on adverse events with ketamine, and there was insufficient evidence to draw meaningful conclusions for the remaining glutamate receptor modulators. However, ketamine's psychotomimetic effects (such as delusions or delirium) may have compromised study blinding in some studies, and so we cannot rule out the potential bias introduced by inadequate blinding procedures. To draw more robust conclusions, further methodologically sound RCTs (with adequate blinding) are needed to explore different modes of administration of ketamine, and to study different methods of sustaining antidepressant response, such as repeated administrations.
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Affiliation(s)
| | | | | | - Styliani Spyridi
- Department of Rehabilitation Sciences, Faculty of Health Sciences, Cyprus University of Technology, Lemesos, Cyprus
| | | | | | - Philip J Cowen
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Rupert McShane
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Keith Hawton
- Centre for Suicide Research, University Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - Gin S Malhi
- Discipline of Psychiatry, Northern Clinical School, University of Sydney, Sydney, Australia
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Dean RL, Hurducas C, Hawton K, Spyridi S, Cowen PJ, Hollingsworth S, Marquardt T, Barnes A, Smith R, McShane R, Turner EH, Cipriani A. Ketamine and other glutamate receptor modulators for depression in adults with unipolar major depressive disorder. Cochrane Database Syst Rev 2021; 9:CD011612. [PMID: 34510411 PMCID: PMC8434915 DOI: 10.1002/14651858.cd011612.pub3] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Many studies have recently been conducted to assess the antidepressant efficacy of glutamate modification in mood disorders. This is an update of a review first published in 2015 focusing on the use of glutamate receptor modulators in unipolar depression. OBJECTIVES To assess the effects - and review the acceptability and tolerability - of ketamine and other glutamate receptor modulators in alleviating the acute symptoms of depression in people with unipolar major depressive disorder. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase and PsycINFO all years to July 2020. We did not apply any restrictions to date, language or publication status. SELECTION CRITERIA Double- or single-blinded randomised controlled trials (RCTs) comparing ketamine, memantine, esketamine or other glutamate receptor modulators with placebo (pill or saline infusion), other active psychotropic drugs, or electroconvulsive therapy (ECT) in adults with unipolar major depression. DATA COLLECTION AND ANALYSIS Three review authors independently identified studies, assessed trial quality and extracted data. The primary outcomes were response rate (50% reduction on a standardised rating scale) and adverse events. We decided a priori to measure the efficacy outcomes at different time points and run sensitivity/subgroup analyses. Risk of bias was assessed using the Cochrane tool, and certainty of the evidence was assessed using GRADE. MAIN RESULTS Thirty-one new studies were identified for inclusion in this updated review. Overall, we included 64 studies (5299 participants) on ketamine (31 trials), esketamine (9), memantine (5), lanicemine (4), D-cycloserine (2), Org26576 (2), riluzole (2), atomoxetine (1), basimglurant (1), citicoline (1), CP-101,606 (1), decoglurant (1), MK-0657 (1), N-acetylcysteine (1), rapastinel (1), and sarcosine (1). Forty-eight studies were placebo-controlled, and 48 were two-arm studies. The majority of trials defined an inclusion criterion for the severity of depressive symptoms at baseline: 29 at least moderate depression; 17 severe depression; and five mild-to-moderate depression. Nineteen studies recruited only patients with treatment-resistant depression, defined as inadequate response to at least two antidepressants. The majority of studies investigating ketamine administered as a single dose, whilst all of the included esketamine studies used a multiple dose regimen (most frequently twice a week for four weeks). Most studies looking at ketamine used intravenous administration, whilst the majority of esketamine trials used intranasal routes. The evidence suggests that ketamine may result in an increase in response and remission compared with placebo at 24 hours odds ratio (OR) 3.94, 95% confidence interval (CI) 1.54 to 10.10; n = 185, studies = 7, very low-certainty evidence). Ketamine may reduce depression rating scale scores over placebo at 24 hours, but the evidence is very uncertain (standardised mean difference (SMD) -0.87, 95% CI -1.26 to -0.48; n = 231, studies = 8, very low-certainty evidence). There was no difference in the number of participants assigned to ketamine or placebo who dropped out for any reason (OR 1.25, 95% CI 0.19 to 8.28; n = 201, studies = 6, very low-certainty evidence). When compared with midazolam, the evidence showed that ketamine increases remission rates at 24 hours (OR 2.21, 95% CI 0.67 to 7.32; n = 122,studies = 2, low-certainty evidence). The evidence is very uncertain about the response efficacy of ketamine at 24 hours in comparison with midazolam, and its ability to reduce depression rating scale scores at the same time point (OR 2.48, 95% CI 1.00 to 6.18; n = 296, studies = 4,very low-certainty evidence). There was no difference in the number of participants who dropped out of studies for any reason between ketamine and placebo (OR 0.33, 95% CI 0.05 to 2.09; n = 72, studies = 1, low-certainty evidence). Esketamine treatment likely results in a large increase in participants achieving remission at 24 hours compared with placebo (OR 2.74, 95% CI 1.71 to 4.40; n = 894, studies = 5, moderate-certainty evidence). Esketamine probably results in decreases in depression rating scale scores at 24 hours compared with placebo (SMD -0.31, 95% CI -0.45 to -0.17; n = 824, studies = 4, moderate-certainty evidence). Our findings show that esketamine increased response rates, although this evidence is uncertain (OR 2.11, 95% CI 1.20 to 3.68; n = 1071, studies = 5, low-certainty evidence). There was no evidence that participants assigned to esketamine treatment dropped out of trials more frequently than those assigned to placebo for any reason (OR 1.58, 95% CI 0.92 to 2.73; n = 773, studies = 4,moderate-certainty evidence). We found very little evidence for the remaining glutamate receptor modulators. We rated the risk of bias as low or unclear for most domains, though lack of detail regarding masking of treatment in the studies reduced our certainty in the effect for all outcomes. AUTHORS' CONCLUSIONS Our findings show that ketamine and esketamine may be more efficacious than placebo at 24 hours. How these findings translate into clinical practice, however, is not entirely clear. The evidence for use of the remaining glutamate receptor modulators is limited as very few trials were included in the meta-analyses for each comparison and the majority of comparisons included only one study. Long term non-inferiority RCTs comparing repeated ketamine and esketamine, and rigorous real-world monitoring are needed to establish comprehensive data on safety and efficacy.
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Affiliation(s)
| | | | - Keith Hawton
- Centre for Suicide Research, Department of Psychiatry, University of Oxford, Oxford, UK
| | - Styliani Spyridi
- Department of Rehabilitation Sciences, Faculty of Health Sciences, Cyprus University of Technology, Lemesos, Cyprus
| | - Philip J Cowen
- Department of Psychiatry, University of Oxford, Oxford, UK
| | | | | | | | | | - Rupert McShane
- Oxford Health NHS Foundation Trust, Oxford, UK
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Erick H Turner
- Portland Veterans Affairs Medical Center, P3MHDC, Portland, USA
- Department of Psychiatry, Oregon Health & Science University, Portland, Oregon, USA
| | - Andrea Cipriani
- Oxford Health NHS Foundation Trust, Oxford, UK
- Department of Psychiatry, University of Oxford, Oxford, UK
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Gil-Sierra MD, Alegre-Del Rey EJ, Alarcon de la Lastra-Romero C, Sánchez-Hidalgo M. Use of docetaxel in low- and high-burden metastatic hormone-sensitive prostate cancer: A systematic review and assessment of subgroup analyses. J Oncol Pharm Pract 2021; 27:1743-1750. [PMID: 34424094 DOI: 10.1177/10781552211037322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Use of docetaxel in low- and high-burden metastatic hormone-sensitive prostate cancer presents considerable controversy. There is literature suggesting lack of benefit for low-volume of metastases. OBJECTIVE The study aims to develop a systematic review and methodological assessment of subset analysis about use of docetaxel in metastatic hormone-sensitive prostate cancer regarding volume of metastatic disease. METHODS A systematic review in the Pubmed® database was conducted up to 25 September 2020. A reference tracking was also developed. Randomised clinical trials with subgroup analysis according volume of metastatic disease for overall survival were selected. Two methodologies were used. One of them considered statistical interaction of subsets (p(i) < 0.1), pre-specification, biological plausibility and consistency among subset results of similar randomised clinical trials. The second methodology was a two-part validated tool: preliminary questions to discard subset analysis without minimal relevance and a checklist The checklist provides recommendations for applicability of subgroup analysis in clinical practice. RESULTS A total of 31 results were found in systematic reviews in the Pubmed® database. One result was identified in the reference tracking. Of the total of 32 results, four randomised clinical trials were included in the study. About first methodology, statistical interaction among subgroups was obtained in one randomised clinical trial. Subgroup analysis was pre-specified in two randomised clinical trials. Biological plausibility was reasonable. No external consistency among results of subgroup analyses in randomised clinical trials was observed. Preliminary questions of second methodology rejected applicability of subgroup analysis in three randomised clinical trials. A 'null' recommendation for applicability of subset results was obtained in the remaining randomised clinical trial. CONCLUSIONS Patients with low- and high-burden metastatic hormone-sensitive prostate cancer would benefit from docetaxel therapy. No consistent differences for overall survival were observed in subgroup analyses regarding volume of metastatic disease.
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Affiliation(s)
- Manuel David Gil-Sierra
- Department of Pharmacology, Facultad de Farmacia, 16778Universidad de Sevilla, Spain.,Pharmacy Department, 16875Hospital Universitario Puerto Real, Spain
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Munkholm K, Paludan-Müller AS. Caution is advised when interpreting subgroup analyses. Neuropsychopharmacology 2021; 46:1551. [PMID: 33947967 PMCID: PMC8280125 DOI: 10.1038/s41386-021-01025-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/08/2021] [Accepted: 04/19/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Klaus Munkholm
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark. .,Open Patient data Exploratory Network (OPEN), Odense University Hospital, Odense, Denmark.
| | - Asger Sand Paludan-Müller
- grid.10825.3e0000 0001 0728 0170Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark ,grid.7143.10000 0004 0512 5013Open Patient data Exploratory Network (OPEN), Odense University Hospital, Odense, Denmark
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Ooms A, Dutton SJ, Parsons S, Fordham B, Hing C, Lamb S, Smith T. Statistical analysis plan for a pragmatic phase III randomised controlled trial examining behaviour change physiotherapy intervention to increase physical activity following hip and knee replacements: the PEP-TALK trial. Trials 2021; 22:467. [PMID: 34284802 PMCID: PMC8290138 DOI: 10.1186/s13063-021-05362-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 06/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Total hip (THR) and total knee replacements (TKR) are two highly successful orthopaedic procedures that reduce pain for people with osteoarthritis. Previous evidence suggests that physical activity, at best, remains the same pre- to post-operatively, and in some instances declines. The PEP-TALK trial evaluates the effects of a group-based, behaviour change intervention on physical activity following a THR or TKR. METHODS PEP-TALK is an open, phase III, pragmatic, multi-centre, parallel, two-arm, two-way superiority randomised controlled trial investigating the effectiveness of usual care plus a behaviour change therapy compared with usual care alone following primary THR or TKR. The primary outcome is the UCLA Activity Score at 12 months post-randomisation which will be analysed using a linear mixed effects model. Secondary outcomes measured at 6 months and 12 months after randomisation include the UCLA Activity Score, Lower Extremity Functional Scale, Oxford Hip/Knee Score, Numerical Rating Scale for Pain, Generalised Self-Efficacy Scale, Tampa Scale for Kinesiophobia, Hospital Anxiety and Depression Scale, EuroQoL EQ-5D-5L index and EQ-VAS and complications or adverse events. Full details of the planned analysis approaches for the primary and secondary outcomes, as well as the planned sensitivity analyses to be undertaken due to the COVID-19 pandemic, are described here. The PEP-TALK study protocol has been published previously. DISCUSSION This paper provides details of the planned statistical analyses for the PEP-TALK trial. This is aimed to reduce the risk of outcome reporting bias and enhance transparency in reporting. TRIAL REGISTRATION International Standard Randomised Controlled Trials database, ISRCTN Number: 29770908 . Registered on October 2018.
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Affiliation(s)
- Alexander Ooms
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - Susan J Dutton
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Scott Parsons
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Centre for Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Beth Fordham
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Centre for Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Caroline Hing
- University of London St George's Molecular and Clinical Sciences Research Institute, London, UK
| | - Sarah Lamb
- College of Medicine and Health Sciences, University of Exeter, Exeter, Devon, UK
| | - Toby Smith
- Centre for Rehabilitation Research in Oxford, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
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Sohani ZN, Alyass A, Pilote L. Clinical Trials of Heart Failure: Is There a Question of Sex? Can J Cardiol 2021; 37:1303-1309. [PMID: 34273472 DOI: 10.1016/j.cjca.2021.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 07/05/2021] [Accepted: 07/05/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- Zahra N Sohani
- Department of Medicine, McGill University, Montréal, Québec, Canada
| | - Akram Alyass
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Louise Pilote
- Department of Medicine, McGill University, Montréal, Québec, Canada; Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montréal, Québec, Canada; Division of General Internal Medicine, Department of Medicine, McGill University, Montréal, Québec, Canada.
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Khan YA, Fan E, Ferguson ND. Precision Medicine and Heterogeneity of Treatment Effect in Therapies for Acute Respiratory Distress Syndrome. Chest 2021; 160:1729-1738. [PMID: 34270967 PMCID: PMC8277554 DOI: 10.1016/j.chest.2021.07.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 06/28/2021] [Accepted: 07/05/2021] [Indexed: 12/16/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a clinically heterogenous syndrome, rather than a distinct disease. This heterogeneity at least partially explains the difficulty in studying treatments for these patients and contributes to the numerous trials of therapies for the syndrome that have not shown benefit. Recent studies have identified different subphenotypes within the heterogenous patient population. These different subphenotypes likely have variable clinical responses to specific therapies, a concept known as heterogeneity of treatment effect (HTE). Recognizing different subphenotypes and HTE has important implications for the clinical management of patients with ARDS. In this review, we will present studies that have identified different subphenotypes and discuss how they can modify the effects of therapies evaluated in trials that are commonly considered to have demonstrated no overall benefit in patients with ARDS.
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Affiliation(s)
- Yasin A Khan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Toronto General Hospital Research Institute, Toronto, Canada; Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Toronto General Hospital Research Institute, Toronto, Canada; Department of Physiology, University of Toronto, Toronto, Canada; Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada.
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47
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Coomar D, Hazlehurst JM, Austin F, Foster C, Hitman GA, Heslehurst N, Iliodromiti S, Betran AP, Moss N, Poston L, Nirantharakumar K, Roberts T, Simpson SA, Teede HJ, Riley R, Allotey J, Thangaratinam S. Diet and physical activity in pregnancy to prevent gestational diabetes: a protocol for an individual participant data (IPD) meta-analysis on the differential effects of interventions with economic evaluation. BMJ Open 2021; 11:e048119. [PMID: 34117047 PMCID: PMC8202105 DOI: 10.1136/bmjopen-2020-048119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Mothers with gestational diabetes mellitus (GDM) are at increased risk of pregnancy-related complications and developing type 2 diabetes after delivery. Diet and physical activity-based interventions may prevent GDM, but variations in populations, interventions and outcomes in primary trials have limited the translation of available evidence into practice. We plan to undertake an individual participant data (IPD) meta-analysis of randomised trials to assess the differential effects and cost-effectiveness of diet and physical activity-based interventions in preventing GDM and its complications. METHODS The International Weight Management in Pregnancy Collaborative Network database is a living repository of IPD from randomised trials on diet and physical activity in pregnancy identified through a systematic literature search. We shall update our existing search on MEDLINE, Embase, BIOSIS, LILACS, Pascal, Science Citation Index, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects and Health Technology Assessment Database without language restriction to identify relevant trials until March 2021. Primary researchers will be invited to join the Network and share their IPD. Trials including women with GDM at baseline will be excluded. We shall perform a one and two stage random-effect meta-analysis for each intervention type (all interventions, diet-based, physical activity-based and mixed approach) to obtain summary intervention effects on GDM with 95% CIs and summary treatment-covariate interactions. Heterogeneity will be summarised using I2 and tau2 statistics with 95% prediction intervals. Publication and availability bias will be assessed by examining small study effects. Study quality of included trials will be assessed by the Cochrane Risk of Bias tool, and the Grading of Recommendations, Assessment, Development and Evaluations approach will be used to grade the evidence in the results. A model-based economic analysis will be carried out to assess the cost-effectiveness of interventions to prevent GDM and its complications compared with usual care. ETHICS AND DISSEMINATION Ethics approval is not required. The study is registered on the International Prospective Register of Systematic Reviews (CRD42020212884). Results will be submitted for publication in peer-reviewed journals.
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Affiliation(s)
- Dyuti Coomar
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jonathan M Hazlehurst
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Frances Austin
- Maternity Dietetic Service, Women's Health Division, Barts Health NHS Trust, Antenatal Clinic, Royal London Hospital and Newham University Hospital, London, UK
| | - Charlie Foster
- Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, University of Bristol, Bristol, UK
| | - Graham A Hitman
- Centre for Genomic Medicine and Child Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Nicola Heslehurst
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Stamatina Iliodromiti
- Centre for Women's Health, Institute of Population Health Sciences, Queen Mary University of London, London, UK
| | - Ana Pilar Betran
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Ngawai Moss
- Katie's Team Patient and Public Involvement Advisory Group, Queen Mary University of London, London, UK
| | - Lucilla Poston
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | | | - Tracy Roberts
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Sharon A Simpson
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Helena J Teede
- Monash Centre for Health Research and Implementation, School of Public Health, Monash University, Melbourne, Victoria, Australia
| | - Richard Riley
- Centre for Prognosis Research, School of Medicine, Keele University, Keele, UK
| | - John Allotey
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Pragmatic Clinical Trials Unit, Institute of Population Health Sciences, Barts and the London, School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Shakila Thangaratinam
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
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Edgar K, Jackson D, Rhodes K, Duffy T, Burman CF, Sharples LD. Frequentist rules for regulatory approval of subgroups in phase III trials: A fresh look at an old problem. Stat Methods Med Res 2021; 30:1725-1743. [PMID: 34077288 PMCID: PMC8411475 DOI: 10.1177/09622802211017574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background The number of Phase III trials that include a biomarker in design and
analysis has increased due to interest in personalised medicine. For genetic
mutations and other predictive biomarkers, the trial sample comprises two
subgroups, one of which, say B+ is known or suspected to achieve a larger treatment effect
than the other B−. Despite treatment effect heterogeneity, trials often draw
patients from both subgroups, since the lower responding B− subgroup may also gain benefit from the intervention. In
this case, regulators/commissioners must decide what constitutes sufficient
evidence to approve the drug in the B− population. Methods and Results Assuming trial analysis can be completed using generalised linear models, we
define and evaluate three frequentist decision rules for approval. For rule
one, the significance of the average treatment effect in B− should exceed a pre-defined minimum value, say
ZB−>L. For rule two, the data from the low-responding group
B− should increase statistical significance. For rule three,
the subgroup-treatment interaction should be non-significant, using type I
error chosen to ensure that estimated difference between the two subgroup
effects is acceptable. Rules are evaluated based on conditional power, given
that there is an overall significant treatment effect. We show how different
rules perform according to the distribution of patients across the two
subgroups and when analyses include additional (stratification) covariates
in the analysis, thereby conferring correlation between subgroup
effects. Conclusions When additional conditions are required for approval of a new treatment in a
lower response subgroup, easily applied rules based on minimum effect sizes
and relaxed interaction tests are available. Choice of rule is influenced by
the proportion of patients sampled from the two subgroups but less so by the
correlation between subgroup effects.
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Affiliation(s)
- K Edgar
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - D Jackson
- Statistical Innovation, Oncology R&D, AstraZeneca, AstraZeneca, Cambridge, UK
| | - K Rhodes
- Statistical Innovation, Oncology R&D, AstraZeneca, AstraZeneca, Cambridge, UK
| | - T Duffy
- Statistical Innovation, BioPharmaceutical R&D, AstraZeneca, Gothenburg, Sweden
| | - C-F Burman
- Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - L D Sharples
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
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Czwikla G, Boen F, Cook DG, de Jong J, Harris T, Hilz LK, Iliffe S, Lechner L, Morris RW, Muellmann S, Peels DA, Pischke CR, Schüz B, Stevens M, Telkmann K, van Lenthe FJ, Vanderlinden J, Bolte G. Equity-specific effects of interventions to promote physical activity among middle-aged and older adults: results from applying a novel equity-specific re-analysis strategy. Int J Behav Nutr Phys Act 2021; 18:65. [PMID: 34001171 PMCID: PMC8130354 DOI: 10.1186/s12966-021-01131-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/28/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Reducing inequalities in physical activity (PA) and PA-associated health outcomes is a priority for public health. Interventions to promote PA may reduce inequalities, but may also unintentionally increase them. Thus, there is a need to analyze equity-specific intervention effects. However, the potential for analyzing equity-specific effects of PA interventions has not yet been sufficiently exploited. The aim of this study was to set out a novel equity-specific re-analysis strategy tried out in an international interdisciplinary collaboration. METHODS The re-analysis strategy comprised harmonizing choice and definition of outcomes, exposures, socio-demographic indicators, and statistical analysis strategies across studies, as well as synthesizing results. It was applied in a collaboration of a convenience sample of eight European PA intervention studies in adults aged ≥45 years. Weekly minutes of moderate-to-vigorous PA was harmonized as outcome. Any versus no intervention was harmonized as exposure. Gender, education, income, area deprivation, and marital status were harmonized as socio-demographic indicators. Interactions between the intervention and socio-demographic indicators on moderate-to-vigorous PA were analyzed using multivariable linear regression and random-effects meta-analysis. RESULTS The collaborative experience shows that the novel re-analysis strategy can be applied to investigate equity-specific effects of existing PA interventions. Across our convenience sample of studies, no consistent pattern of equity-specific intervention effects was found. Pooled estimates suggested that intervention effects did not differ by gender, education, income, area deprivation, and marital status. CONCLUSIONS To exploit the potential for equity-specific effect analysis, we encourage future studies to apply the strategy to representative samples of existing study data. Ensuring sufficient representation of 'hard to reach' groups such as the most disadvantaged in study samples is of particular importance. This will help to extend the limited evidence required for the design and prioritization of future interventions that are most likely to reduce health inequalities.
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Affiliation(s)
- Gesa Czwikla
- Department of Social Epidemiology, Institute of Public Health and Nursing Research, University of Bremen, Bremen, Germany.
- Health Sciences Bremen, University of Bremen, Bremen, Germany.
| | - Filip Boen
- Physical Activity, Sports & Health Research Group, Department of Movement Sciences, KU Leuven, Leuven, Belgium
| | - Derek G Cook
- Population Health Research Institute, St George's University of London, London, UK
| | - Johan de Jong
- School of Sports Studies, Hanze University of Applied Sciences, Groningen, The Netherlands
| | - Tess Harris
- Population Health Research Institute, St George's University of London, London, UK
| | - Lisa K Hilz
- Department of Social Epidemiology, Institute of Public Health and Nursing Research, University of Bremen, Bremen, Germany
- Health Sciences Bremen, University of Bremen, Bremen, Germany
| | - Steve Iliffe
- Research Department of Primary Care & Population Health, University College London, London, UK
| | - Lilian Lechner
- Faculty of Psychology, Open University, Heerlen, The Netherlands
| | - Richard W Morris
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Saskia Muellmann
- Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Denise A Peels
- Faculty of Psychology, Open University, Heerlen, The Netherlands
| | - Claudia R Pischke
- Institute of Medical Sociology, Centre for Health and Society, Medical Faculty, Heinrich Heine UniversityDuesseldorf, Duesseldorf, Germany
| | - Benjamin Schüz
- Health Sciences Bremen, University of Bremen, Bremen, Germany
- Department of Prevention and Health Promotion, Institute of Public Health and Nursing Research, University of Bremen, Bremen, Germany
| | - Martin Stevens
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Klaus Telkmann
- Department of Social Epidemiology, Institute of Public Health and Nursing Research, University of Bremen, Bremen, Germany
- Health Sciences Bremen, University of Bremen, Bremen, Germany
| | - Frank J van Lenthe
- Department of Public Health, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Julie Vanderlinden
- Physical Activity, Sports & Health Research Group, Department of Movement Sciences, KU Leuven, Leuven, Belgium
| | - Gabriele Bolte
- Department of Social Epidemiology, Institute of Public Health and Nursing Research, University of Bremen, Bremen, Germany
- Health Sciences Bremen, University of Bremen, Bremen, Germany
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50
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Bruce J, Hossain A, Lall R, Withers EJ, Finnegan S, Underwood M, Ji C, Bojke C, Longo R, Hulme C, Hennings S, Sheridan R, Westacott K, Ralhan S, Martin F, Davison J, Shaw F, Skelton DA, Treml J, Willett K, Lamb SE. Fall prevention interventions in primary care to reduce fractures and falls in people aged 70 years and over: the PreFIT three-arm cluster RCT. Health Technol Assess 2021; 25:1-114. [PMID: 34075875 DOI: 10.3310/hta25340] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Falls and fractures are a major problem. OBJECTIVES To investigate the clinical effectiveness and cost-effectiveness of alternative falls prevention interventions. DESIGN Three-arm, pragmatic, cluster randomised controlled trial with parallel economic analysis. The unit of randomisation was the general practice. SETTING Primary care. PARTICIPANTS People aged ≥ 70 years. INTERVENTIONS All practices posted an advice leaflet to each participant. Practices randomised to active intervention arms (exercise and multifactorial falls prevention) screened participants for falls risk using a postal questionnaire. Active treatments were delivered to participants at higher risk of falling. MAIN OUTCOME MEASURES The primary outcome was fracture rate over 18 months, captured from Hospital Episode Statistics, general practice records and self-report. Secondary outcomes were falls rate, health-related quality of life, mortality, frailty and health service resource use. Economic evaluation was expressed in terms of incremental cost per quality-adjusted life-year and incremental net monetary benefit. RESULTS Between 2011 and 2014, we randomised 63 general practices (9803 participants): 21 practices (3223 participants) to advice only, 21 practices (3279 participants) to exercise and 21 practices (3301 participants) to multifactorial falls prevention. In the active intervention arms, 5779 out of 6580 (87.8%) participants responded to the postal fall risk screener, of whom 2153 (37.3%) were classed as being at higher risk of falling and invited for treatment. The rate of intervention uptake was 65% (697 out of 1079) in the exercise arm and 71% (762 out of 1074) in the multifactorial falls prevention arm. Overall, 379 out of 9803 (3.9%) participants sustained a fracture. There was no difference in the fracture rate between the advice and exercise arms (rate ratio 1.20, 95% confidence interval 0.91 to 1.59) or between the advice and multifactorial falls prevention arms (rate ratio 1.30, 95% confidence interval 0.99 to 1.71). There was no difference in falls rate over 18 months (exercise arm: rate ratio 0.99, 95% confidence interval 0.86 to 1.14; multifactorial falls prevention arm: rate ratio 1.13, 95% confidence interval 0.98 to 1.30). A lower rate of falls was observed in the exercise arm at 8 months (rate ratio 0.78, 95% confidence interval 0.64 to 0.96), but not at other time points. There were 289 (2.9%) deaths, with no differences by treatment arm. There was no evidence of effects in prespecified subgroup comparisons, nor in nested intention-to-treat analyses that considered only those at higher risk of falling. Exercise provided the highest expected quality-adjusted life-years (1.120), followed by advice and multifactorial falls prevention, with 1.106 and 1.114 quality-adjusted life-years, respectively. NHS costs associated with exercise (£3720) were lower than the costs of advice (£3737) or of multifactorial falls prevention (£3941). Although incremental differences between treatment arms were small, exercise dominated advice, which in turn dominated multifactorial falls prevention. The incremental net monetary benefit of exercise relative to treatment valued at £30,000 per quality-adjusted life-year is modest, at £191, and for multifactorial falls prevention is £613. Exercise is the most cost-effective treatment. No serious adverse events were reported. LIMITATIONS The rate of fractures was lower than anticipated. CONCLUSIONS Screen-and-treat falls prevention strategies in primary care did not reduce fractures. Exercise resulted in a short-term reduction in falls and was cost-effective. FUTURE WORK Exercise is the most promising intervention for primary care. Work is needed to ensure adequate uptake and sustained effects. TRIAL REGISTRATION Current Controlled Trials ISRCTN71002650. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 34. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Julie Bruce
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Anower Hossain
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK.,Institute of Statistical Research and Training, University of Dhaka, Dhaka, Bangladesh
| | - Ranjit Lall
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Emma J Withers
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Susanne Finnegan
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Martin Underwood
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Chen Ji
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Chris Bojke
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Roberta Longo
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Claire Hulme
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Susie Hennings
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK
| | - Ray Sheridan
- General Medicine/Care of the Elderly, Royal Devon and Exeter Hospital, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Katharine Westacott
- Elderly Care Department, Warwick Hospital, South Warwickshire NHS Foundation Trust, Warwick, UK
| | - Shvaita Ralhan
- Gerontology Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Finbarr Martin
- St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - John Davison
- Falls and Syncope Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Fiona Shaw
- Falls and Syncope Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Dawn A Skelton
- Centre for Living, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Jonathan Treml
- Geriatric Medicine, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Keith Willett
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah E Lamb
- Warwick Clinical Trials Unit, Division of Health Sciences, University of Warwick, Coventry, UK.,College of Medicine and Health, University of Exeter, Exeter, UK.,Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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