Adaptive design and estimation in randomized clinical trials with correlated observations

Clinical trial designs involving correlated data often arise in biomedical research. The intracluster correlation needs to be taken into account to ensure the validity of sample size and power calculations. In contrast to the fixed-sample designs, we propose a flexible trial design with adaptive monitoring and inference procedures. The total sample size is not predetermined, but adaptively re-estimated using observed data via a systematic mechanism. The final inference is based on a weighted average of the block-wise test statistics using generalized estimating equations, where the weight for each block depends on cumulated data from the ongoing trial. When there are no significant treatment effects, the devised stopping rule allows for early termination of the trial and acceptance of the null hypothesis. The proposed design updates information regarding both the effect size and within-cluster correlation based on the cumulated data in order to achieve a desired power. Estimation of the parameter of interest and its confidence interval are proposed. We conduct simulation studies to examine the operating characteristics and illustrate the proposed method with an example.     

Marginal analysis of longitudinal ordinal data with misclassification in both response and covariates

Marginal methods have been widely used for the analysis of longitudinal ordinal and categorical data. These models do not require full parametric assumptions on the joint distribution of repeated response measurements but only specify the marginal or even association structures. However, inference results obtained from these methods often incur serious bias when variables are subject to error. In this paper, we tackle the problem that misclassification exists in both response and categorical covariate variables. We develop a marginal method for misclassification adjustment, which utilizes second‐order estimating functions and a functional modeling approach, and can yield consistent estimates and valid inference for mean and association parameters. We propose a two‐stage estimation approach for cases in which validation data are available. Our simulation studies show good performance of the proposed method under a variety of settings. Although the proposed method is phrased to data with a longitudinal design, it also applies to correlated data arising from clustered and family studies, in which association parameters may be of scientific interest. The proposed method is applied to analyze a dataset from the Framingham Heart Study as an illustration.     

Superiority inferences on individual endpoints following noninferiority testing in clinical trials

We consider the problem of drawing superiority inferences on individual endpoints following non-inferiority testing. R?hmel et al. (2006) pointed out this as an important problem which had not been addressed by the previous procedures that only tested for global superiority. R?hmel et al. objected to incorporating the non-inferiority tests in the assessment of the global superiority test by exploiting the relationship between the two, since the results of the latter test then depend on the non-inferiority margins specified for the former test. We argue that this is justified, besides the fact that it enhances the power of the global superiority test. We provide a closed testing formulation which generalizes the three-step procedure proposed by R?hmel et al. for two endpoints. For the global superiority test, R?hmel et al. suggest using the L?uter (1996) test which is modified to make it monotone. The resulting test not only is complicated to use, but the modification does not readily extend to more than two endpoints, and it is less powerful in general than several of its competitors. This is verified in a simulation study. Instead, we suggest applying the one-sided likelihood ratio test used by Perlman and Wu (2004) or the union-intersection t(max) test used by Tamhane and Logan (2004).     

Improving efficiency of inference in clinical trials with external control data

Suppose we are interested in the effect of a treatment in a clinical trial. The efficiency of inference may be limited due to small sample size. However, external control data are often available from historical studies. Motivated by an application to Helicobacter pylori infection, we show how to borrow strength from such data to improve efficiency of inference in the clinical trial. Under an exchangeability assumption about the potential outcome mean, we show that the semiparametric efficiency bound for estimating the average treatment effect can be reduced by incorporating both the clinical trial data and external controls. We then derive a doubly robust and locally efficient estimator. The improvement in efficiency is prominent especially when the external control data set has a large sample size and small variability. Our method allows for a relaxed overlap assumption, and we illustrate with the case where the clinical trial only contains a treated group. We also develop doubly robust and locally efficient approaches that extrapolate the causal effect in the clinical trial to the external population and the overall population. Our results also offer a meaningful implication for trial design and data collection. We evaluate the finite-sample performance of the proposed estimators via simulation. In the Helicobacter pylori infection application, our approach shows that the combination treatment has potential efficacy advantages over the triple therapy.     

Analysis of relation between virologic responses and immunologic responses, patient's factors in AIDS clinical trials using a semiparametric mixed-effects model

In this article we propose to use a semiparametric mixed-effects model based on an exploratory analysis of clinical trial data for a study of the relation between virologic responses and immunologic markers such as CD4+ and CD8 counts, and host-specific factors in AIDS clinical trials. The regression spline technique, used for inference for parameters in the model, reduces the unknown nonparametric components to parametric functions. It is simple and straightforward to implement the procedures using readily available software, and parameter inference can be developed from standard parametric models. We apply the model and the proposed method to an AIDS clinical study. Our findings indicate that viral load level is positively related to baseline viral load level, negatively related to CD4+ cell counts, but unrelated to CD8 cell counts and patient's age neither.     

Design of long-term HIV dynamic studies using semiparametric mixed-effects models

Studies of HIV dynamics in AIDS research are very important in understanding the pathogenesis of HIV-1 infection and also in assessing the effectiveness of antiviral therapies. There are many AIDS clinical trials on HIV dynamics currently in development worldwide, giving rise to many design issues yet to be addressed. For example, most studies are focused on short-term viral dynamics and the existing models may not be applicable to describe long-term virologic response. In this paper, we use a simulation-based approach to study the designs of long-term viral dynamics under semiparametric nonlinear mixed-effects models. These models not only can preserve the meaningful interpretation of the short-term HIV dynamics, but also characterize the long-term virologic responses to antiretroviral (ARV) treatment. We investigate a number of feasible clinical protocol designs similar to those currently used in AIDS clinical trials. In particular, we evaluate whether earlier samplings can result in more useful information about the viral response trajectory; we also evaluate the effectiveness of two strategies: more frequent samplings per subject with fewer subjects versus fewer samplings per subject with more subjects while keeping the total number of samplings constant. The results of our investigation provide quantitative guidance for designing and selecting ARV therapy.     

The analysis of stratified 2 x 2 contingency tables

We consider the problem of testing for independence against the consistent superiority of one treatment over another when the response variable is binary and is compared across two treatments in each of several strata. Specifically, we consider the randomized clinical trial setting. A number of issues arise in this context. First, should tables be combined if there are small or zero margins? Second, should one assume a common odds ratio across strata? Third, if the odds ratios differ across strata, then how does the standard test (based on a common odds ratio) perform? Fourth, are there other analyzes that are more appropriate for handling a situation in which the odds ratios may differ across strata? In addressing these issues we find that the frequently used Cochran–Mantel–Haenszel test may have a poor power profile, despite being optimal when the odds ratios are common. We develop novel tests that are analogous to the Smirnov, modified Smirnov, convex hull, and adaptive tests that have been proposed for ordered categorical data. (© 2006 WILEY‐VCH Verlag GmbH & Co. KGaA, Weinheim)     

Relative efficiency of unequal versus equal cluster sizes in cluster randomized trials using generalized estimating equation models

There is growing interest in conducting cluster randomized trials (CRTs). For simplicity in sample size calculation, the cluster sizes are assumed to be identical across all clusters. However, equal cluster sizes are not guaranteed in practice. Therefore, the relative efficiency (RE) of unequal versus equal cluster sizes has been investigated when testing the treatment effect. One of the most important approaches to analyze a set of correlated data is the generalized estimating equation (GEE) proposed by Liang and Zeger, in which the “working correlation structure” is introduced and the association pattern depends on a vector of association parameters denoted by ρ. In this paper, we utilize GEE models to test the treatment effect in a two‐group comparison for continuous, binary, or count data in CRTs. The variances of the estimator of the treatment effect are derived for the different types of outcome. RE is defined as the ratio of variance of the estimator of the treatment effect for equal to unequal cluster sizes. We discuss a commonly used structure in CRTs—exchangeable, and derive the simpler formula of RE with continuous, binary, and count outcomes. Finally, REs are investigated for several scenarios of cluster size distributions through simulation studies. We propose an adjusted sample size due to efficiency loss. Additionally, we also propose an optimal sample size estimation based on the GEE models under a fixed budget for known and unknown association parameter (ρ) in the working correlation structure within the cluster.     

Influence of cluster-period cells in stepped wedge cluster randomized trials

Stepped wedge cluster randomized trials (SWCRT) are increasingly used for the evaluation of complex interventions in health services research. They randomly allocate treatments to clusters that switch to intervention under investigation at variable time points without returning to control condition. The resulting unbalanced allocation over time periods and the uncertainty about the underlying correlation structures at cluster-level renders designing and analyzing SWCRTs a challenge. Adjusting for time trends is recommended, appropriate parameterizations depend on the particular context. For sample size calculation, the covariance structure and covariance parameters are usually assumed to be known. These assumptions greatly affect the influence single cluster-period cells have on the effect estimate. Thus, it is important to understand how cluster-period cells contribute to the treatment effect estimate. We therefore discuss two measures of cell influence. These are functions of the design characteristics and covariance structure only and can thus be calculated at the planning stage: the coefficient matrix as discussed by Matthews and Forbes and information content (IC) as introduced by Kasza and Forbes. The main result is a new formula for IC that is more general and computationally more efficient. The formula applies to any generalized least squares estimator, especially for any type of time trend adjustment or nonblock diagonal matrices. We further show a functional relationship between IC and the coefficient matrix. We give two examples that tie in with current literature. All discussed tools and methods are implemented in the R package SteppedPower .     

The relationship between virologic and immunologic responses in AIDS clinical research using mixed-effects varying-coefficient models with measurement error

In this article we study the relationship between virologic and immunologic responses in AIDS clinical trials. Since plasma HIV RNA copies (viral load) and CD4+ cell counts are crucial virologic and immunologic markers for HIV infection, it is important to study their relationship during HIV/AIDS treatment. We propose a mixed-effects varying-coefficient model based on an exploratory analysis of data from a clinical trial. Since both viral load and CD4+ cell counts are subject to measurement error, we also consider the measurement error problem in covariates in our model. The regression spline method is proposed for inference for parameters in the proposed model. The regression spline method transforms the unknown nonparametric components into parametric functions. It is relatively simple to implement using readily available software, and parameter inference can be developed from standard parametric models. We apply the proposed models and methods to an AIDS clinical study. From this study, we find an interesting relationship between viral load and CD4+ cell counts during antiviral treatments. Biological interpretations and clinical implications are discussed.