Rose Eric J, Moodie Erica E M, Shortreed Susan
Department of Epidemiology and Biostatistics, University at Albany, Rensselaer, NY, 12144, USA.
Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, H3A 1G1, Canada.
Obs Stud. 2023;9(4):25-48. doi: 10.1353/obs.2023.a906627.
Significant attention has been given to developing data-driven methods for tailoring patient care based on individual patient characteristics. Dynamic treatment regimes formalize this approach through a sequence of decision rules that map patient information to a suggested treatment. The data for estimating and evaluating treatment regimes are ideally gathered through the use of Sequential Multiple Assignment Randomized Trials (SMARTs), though longitudinal observational studies are commonly used due to the potentially prohibitive costs of conducting a SMART. Observational studies are typically powered for simple comparisons of fixed treatment sequences; a priori power or sample size calculations for tailored strategies are rarely if ever undertaken. This has lead to many studies that fail to find a statistically significant benefit to tailoring treatment. We develop power analyses for the estimation of dynamic treatment regimes from observational studies. Our approach uses pilot data to estimate the power for comparing the value of the optimal regime, i.e., the expected outcome if all patients in the population were treated by following the optimal regime, with a known comparison mean. This allows for calculations that ensure a study has sufficient power to detect the need for tailoring, should it be present. Our approach also ensures the value of the estimated optimal treatment regime has a high probability of being within a range of the value of the true optimal regime, set a priori. We examine the performance of the proposed procedure with a simulation study and use it to size a study for reducing depressive symptoms using data from electronic health records.
人们已经高度关注开发基于个体患者特征来定制患者护理的数据驱动方法。动态治疗方案通过一系列将患者信息映射到建议治疗方法的决策规则,使这种方法形式化。估计和评估治疗方案的数据理想情况下是通过使用序贯多重分配随机试验(SMART)收集的,不过由于进行SMART的成本可能过高,纵向观察性研究也经常被使用。观察性研究通常旨在对固定治疗序列进行简单比较;很少(如果有的话)会对定制策略进行先验功效或样本量计算。这导致许多研究未能发现定制治疗具有统计学上的显著益处。我们为从观察性研究中估计动态治疗方案开发了功效分析方法。我们的方法使用试点数据来估计用于比较最优方案价值的功效,即如果总体中的所有患者都按照最优方案接受治疗时的预期结果与已知比较均值。这使得我们能够进行计算,确保研究有足够的功效来检测是否需要定制(如果需要的话)。我们的方法还确保估计的最优治疗方案的价值有很高的概率处于预先设定的真实最优方案价值范围内。我们通过模拟研究检验了所提出程序的性能,并使用它来确定一项利用电子健康记录数据减少抑郁症状的研究的规模。