Missing data in clinical trials: control‐based mean imputation and sensitivity analysis

In some randomized (drug versus placebo) clinical trials, the estimand of interest is the between‐treatment difference in population means of a clinical endpoint that is free from the confounding effects of “rescue” medication (e.g., HbA1c change from baseline at 24 weeks that would be observed without rescue medication regardless of whether or when the assigned treatment was discontinued). In such settings, a missing data problem arises if some patients prematurely discontinue from the trial or initiate rescue medication while in the trial, the latter necessitating the discarding of post‐rescue data. We caution that the commonly used mixed‐effects model repeated measures analysis with the embedded missing at random assumption can deliver an exaggerated estimate of the aforementioned estimand of interest. This happens, in part, due to implicit imputation of an overly optimistic mean for “dropouts” (i.e., patients with missing endpoint data of interest) in the drug arm. We propose an alternative approach in which the missing mean for the drug arm dropouts is explicitly replaced with either the estimated mean of the entire endpoint distribution under placebo (primary analysis) or a sequence of increasingly more conservative means within a tipping point framework (sensitivity analysis); patient‐level imputation is not required. A supplemental “dropout = failure” analysis is considered in which a common poor outcome is imputed for all dropouts followed by a between‐treatment comparison using quantile regression. All analyses address the same estimand and can adjust for baseline covariates. Three examples and simulation results are used to support our recommendations.     

Sensitivity analyses for partially observed recurrent event data

Recurrent events involve the occurrences of the same type of event repeatedly over time and are commonly encountered in longitudinal studies. Examples include seizures in epileptic studies or occurrence of cancer tumors. In such studies, interest lies in the number of events that occur over a fixed period of time. One considerable challenge in analyzing such data arises when a large proportion of patients discontinues before the end of the study, for example, because of adverse events, leading to partially observed data. In this situation, data are often modeled using a negative binomial distribution with time‐in‐study as offset. Such an analysis assumes that data are missing at random (MAR). As we cannot test the adequacy of MAR, sensitivity analyses that assess the robustness of conclusions across a range of different assumptions need to be performed. Sophisticated sensitivity analyses for continuous data are being frequently performed. However, this is less the case for recurrent event or count data. We will present a flexible approach to perform clinically interpretable sensitivity analyses for recurrent event data. Our approach fits into the framework of reference‐based imputations, where information from reference arms can be borrowed to impute post‐discontinuation data. Different assumptions about the future behavior of dropouts dependent on reasons for dropout and received treatment can be made. The imputation model is based on a flexible model that allows for time‐varying baseline intensities. We assess the performance in a simulation study and provide an illustration with a clinical trial in patients who suffer from bladder cancer. Copyright © 2015 John Wiley & Sons, Ltd.     

Multiple imputation using multivariate gh transformations

Multiple imputation has emerged as a popular approach to handling data sets with missing values. For incomplete continuous variables, imputations are usually produced using multivariate normal models. However, this approach might be problematic for variables with a strong non-normal shape, as it would generate imputations incoherent with actual distributions and thus lead to incorrect inferences. For non-normal data, we consider a multivariate extension of Tukey's gh distribution/transformation [38] to accommodate skewness and/or kurtosis and capture the correlation among the variables. We propose an algorithm to fit the incomplete data with the model and generate imputations. We apply the method to a national data set for hospital performance on several standard quality measures, which are highly skewed to the left and substantially correlated with each other. We use Monte Carlo studies to assess the performance of the proposed approach. We discuss possible generalizations and give some advices to practitioners on how to handle non-normal incomplete data.     

Reference‐based sensitivity analysis for time‐to‐event data

The analysis of time‐to‐event data typically makes the censoring at random assumption, ie, that—conditional on covariates in the model—the distribution of event times is the same, whether they are observed or unobserved (ie, right censored). When patients who remain in follow‐up stay on their assigned treatment, then analysis under this assumption broadly addresses the de jure, or “while on treatment strategy” estimand. In such cases, we may well wish to explore the robustness of our inference to more pragmatic, de facto or “treatment policy strategy,” assumptions about the behaviour of patients post‐censoring. This is particularly the case when censoring occurs because patients change, or revert, to the usual (ie, reference) standard of care. Recent work has shown how such questions can be addressed for trials with continuous outcome data and longitudinal follow‐up, using reference‐based multiple imputation. For example, patients in the active arm may have their missing data imputed assuming they reverted to the control (ie, reference) intervention on withdrawal. Reference‐based imputation has two advantages: (a) it avoids the user specifying numerous parameters describing the distribution of patients' postwithdrawal data and (b) it is, to a good approximation, information anchored, so that the proportion of information lost due to missing data under the primary analysis is held constant across the sensitivity analyses. In this article, we build on recent work in the survival context, proposing a class of reference‐based assumptions appropriate for time‐to‐event data. We report a simulation study exploring the extent to which the multiple imputation estimator (using Rubin's variance formula) is information anchored in this setting and then illustrate the approach by reanalysing data from a randomized trial, which compared medical therapy with angioplasty for patients presenting with angina.     

A structured framework for assessing sensitivity to missing data assumptions in longitudinal clinical trials

The objective of this research was to demonstrate a framework for drawing inference from sensitivity analyses of incomplete longitudinal clinical trial data via a re‐analysis of data from a confirmatory clinical trial in depression. A likelihood‐based approach that assumed missing at random (MAR) was the primary analysis. Robustness to departure from MAR was assessed by comparing the primary result to those from a series of analyses that employed varying missing not at random (MNAR) assumptions (selection models, pattern mixture models and shared parameter models) and to MAR methods that used inclusive models. The key sensitivity analysis used multiple imputation assuming that after dropout the trajectory of drug‐treated patients was that of placebo treated patients with a similar outcome history (placebo multiple imputation). This result was used as the worst reasonable case to define the lower limit of plausible values for the treatment contrast. The endpoint contrast from the primary analysis was ? 2.79 (p = .013). In placebo multiple imputation, the result was ? 2.17. Results from the other sensitivity analyses ranged from ? 2.21 to ? 3.87 and were symmetrically distributed around the primary result. Hence, no clear evidence of bias from missing not at random data was found. In the worst reasonable case scenario, the treatment effect was 80% of the magnitude of the primary result. Therefore, it was concluded that a treatment effect existed. The structured sensitivity framework of using a worst reasonable case result based on a controlled imputation approach with transparent and debatable assumptions supplemented a series of plausible alternative models under varying assumptions was useful in this specific situation and holds promise as a generally useful framework. Copyright © 2012 John Wiley & Sons, Ltd.     

Inferences on missing information under multiple imputation and two-stage multiple imputation

In the presence of missing values, researchers may be interested in the rates of missing information. The rates of missing information are (a) important for assessing how the missing information contributes to inferential uncertainty about, Q, the population quantity of interest, (b) are an important component in the decision of the number of imputations, and (c) can be used to test model uncertainty and model fitting. In this article I will derive the asymptotic distribution of the rates of missing information in two scenarios: the conventional multiple imputation (MI), and the two-stage MI. Numerically I will show that the proposed asymptotic distribution agrees with the simulated one. I will also suggest the number of imputations needed to obtain reliable missing information rate estimates for each method, based on the asymptotic distribution.     

START: single‐to‐double arm transition design for phase II clinical trials

Phase II clinical trials designed for evaluating a drug's treatment effect can be either single‐arm or double‐arm. A single‐arm design tests the null hypothesis that the response rate of a new drug is lower than a fixed threshold, whereas a double‐arm scheme takes a more objective comparison of the response rate between the new treatment and the standard of care through randomization. Although the randomized design is the gold standard for efficacy assessment, various situations may arise where a single‐arm pilot study prior to a randomized trial is necessary. To combine the single‐ and double‐arm phases and pool the information together for better decision making, we propose a Single‐To‐double ARm Transition design (START) with switching hypotheses tests, where the first stage compares the new drug's response rate with a minimum required level and imposes a continuation criterion, and the second stage utilizes randomization to determine the treatment's superiority. We develop a software package in R to calibrate the frequentist error rates and perform simulation studies to assess the trial characteristics. Finally, a metastatic pancreatic cancer trial is used for illustrating the decision rules under the proposed START design.     

Tukey's gh Distribution for Multiple Imputation

Tukey proposed a class of distributions, the g-and-h family (gh family), based on a transformation of a standard normal variable to accommodate different skewness and elongation in the distribution of variables arising in practical applications. It is easy to draw values from this distribution even though it is hard to explicitly state the probability density function. Given this flexibility, the gh family may be extremely useful in creating multiple imputations for missing data. This article demonstrates how this family, as well as its generalizations, can be used in the multiple imputation analysis of incomplete data. The focus of this article is on a scalar variable with missing values. In the absence of any additional information, data are missing completely at random, and hence the correct analysis is the complete-case analysis. Thus, the application of the gh multiple imputation to the scalar cases affords comparison with the correct analysis and with other model-based multiple imputation methods. Comparisons are made using simulated datasets and the data from a survey of adolescents ascertaining driving after drinking alcohol.     

Nonparametric curve estimation with missing data: A general empirical process approach

A general nonparametric imputation procedure, based on kernel regression, is proposed to estimate points as well as set- and function-indexed parameters when the data are missing at random (MAR). The proposed method works by imputing a specific function of a missing value (and not the missing value itself), where the form of this specific function is dictated by the parameter of interest. Both single and multiple imputations are considered. The associated empirical processes provide the right tool to study the uniform convergence properties of the resulting estimators. Our estimators include, as special cases, the imputation estimator of the mean, the estimator of the distribution function proposed by Cheng and Chu [1996. Kernel estimation of distribution functions and quantiles with missing data. Statist. Sinica 6, 63–78], imputation estimators of a marginal density, and imputation estimators of regression functions.     

Missing data sensitivity analysis for recurrent event data using controlled imputation

Statistical analyses of recurrent event data have typically been based on the missing at random assumption. One implication of this is that, if data are collected only when patients are on their randomized treatment, the resulting de jure estimator of treatment effect corresponds to the situation in which the patients adhere to this regime throughout the study. For confirmatory analysis of clinical trials, sensitivity analyses are required to investigate alternative de facto estimands that depart from this assumption. Recent publications have described the use of multiple imputation methods based on pattern mixture models for continuous outcomes, where imputation for the missing data for one treatment arm (e.g. the active arm) is based on the statistical behaviour of outcomes in another arm (e.g. the placebo arm). This has been referred to as controlled imputation or reference‐based imputation. In this paper, we use the negative multinomial distribution to apply this approach to analyses of recurrent events and other similar outcomes. The methods are illustrated by a trial in severe asthma where the primary endpoint was rate of exacerbations and the primary analysis was based on the negative binomial model. Copyright © 2014 John Wiley & Sons, Ltd.     

Simultaneous confidence interval for assessing non‐inferiority with assay sensitivity in a three‐arm trial with binary endpoints

A three‐arm trial including an experimental treatment, an active reference treatment and a placebo is often used to assess the non‐inferiority (NI) with assay sensitivity of an experimental treatment. Various hypothesis‐test‐based approaches via a fraction or pre‐specified margin have been proposed to assess the NI with assay sensitivity in a three‐arm trial. There is little work done on confidence interval in a three‐arm trial. This paper develops a hybrid approach to construct simultaneous confidence interval for assessing NI and assay sensitivity in a three‐arm trial. For comparison, we present normal‐approximation‐based and bootstrap‐resampling‐based simultaneous confidence intervals. Simulation studies evidence that the hybrid approach with the Wilson score statistic performs better than other approaches in terms of empirical coverage probability and mesial‐non‐coverage probability. An example is used to illustrate the proposed approaches.     

A Simple Method to Ensure Plausible Multiple Imputation for Continuous Multivariate Data

Multiple Imputation (MI) is an established approach for handling missing values. We show that MI for continuous data under the multivariate normal assumption is susceptible to generating implausible values. Our proposed remedy, is to: (1) transform the observed data into quantiles of the standard normal distribution; (2) obtain a functional relationship between the observed data and it's corresponding standard normal quantiles; (3) undertake MI using the quantiles produced in step 1; and finally, (4) use the functional relationship to transform the imputations into their original domain. In conclusion, our approach safeguards MI from imputing implausible values.     

Identifying treatment effects using trimmed means when data are missing not at random

Patients often discontinue from a clinical trial because their health condition is not improving or they cannot tolerate the assigned treatment. Consequently, the observed clinical outcomes in the trial are likely better on average than if every patient had completed the trial. If these differences between trial completers and non-completers cannot be explained by the observed data, then the study outcomes are missing not at random (MNAR). One way to overcome this problem—the trimmed means approach for missing data due to study discontinuation—sets missing values as the worst observed outcome and then trims away a fraction of the distribution from each treatment arm before calculating differences in treatment efficacy (Permutt T, Li F. Trimmed means for symptom trials with dropouts. Pharm Stat. 2017;16(1):20–28). In this paper, we derive sufficient and necessary conditions for when this approach can identify the average population treatment effect. Simulation studies show the trimmed means approach's ability to effectively estimate treatment efficacy when data are MNAR and missingness due to study discontinuation is strongly associated with an unfavorable outcome, but trimmed means fail when data are missing at random. If the reasons for study discontinuation in a clinical trial are known, analysts can improve estimates with a combination of multiple imputation and the trimmed means approach when the assumptions of each hold. We compare the methodology to existing approaches using data from a clinical trial for chronic pain. An R package trim implements the method. When the assumptions are justifiable, using trimmed means can help identify treatment effects notwithstanding MNAR data.     

Some practical considerations in three‐arm non‐inferiority trial design

Non‐inferiority trials aim to demonstrate whether an experimental therapy is not unacceptably worse than an active reference therapy already in use. When applicable, a three‐arm non‐inferiority trial, including an experiment therapy, an active reference therapy, and a placebo, is often recommended to assess assay sensitivity and internal validity of a trial. In this paper, we share some practical considerations based on our experience from a phase III three‐arm non‐inferiority trial. First, we discuss the determination of the total sample size and its optimal allocation based on the overall power of the non‐inferiority testing procedure and provide ready‐to‐use R code for implementation. Second, we consider the non‐inferiority goal of ‘capturing all possibilities’ and show that it naturally corresponds to a simple two‐step testing procedure. Finally, using this two‐step non‐inferiority testing procedure as an example, we compare extensively commonly used frequentist p ‐value methods with the Bayesian posterior probability approach. Copyright © 2016 John Wiley & Sons, Ltd.     

Treatment policy estimands for recurrent event data using data collected after cessation of randomised treatment

In the past, many clinical trials have withdrawn subjects from the study when they prematurely stopped their randomised treatment and have therefore only collected ‘on‐treatment’ data. Thus, analyses addressing a treatment policy estimand have been restricted to imputing missing data under assumptions drawn from these data only. Many confirmatory trials are now continuing to collect data from subjects in a study even after they have prematurely discontinued study treatment as this event is irrelevant for the purposes of a treatment policy estimand. However, despite efforts to keep subjects in a trial, some will still choose to withdraw. Recent publications for sensitivity analyses of recurrent event data have focused on the reference‐based imputation methods commonly applied to continuous outcomes, where imputation for the missing data for one treatment arm is based on the observed outcomes in another arm. However, the existence of data from subjects who have prematurely discontinued treatment but remained in the study has now raised the opportunity to use this ‘off‐treatment’ data to impute the missing data for subjects who withdraw, potentially allowing more plausible assumptions for the missing post‐study‐withdrawal data than reference‐based approaches. In this paper, we introduce a new imputation method for recurrent event data in which the missing post‐study‐withdrawal event rate for a particular subject is assumed to reflect that observed from subjects during the off‐treatment period. The method is illustrated in a trial in chronic obstructive pulmonary disease (COPD) where the primary endpoint was the rate of exacerbations, analysed using a negative binomial model.     

Handling of missing data in long‐term clinical trials: a case study

Missing data in clinical trials is a well‐known problem, and the classical statistical methods used can be overly simple. This case study shows how well‐established missing data theory can be applied to efficacy data collected in a long‐term open‐label trial with a discontinuation rate of almost 50%. Satisfaction with treatment in chronically constipated patients was the efficacy measure assessed at baseline and every 3 months postbaseline. The improvement in treatment satisfaction from baseline was originally analyzed with a paired t‐test ignoring missing data and discarding the correlation structure of the longitudinal data. As the original analysis started from missing completely at random assumptions regarding the missing data process, the satisfaction data were re‐examined, and several missing at random (MAR) and missing not at random (MNAR) techniques resulted in adjusted estimate for the improvement in satisfaction over 12 months. Throughout the different sensitivity analyses, the effect sizes remained significant and clinically relevant. Thus, even for an open‐label trial design, sensitivity analysis, with different assumptions for the nature of dropouts (MAR or MNAR) and with different classes of models (selection, pattern‐mixture, or multiple imputation models), has been found useful and provides evidence towards the robustness of the original analyses; additional sensitivity analyses could be undertaken to further qualify robustness. Copyright © 2012 John Wiley & Sons, Ltd.     

An evaluation of the trimmed mean approach in clinical trials with dropout

The trimmed mean is a method of dealing with patient dropout in clinical trials that considers early discontinuation of treatment a bad outcome rather than leading to missing data. The present investigation is the first comprehensive assessment of the approach across a broad set of simulated clinical trial scenarios. In the trimmed mean approach, all patients who discontinue treatment prior to the primary endpoint are excluded from analysis by trimming an equal percentage of bad outcomes from each treatment arm. The untrimmed values are used to calculated means or mean changes. An explicit intent of trimming is to favor the group with lower dropout because having more completers is a beneficial effect of the drug, or conversely, higher dropout is a bad effect. In the simulation study, difference between treatments estimated from trimmed means was greater than the corresponding effects estimated from untrimmed means when dropout favored the experimental group, and vice versa. The trimmed mean estimates a unique estimand. Therefore, comparisons with other methods are difficult to interpret and the utility of the trimmed mean hinges on the reasonableness of its assumptions: dropout is an equally bad outcome in all patients, and adherence decisions in the trial are sufficiently similar to clinical practice in order to generalize the results. Trimming might be applicable to other inter‐current events such as switching to or adding rescue medicine. Given the well‐known biases in some methods that estimate effectiveness, such as baseline observation carried forward and non‐responder imputation, the trimmed mean may be a useful alternative when its assumptions are justifiable.     

EMPIRICAL LIKELIHOOD‐BASED INFERENCES FOR PARTIALLY LINEAR MODELS WITH MISSING COVARIATES

This paper considers statistical inference for partially linear models Y = X ^? β +ν(Z) +? when the linear covariate X is missing with missing probability π depending upon (Y, Z). We propose empirical likelihood‐based statistics to construct confidence regions for β and ν(z). The resulting empirical likelihood ratio statistics are shown to be asymptotically chi‐squared‐distributed. The finite‐sample performance of the proposed statistics is assessed by simulation experiments. The proposed methods are applied to a dataset from an AIDS clinical trial.     

A New Procedure to Monitor the Mean of a Quality Characteristic

The Shewhart, Bonferroni-adjustment, and analysis of means (ANOM) control charts are typically applied to monitor the mean of a quality characteristic. The Shewhart and Bonferroni procedure are utilized to recognize special causes in production process, where the control limits are constructed by assuming normal distribution for known parameters (mean and standard deviation), and approximately normal distribution regarding to unknown parameters. The ANOM method is an alternative to the analysis of variance method. It can be used to establish the mean control charts by applying equicorrelated multivariate non central t distribution. In this article, we establish new control charts, in phases I and II monitoring, based on normal and t distributions having as a cause a known (or unknown) parameter (standard deviation). Our proposed methods are at least as effective as the classical Shewhart methods and have some advantages.     

Sample size needed to get given ratio of endpoints for confidence interval of standard deviation in a normal distribution

Confidence interval (CI) for a standard deviation in a normal distribution, based on pivotal quantity with a Chi-square distribution, is considered. As a measure of CI quality, the ratio of its endpoints is taken. There are given formulas for sample sizes so that this ratio does not exceed a fixed value. Both equally tailed and minimum ratio of endpoint CIs are considered.