Dataset Information

Adherence adjustment in the Coronary Drug Project: A call for better per-protocol effect estimates in randomized trials.

ABSTRACT: In many randomized controlled trials, patients and doctors are more interested in the per-protocol effect than in the intention-to-treat effect. However, valid estimation of the per-protocol effect generally requires adjustment for prognostic factors associated with adherence. These adherence adjustments have been strongly questioned in the clinical trials community, especially after 1980 when the Coronary Drug Project team found that adherers to placebo had lower 5-year mortality than non-adherers to placebo.We replicated the original Coronary Drug Project findings from 1980 and re-analyzed the Coronary Drug Project data using technical and conceptual developments that have become established since 1980. Specifically, we used logistic models for binary outcomes, decoupled the definition of adherence from loss to follow-up, and adjusted for pre-randomization covariates via standardization and for post-randomization covariates via inverse probability weighting.The original Coronary Drug Project analysis reported a difference in 5-year mortality between adherers and non-adherers in the placebo arm of 9.4?percentage points. Using modern approaches, we found that this difference was reduced to 2.5 (95% confidence interval: -2.1 to 7.0).Valid estimation of per-protocol effects may be possible in randomized clinical trials when analysts use appropriate methods to adjust for post-randomization variables.

SUBMITTER: Murray EJ

PROVIDER: S-EPMC4942353 | biostudies-literature | 2016 Aug

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Adherence adjustment in the Coronary Drug Project: A call for better per-protocol effect estimates in randomized trials.

Murray Eleanor J EJ Hernán Miguel A MA

Clinical trials (London, England) 20160307 4

<h4>Background</h4>In many randomized controlled trials, patients and doctors are more interested in the per-protocol effect than in the intention-to-treat effect. However, valid estimation of the per-protocol effect generally requires adjustment for prognostic factors associated with adherence. These adherence adjustments have been strongly questioned in the clinical trials community, especially after 1980 when the Coronary Drug Project team found that adherers to placebo had lower 5-year morta ...[more]

PMID: 26951361

Similar Datasets

Project description:Advances in bioacoustic technology, such as the use of automatic recording devices, allow wildlife monitoring at large spatial scales. However, such technology can produce enormous amounts of audio data that must be processed and analyzed. One potential solution to this problem is the use of automated sound recognition tools, but we lack a general framework for developing and validating these tools. Recognizers are computer models of an animal sound assembled from "training data" (i.e., actual samples of vocalizations). The settings of variables used to create recognizers can impact performance, and the use of different settings can result in large differences in error rates that can be exploited for different monitoring objectives. We used Song Scope (Wildlife Acoustics Inc.) to build recognizers and vocalizations of the wood frog (Lithobates sylvaticus) to test how different settings and amounts of training data influence recognizer performance. Performance was evaluated using precision (the probability of a recognizer match being a true match) and sensitivity (the proportion of vocalizations detected) based on a receiver operating characteristic (ROC) curve-determined score threshold. Evaluations were conducted using recordings not used to build the recognizer. Wood frog recognizer performance was sensitive to setting changes in four out of nine variables, and small improvements were achieved by using additional training data from different sites and from the same recording, but not from different recordings from the same site. Overall, the effect of changes to variable settings was much greater than the effect of increasing training data. Additionally, by testing the performance of the recognizer on vocalizations not used to build the recognizer, we discovered that Type I error rates appear idiosyncratic and do not recommend extrapolation from training to new data, whereas Type II errors showed more consistency and extrapolation can be justified. Optimizing variable settings on independent recordings led to a better match between recognizer performance and monitoring objectives. We provide general recommendations for application of this methodology with other species and make some suggestions for improvements.

Project description:BACKGROUND:The per-protocol effect is the effect that would have been observed in a randomized trial had everybody followed the protocol. Though obtaining a valid point estimate for the per-protocol effect requires assumptions that are unverifiable and often implausible, lower and upper bounds for the per-protocol effect may be estimated under more plausible assumptions. Strategies for obtaining bounds, known as "partial identification" methods, are especially promising in randomized trials. RESULTS:We estimated bounds for the per-protocol effect of colorectal cancer screening in the Norwegian Colorectal Cancer Prevention trial, a randomized trial of one-time sigmoidoscopy screening in 98,792 men and women aged 50-64 years. The screening was not available to the control arm, while approximately two thirds of individuals in the treatment arm attended the screening. Study outcomes included colorectal cancer incidence and mortality over 10 years of follow-up. Without any assumptions, the data alone provide little information about the size of the effect. Under the assumption that randomization had no effect on the outcome except through screening, a point estimate for the risk under no screening and bounds for the risk under screening are achievable. Thus, the 10-year risk difference for colorectal cancer was estimated to be at least -0.6 % but less than 37.0 %. Bounds for the risk difference for colorectal cancer mortality (-0.2 to 37.4 %) and all-cause mortality (-5.1 to 32.6 %) had similar widths. These bounds appear helpful in quantifying the maximum possible effectiveness, but cannot rule out harm. By making further assumptions about the effect in the subpopulation who would not attend screening regardless of their randomization arm, narrower bounds can be achieved. CONCLUSIONS:Bounding the per-protocol effect under several sets of assumptions illuminates our reliance on unverifiable assumptions, highlights the range of effect sizes we are most confident in, and can sometimes demonstrate whether to expect certain subpopulations to receive more benefit or harm than others. TRIAL REGISTRATION:Clinicaltrials.gov identifier NCT00119912 (registered 6 July 2005).

Dataset Information

Adherence adjustment in the Coronary Drug Project: A call for better per-protocol effect estimates in randomized trials.

Publications

Adherence adjustment in the Coronary Drug Project: A call for better per-protocol effect estimates in randomized trials.

Similar Datasets

OmicsDI is part of the ELIXIR infrastructure

Tweets