Concerns have been expressed over the validity of statistical inference under covariate-adaptive randomization despite the extensive use in clinical trials. In the literature, the inferential properties under covariate-adaptive randomization have been mainly studied for continuous responses; in particular, it is well known that the usual two sample t-test for treatment effect is typically conservative, in the sense that the actual test size is smaller than the nominal level. This phenomenon of invalid tests has also been found for generalized linear models without adjusting for the covariates and are sometimes more worrisome due to inflated Type I error. The purpose of this study is to examine the unadjusted test for treatment effect under generalized linear models and covariate-adaptive randomization. For a large class of covariate-adaptive randomization methods, we obtain the asymptotic distribution of the test statistic under the null hypothesis and derive the conditions under which the test is conservative, valid, or anti-conservative. Several commonly used generalized linear models, such as logistic regression and Poisson regression, are discussed in detail. An adjustment method is also proposed to achieve a valid size based on the asymptotic results. Numerical studies confirm the theoretical findings and demonstrate the effectiveness of the proposed adjustment method.
Pocock and Simon's marginal procedure (Pocock and Simon, 1975) is often implemented forbalancing treatment allocation over influential covariates in clinical trials. However, the theoretical properties of Pocock and Simion's procedure have remained largely elusive for decades. In this paper, we propose a general framework for covariate-adaptive designs and establish the corresponding theory under widely satisfied conditions. As a special case, we obtain the theoretical properties of Pocock and Simon's marginal procedure: the marginal imbalances and overall imbalance are bounded in probability,…
Towards Best Practices for Covariate Adjustment in Regulatory Trials: From Fixed to Data-Adaptive Approaches
University of California Berkeley（加州大学伯克利分校）；Division of Biometrics IV, OB/OTS/CDER/FDA（美国食品药品监督管理局药物评价与研究中心生物统计学第四处）；Harvard T.H. Chan School of Public Health（哈佛大学陈曾熙公共卫生学院）；Beth Israel Deaconess Hospital（贝斯以色列女执事医疗中心）；Novo Nordisk A/S（诺和诺德公司）；Pfizer Inc.（辉瑞公司）；Northeastern University（东北大学）；Gilead Sciences（吉利德科学公司）；National Center for the Advancement of Translational Science, National Institutes of Health（美国国立卫生研究院转化科学促进国家中心）；Section of Epidemiology, Biostatistics and Biodemography, University of Southern Denmark（南丹麦大学流行病学、生物统计学和生物人口学系）；Forum for Collaborative Research, School of Public Health, University of California Berkeley（加州大学伯克利分校公共卫生学院合作研究论坛）；OncoBrain Inc（OncoBrain 公司）；Moffitt Cancer Center（莫菲特癌症中心）；Department of Biostatistics, University of Michigan（密歇根大学生物统计学系）；Department of Mathematics, Computer Science and Statistics, Ghent University（根特大学数学、计算机科学和统计系）；Department of Mathematics and Data Science, Vrije Universiteit Brussel（布鲁塞尔自由大学数学与数据科学系）
Identifying a biomarker or treatment-dose threshold that marks a specified level of risk is an important problem, especially in clinical trials. This risk, viewed as a function of thresholds and possibly adjusted for covariates, we call the threshold-response function. Extending the work of Donovan, Hudgens and Gilbert (2019), we propose a nonparametric efficient estimator for the covariate-adjusted threshold-response function, which utilizes machine learning and Targeted Minimum-Loss Estimation (TMLE). We additionally propose a more general estimator, based on sequential regression, that also…
Randomized block factorial experiments are widely used in industrial engineering, clinical trials, and social science. Researchers often use a linear model and analysis of covariance to analyze experimental results; however, limited studies have addressed the validity and robustness of the resulting inferences because assumptions for a linear model might not be justified by randomization in randomized block factorial experiments. In this paper, we establish a new finite population joint central limit theorem for usual (unadjusted) factorial effect estimators in randomized block $2^K$ factorial…
We argue that randomized controlled trials (RCTs) are special even among settings where average treatment effects are identified by a nonparametric unconfoundedness assumption. This claim follows from two results of Robins and Ritov (1997): (1) with at least one continuous covariate control, no estimator of the average treatment effect exists which is uniformly consistent without further assumptions, (2) knowledge of the propensity score yields a uniformly consistent estimator and honest confidence intervals that shrink at parametric rates with increasing sample size, regardless of how complic…
The focus of this paper is on quantifying the capacity of covariates in devising efficient treatment rules when data from a randomized trial are available. Conventional one-variable-at-a-time subgroup analysis based on statistical hypothesis testing of covariate-by-treatment interaction is ill-suited for this purpose. The application of decision theory results in treatment rules that compare the expected benefit of treatment given the patient's covariates against a treatment threshold. However, determining treatment threshold is often context-specific, and any given threshold might seem arbitr…
When the difference between treatments in a clinical trial is estimated by a difference in means, then it is well known that randomization ensures unbiassed estimation, even if no account is taken of important baseline covariates. However, when the treatment effect is assessed by other summaries, e.g. by an odds ratio if the outcome is binary, then bias can arise if some covariates are omitted, regardless of the use of randomization for treatment allocation or the size of the trial. We present accurate closed-form approximations for this asymptotic bias when important Normally distributed cova…
The first step towards investigating the effectiveness of a treatment via a randomized trial is to split the population into control and treatment groups then compare the average response of the treatment group receiving the treatment to the control group receiving the placebo. In order to ensure that the difference between the two groups is caused only by the treatment, it is crucial that the control and the treatment groups have similar statistics. Indeed, the validity and reliability of a trial are determined by the similarity of two groups' statistics. Covariate balancing methods increase …
The present paper deals with the problem of allocating patients to two competing treatments in the presence of covariates or prognostic factors in order to achieve a good trade-off among ethical concerns, inferential precision and randomness in the treatment allocations. In particular we suggest a multipurpose design methodology that combines efficiency and ethical gain when the linear homoscedastic model with both treatment/covariate interactions and interactions among covariates is adopted. The ensuing compound optimal allocations of the treatments depend on the covariates and their distribu…
The rapid finding of effective therapeutics requires the efficient use of available resources in clinical trials. The use of covariate adjustment can yield statistical estimates with improved precision, resulting in a reduction in the number of participants required to draw futility or efficacy conclusions. We focus on time-to-event and ordinal outcomes. A key question for covariate adjustment in randomized studies is how to fit a model relating the outcome and the baseline covariates to maximize precision. We present a novel theoretical result establishing conditions for asymptotic normality …
In clinical trials, there is potential to improve precision and reduce the required sample size by appropriately adjusting for baseline variables in the statistical analysis. This is called covariate adjustment. Despite recommendations by regulatory agencies in favor of covariate adjustment, it remains underutilized leading to inefficient trials. We address two obstacles that make it challenging to use covariate adjustment. A first obstacle is the incompatibility of many covariate adjusted estimators with commonly used boundaries in group sequential designs (GSDs). A second obstacle is the unc…
Analyses of randomised trials are often based on regression models which adjust for baseline covariates, in addition to randomised group. Based on such models, one can obtain estimates of the marginal mean outcome for the population under assignment to each treatment, by averaging the model based predictions across the empirical distribution of the baseline covariates in the trial. We identify under what conditions such estimates are consistent, and in particular show that for canonical generalised linear models, the resulting estimates are always consistent. We show that a recently proposed v…
There has been a split in the statistics community about the need for taking covariates into account in the design phase of a clinical trial. There are many advocates of using stratification and covariate-adaptive randomization to promote balance on certain known covariates. However, balance does not always promote efficiency or ensure more patients are assigned to the better treatment. We describe these procedures, including model-based procedures, for incorporating covariates into the design of clinical trials, and give examples where balance, efficiency and ethical considerations may be in …
Data-Adaptive and Model-Robust Covariate Adjustment for Time-to-Event Outcomes in Stratified Randomized Trials
Cornell Tech, Cornell University（康奈尔科技校区，康奈尔大学）；Department of Biostatistics, Department of Population Health, New York University School of Medicine（纽约大学医学院生物统计学系、人口健康系）
The amount of data collected from patients involved in clinical trials is continuously growing. All patient characteristics are potential covariates that could be used to improve clinical trial analysis and power. However, the restricted number of patients in phases I and II studies limits the possible number of covariates included in the analyses. In this paper, we investigate the cost/benefit ratio of including covariates in the analysis of clinical trials. Within this context, we address the long-running question "What is the optimum number of covariates to include in a clinical trial?" To …
Covariate adjustment is an important tool in the analysis of randomized clinical trials and observational studies. It can be used to increase efficiency and thus power, and to reduce possible bias. While most statistical tests in randomized clinical trials are nonparametric in nature, approaches for covariate adjustment typically rely on specific regression models, such as the linear model for a continuous outcome, the logistic regression model for a dichotomous outcome and the Cox model for survival time. Several recent efforts have focused on model-free covariate adjustment. This paper makes…
We often seek to estimate the causal effect of an exposure on a particular outcome in both randomized and observational settings. One such estimation method is the covariate-adjusted residuals estimator, which was designed for individually or cluster randomized trials. In this manuscript, we study the properties of this estimator and develop a new estimator that utilizes both covariate adjustment and inverse probability weighting We support our theoretical results with a simulation study and an application in an infectious disease setting. The covariate-adjusted residuals estimator is an effic…
Two commonly used methods for improving precision and power in clinical trials are stratified randomization and covariate adjustment. However, many trials do not fully capitalize on the combined precision gains from these two methods, which can lead to wasted resources in terms of sample size and trial duration. We derive consistency and asymptotic normality of model-robust estimators that combine these two methods, and show that these estimators can lead to substantial gains in precision and power. Our theorems cover a class of estimators that handle continuous, binary, and time-to-event outc…
In randomized clinical trials, adjustments for baseline covariates at both design and analysis stages are highly encouraged by regulatory agencies. A recent trend is to use a model-assisted approach for covariate adjustment to gain credibility and efficiency while producing asymptotically valid inference even when the model is incorrect. In this article we present three considerations for better practice when model-assisted inference is applied to adjust for covariates under simple or covariate-adaptive randomized trials: (1) guaranteed efficiency gain: a model-assisted method should often gai…
Attrition is a common occurrence in cluster randomised trials (CRTs) which leads to missing outcome data. Two approaches for analysing such trials are cluster-level analysis and individual-level analysis. This paper compares the performance of unadjusted cluster-level analysis, baseline covariate adjusted cluster-level analysis and linear mixed model (LMM) analysis, under baseline covariate dependent missingness (CDM) in continuous outcomes, in terms of bias, average estimated standard error and coverage probability. The methods of complete case analysis (CCA) and multiple imputation (MI) are …
The ability to generalize experimental results from randomized control trials (RCTs) across locations is crucial for informing policy decisions in targeted regions. Such generalization is often hindered by the lack of identifiability due to unmeasured effect modifiers that compromise direct transport of treatment effect estimates from one location to another. We build upon sensitivity analysis in observational studies and propose an optimization procedure that allows us to get bounds on the treatment effects in targeted regions. Furthermore, we construct more informative bounds by balancing on…
Cluster-randomized trials (CRTs) involve randomizing entire groups of participants -- called clusters -- to treatment arms but are often comprised of a limited or fixed number of available clusters. While covariate adjustment can account for chance imbalances between treatment arms and increase statistical efficiency in individually-randomized trials, analytical methods for individual-level covariate adjustment in small CRTs have received little attention to date. In this paper, we systematically investigate, through extensive simulations, the operating characteristics of propensity score weig…
We present a general framework for using existing data to estimate the efficiency gain from using a covariate-adjusted estimator of a marginal treatment effect in a future randomized trial. We describe conditions under which it is possible to define a mapping from the distribution that generated the existing external data to the relative efficiency of a covariate-adjusted estimator compared to an unadjusted estimator. Under conditions, these relative efficiencies approximate the ratio of sample size needed to achieve a desired power. We consider two situations where the outcome is either fully…
Covariate adjustment has the potential to increase power in the analysis of randomised trials, but mis-specification of the adjustment model could cause error. We explore what error is possible when the adjustment model omits a covariate by randomised treatment interaction, in a setting where the covariate is perfectly balanced between randomised treatments. We use mathematical arguments and analyses of single hypothetical data sets. We show that analysis by a generalised linear model with the canonical link function leads to no error under the null -- that is, if treatment effect is truly zer…
The RobinCar Family: R Tools for Robust Covariate Adjustment in Randomized Clinical Trials
University of Washington（华盛顿大学）；Global Statistical Sciences, Eli Lilly and Company（礼来公司全球统计科学部）；BARDS, MSD（默沙东 BARDS）；AstraZeneca（阿斯利康）；RCONIS；Gilead Sciences（吉利德科学）
Missing outcomes are a commonly occurring problem for cluster randomised trials, which can lead to biased and inefficient inference if ignored or handled inappropriately. Two approaches for analysing such trials are cluster-level analysis and individual-level analysis. In this study, we assessed the performance of unadjusted cluster-level analysis, baseline covariate adjusted cluster-level analysis, random effects logistic regression (RELR) and generalised estimating equations (GEE) when binary outcomes are missing under a baseline covariate dependent missingness mechanism. Missing outcomes we…
To improve precision of estimation and power of testing hypothesis for an unconditional treatment effect in randomized clinical trials with binary outcomes, researchers and regulatory agencies recommend using g-computation as a reliable method of covariate adjustment. However, the practical application of g-computation is hindered by the lack of an explicit robust variance formula that can be used for different unconditional treatment effects of interest. To fill this gap, we provide explicit and robust variance estimators for g-computation estimators and demonstrate through simulations that t…
Background: It has long been advised to account for baseline covariates in the analysis of confirmatory randomised trials, with the main statistical justifications being that this increases power and, when a randomisation scheme balanced covariates, permits a valid estimate of experimental error. There are various methods available to account for covariates but it is not clear how to choose among them. Methods: Taking the perspective of writing a statistical analysis plan, we consider how to choose between the three most promising broad approaches: direct adjustment, standardisation and invers…
Background: Subgroup analyses are frequently conducted in randomized clinical trials to assess evidence of heterogeneous treatment effect across patient subpopulations. Although randomization balances covariates within subgroups in expectation, chance imbalance may be amplified in small subgroups and harm the precision. Covariate adjustment in overall analysis of RCT is often conducted, via either ANCOVA or propensity score weighting, but for subgroup analysis has been rarely discussed. In this article, we develop propensity score weighting methodology for covariate adjustment to improve the p…
