Historical data about disease outcomes can be integrated into the analysis of clinical trials in many ways. We build on existing literature that uses prognostic scores from a predictive model to increase the efficiency of treatment effect estimates via covariate adjustment. Here we go further, utilizing a Bayesian framework that combines prognostic covariate adjustment with an empirical prior distribution learned from the predictive performances of the prognostic model on past trials. The Bayesian approach interpolates between prognostic covariate adjustment with strict type I error control when the prior is diffuse, and a single-arm trial when the prior is sharply peaked. This method is shown theoretically to offer a substantial increase in statistical power, while limiting the type I error rate under reasonable conditions. We demonstrate the utility of our method in simulations and with an analysis of a past Alzheimer's disease clinical trial.
An important task in drug development is to identify patients, which respond better or worse to an experimental treatment. Identifying predictive covariates, which influence the treatment effect and can be used to define subgroups of patients, is a key aspect of this task. Analyses of treatment effect heterogeneity are however known to be challenging, since the number of possible covariates or subgroups is often large, while samples sizes in earlier phases of drug development are often small. In addition, distinguishing predictive covariates from prognostic covariates, which influence the resp…
Covariate adjustment and methods of incorporating historical data in randomized clinical trials (RCTs) each provide opportunities to increase trial power. We unite these approaches for the analysis of RCTs with binary outcomes based on the Cochran-Mantel-Haenszel (CMH) test for marginal risk ratio (RR). In PROCOVA-CMH, subjects are stratified on a single prognostic covariate reflective of their predicted outcome on the control treatment (e.g. placebo). This prognostic score is generated based on baseline covariates through a model trained on historical data. We propose two closed-form prospect…
Estimating causal effects from randomized experiments is central to clinical research. Reducing the statistical uncertainty in these analyses is an important objective for statisticians. Registries, prior trials, and health records constitute a growing compendium of historical data on patients under standard-of-care that may be exploitable to this end. However, most methods for historical borrowing achieve reductions in variance by sacrificing strict type-I error rate control. Here, we propose a use of historical data that exploits linear covariate adjustment to improve the efficiency of trial…
In randomized trials, appropriately adjusting for baseline variables and short-term outcomes can lead to increased precision and reduced sample size. We examine the impact of such adjustment in group sequential designs, i.e., designs with preplanned interim analyses where enrollment may be stopped early for efficacy or futility. We address the following questions: how much precision gain can be obtained by appropriately adjusting for baseline variables and a short-term outcome? How is this precision gain impacted by factors such as the proportion of pipeline participants (those who enrolled bu…
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 …
We develop finite-population asymptotic theory for covariate adjustment in randomization-based causal inference for 2K factorial designs. In particular, we confirm that both the unadjusted and covariate-adjusted estimators of the factorial effects are asymptotically normal, and the latter is more precise than the former.
Conditional power calculations are frequently used to guide the decision whether or not to stop a trial for futility or to modify planned sample size. These ignore the information in short-term endpoints and baseline covariates, and thereby do not make fully efficient use of the information in the data. We therefore propose an interim decision procedure based on the conditional power approach which exploits the information contained in baseline covariates and short-term outcomes. We will realise this by considering the estimation of the treatment effect at the interim analysis as a missing dat…
The Regression Discontinuity (RD) design is a widely used non-experimental method for causal inference and program evaluation. While its canonical formulation only requires a score and an outcome variable, it is common in empirical work to encounter RD analyses where additional variables are used for adjustment. This practice has led to misconceptions about the role of covariate adjustment in RD analysis, from both methodological and empirical perspectives. In this chapter, we review the different roles of covariate adjustment in RD designs, and offer methodological guidance for its correct us…
Identifying effects of actions (treatments) on outcome variables from observational data and causal assumptions is a fundamental problem in causal inference. This identification is made difficult by the presence of confounders which can be related to both treatment and outcome variables. Confounders are often handled, both in theory and in practice, by adjusting for covariates, in other words considering outcomes conditioned on treatment and covariate values, weighed by probability of observing those covariate values. In this paper, we give a complete graphical criterion for covariate adjustme…
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…
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…
When estimating a Global Average Treatment Effect (GATE) under network interference, units can have widely different relationships to the treatment depending on a combination of the structure of their network neighborhood, the structure of the interference mechanism, and how the treatment was distributed in their neighborhood. In this work, we introduce a sequential procedure to generate and select graph- and treatment-based covariates for GATE estimation under regression adjustment. We show that it is possible to simultaneously achieve low bias and considerably reduce variance with such a pro…
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…
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…
Classical randomized experiments, equipped with randomization-based inference, provide assumption-free inference for treatment effects. They have been the gold standard for drawing causal inference and provide excellent internal validity. However, they have also been criticized for questionable external validity, in the sense that the conclusion may not generalize well to a larger population. The randomized survey experiment is a design tool that can help mitigate this concern, by randomly selecting the experimental units from the target population of interest. However, as pointed out by Morga…
The purpose of this work is to improve the efficiency in estimating the average causal effect (ACE) on the survival scale where right-censoring exists and high-dimensional covariate information is available. We propose new estimators using regularized survival regression and survival random forests (SRF) to make the adjustment for the high dimensional covariates to improve efficiency. We study the behavior of the adjusted estimator under mild assumptions and show theoretical guarantees that the proposed estimators are more efficient than the unadjusted ones asymptotically when using SRF for ad…
The question of how individual patient data from cohort studies or historical clinical trials can be leveraged for designing more powerful, or smaller yet equally powerful, clinical trials becomes increasingly important in the era of digitalisation. Today, the traditional statistical analyses approaches may seem questionable to practitioners in light of ubiquitous historical covariate information. Several methodological developments aim at incorporating historical information in the design and analysis of future clinical trials, most importantly Bayesian information borrowing, propensity score…
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…
We consider inference for the mean and covariance functions of covariate adjusted functional data using Local Linear Kernel (LLK) estimators. By means of a double asymptotic, we differentiate between sparse and dense covariate adjusted functional data - depending on the relative order of m (the discretization points per function) and n (the number of functions). Our simulation results demonstrate that the existing asymptotic normality results can lead to severely misleading inferences in finite samples. We explain this phenomenon based on our theoretical results and propose finite-sample corre…
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…
