BACKGROUND AND PURPOSE: Outcome from stroke is highly dependent on baseline conditions. Patients with stroke have a wide range of severities, ages, and etiologies and it has proven difficult to achieve randomization of key variables in clinical trials. We present a new post hoc approach to achieve balance among selected variables. To illustrate the approach, we rebalanced the National Institute of Neurological Diseases and Stroke Recombinant Tissue Plasminogen Activator trial, in which the contribution of baseline imbalances continues to be debated. METHODS: We selected baseline stroke severity (National Institutes of Health Stroke Scale), age, and glucose as matching criteria. The closest matched placebo and treated subjects were identified based on nearness to each other in 3-dimensional Euclidean space. Matching was performed within the quintiles of National Institutes of Health Stroke Scale that have been previously used to assess balance. Subjects who could not be matched were eliminated. Outcomes were assessed using the original specified National Institute of Neurological Diseases and Stroke trial measures. RESULTS: We successfully matched the 2 arms resulting in nearly identical baseline characteristics and distribution among quintiles. Despite fewer subjects after outlier elimination, the primary outcome measures remained significantly improved. After rebalancing, the magnitude of benefit was reduced by 13% to 23%. Benefit was apparent mostly in the large vessel occlusion subtype. CONCLUSION: This study demonstrated the feasibility of rebalancing individual subjects within a randomized trial. After rebalancing and outlier elimination, recombinant tissue plasminogen activator continued to demonstrate improved outcome. That the apparent treatment effect was reduced suggests that imbalances contributed to the magnitude of the original National Institute of Neurological Diseases and Stroke outcomes. This method could in theory be applied to any data set to find matched subjects for outcome or other analyses.
RCT Entities:
BACKGROUND AND PURPOSE: Outcome from stroke is highly dependent on baseline conditions. Patients with stroke have a wide range of severities, ages, and etiologies and it has proven difficult to achieve randomization of key variables in clinical trials. We present a new post hoc approach to achieve balance among selected variables. To illustrate the approach, we rebalanced the National Institute of Neurological Diseases and Stroke Recombinant Tissue Plasminogen Activator trial, in which the contribution of baseline imbalances continues to be debated. METHODS: We selected baseline stroke severity (National Institutes of Health Stroke Scale), age, and glucose as matching criteria. The closest matched placebo and treated subjects were identified based on nearness to each other in 3-dimensional Euclidean space. Matching was performed within the quintiles of National Institutes of Health Stroke Scale that have been previously used to assess balance. Subjects who could not be matched were eliminated. Outcomes were assessed using the original specified National Institute of Neurological Diseases and Stroke trial measures. RESULTS: We successfully matched the 2 arms resulting in nearly identical baseline characteristics and distribution among quintiles. Despite fewer subjects after outlier elimination, the primary outcome measures remained significantly improved. After rebalancing, the magnitude of benefit was reduced by 13% to 23%. Benefit was apparent mostly in the large vessel occlusion subtype. CONCLUSION: This study demonstrated the feasibility of rebalancing individual subjects within a randomized trial. After rebalancing and outlier elimination, recombinant tissue plasminogen activator continued to demonstrate improved outcome. That the apparent treatment effect was reduced suggests that imbalances contributed to the magnitude of the original National Institute of Neurological Diseases and Stroke outcomes. This method could in theory be applied to any data set to find matched subjects for outcome or other analyses.
Authors: Kevin N Sheth; W Taylor Kimberly; Jordan J Elm; Thomas A Kent; Albert J Yoo; Götz Thomalla; Bruce Campbell; Geoffrey A Donnan; Stephen M Davis; Gregory W Albers; Sven Jacobson; Gregory del Zoppo; J Marc Simard; Barney J Stern; Pitchaiah Mandava Journal: Neurocrit Care Date: 2014-08 Impact factor: 3.210
Authors: Ashutosh P Jadhav; Mehdi Bouslama; Amin Aghaebrahim; Leticia C Rebello; Matthew T Starr; Diogo C Haussen; Manasa Ranginani; Matthew K Whalin; Tudor G Jovin; Raul G Nogueira Journal: JAMA Neurol Date: 2017-06-01 Impact factor: 18.302
Authors: Pitchaiah Mandava; William Dalmeida; Jane A Anderson; Perumal Thiagarajan; Roderic H Fabian; Raymond U Weir; Thomas A Kent Journal: Transl Stroke Res Date: 2010-09 Impact factor: 6.829
Authors: Pitchaiah Mandava; Santosh B Murthy; Melody Munoz; Dawn McGuire; Roger P Simon; Andrei V Alexandrov; Karen C Albright; Amelia K Boehme; Sheryl Martin-Schild; Sharyl Martini; Thomas A Kent Journal: Stroke Date: 2013-05-14 Impact factor: 7.914
Authors: Hagen Kunte; Markus A Busch; Katrin Trostdorf; Bernd Vollnberg; Lutz Harms; Rupal I Mehta; Rudolf J Castellani; Pitchaiah Mandava; Thomas A Kent; J Marc Simard Journal: Ann Neurol Date: 2012-11 Impact factor: 10.422
Authors: Pitchaiah Mandava; Sharyl R Martini; Melody Munoz; William Dalmeida; Anand K Sarma; Jane A Anderson; Roderic H Fabian; Thomas A Kent Journal: Transl Stroke Res Date: 2014-04-04 Impact factor: 6.829
Authors: Mehdi Bouslama; Leticia C Rebello; Diogo C Haussen; Jonathan A Grossberg; Aaron M Anderson; Samir R Belagaje; Nicolas A Bianchi; Michael R Frankel; Raul G Nogueira Journal: Interv Neurol Date: 2018-06-19