论文标题

观察性医疗保健数据库中基于风险评估效应异质性的基于风险评估的标准化框架

A standardized framework for risk-based assessment of treatment effect heterogeneity in observational healthcare databases

论文作者

Rekkas, Alexandros, van Klaveren, David, Ryan, Patrick B., Steyerberg, Ewout W., Kent, David M., Rijnbeek, Peter R.

论文摘要

治疗效应的预测方法的异质性声明的重点是基线风险,作为治疗效应的强大预测指标,并在RCT环境中为基于风险的治疗效应异质性提供指导。这项研究的目的是使用标准化的可伸缩框架将这种方法扩展到观测设置。提出的框架包括五个步骤:1)研究目的的定义,即人口,治疗,比较者和感兴趣的结果; 2)识别相关数据库; 3)开发目标结果的预测模型; 4)在调整观察到的混杂状态后,对预测风险的层中相对和绝对治疗效果的估计; 5)结果。我们通过评估血管紧张素转换酶(ACE)抑制剂与β受体阻滞剂对三个疗效和三个观测数据库中的六个安全结果的效果的异质性来证明我们的框架。提出的框架可以补充任何比较有效性研究。我们提供了一个公开可用的R软件包,以将此框架应用于映射到观察性医学结果伙伴关系伙伴关系模型的任何数据库。在我们的示范中,急性心肌梗死风险低的患者对所有三种疗效结果都获得了绝对的绝对益处,尽管他们在最高风险季度更为明显,尤其是对于患有心力衰竭的住院治疗。但是,即使调整了观察到的混杂,诊断失败也显示出残留失衡的证据。我们的框架允许评估跨风险层的差异治疗效果,这为考虑替代治疗之间的利益障碍权衡提供了机会。

The Predictive Approaches to Treatment Effect Heterogeneity statement focused on baseline risk as a robust predictor of treatment effect and provided guidance on risk-based assessment of treatment effect heterogeneity in the RCT setting. The aim of this study was to extend this approach to the observational setting using a standardized scalable framework. The proposed framework consists of five steps: 1) definition of the research aim, i.e., the population, the treatment, the comparator and the outcome(s) of interest; 2) identification of relevant databases; 3) development of a prediction model for the outcome(s) of interest; 4) estimation of relative and absolute treatment effect within strata of predicted risk, after adjusting for observed confounding; 5) presentation of the results. We demonstrate our framework by evaluating heterogeneity of the effect of angiotensin-converting enzyme (ACE) inhibitors versus beta blockers on three efficacy and six safety outcomes across three observational databases. The proposed framework can supplement any comparative effectiveness study. We provide a publicly available R software package for applying this framework to any database mapped to the Observational Medical Outcomes Partnership Common Data Model. In our demonstration, patients at low risk of acute myocardial infarction received negligible absolute benefits for all three efficacy outcomes, though they were more pronounced in the highest risk quarter, especially for hospitalization with heart failure. However, failing diagnostics showed evidence of residual imbalances even after adjustment for observed confounding. Our framework allows for the evaluation of differential treatment effects across risk strata, which offers the opportunity to consider the benefit-harm trade-off between alternative treatments.

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