Bayesian meta-analyses for comparative effectiveness and informing coverage decisions

Med Care. 2010 Jun;48(6 Suppl):S137-44. doi: 10.1097/MLR.0b013e3181e24563.

Abstract

Background: Evidence-based medicine is increasingly expected in health care decision-making. The Centers for Medicare and Medicaid have initiated efforts to understand the applicability of Bayesian techniques for synthesizing evidence. As a case study, a Bayesian analysis of clinical trials of implantable cardioverter defibrillators was undertaken using patient-level data not typically available for analysis.

Purpose: Conduct Bayesian meta-analyses of the defibrillator trials using published results to demonstrate a Bayesian approach useful to policy makers. DATA SOURCES, STUDY SELECTION, DATA EXTRACTION: We reconsidered trials in a 2007 systematic review by Ezekowitz et al (Ann Intern Med. 2007;147:251-262) and extracted information from the original published articles. Employing a Bayesian hierarchical approach, we developed a base model and 2 variants, and modeled hazard ratios separately within each year of follow-up. We considered sequential meta-analyses over time and found the predictive distribution of the results of the next trial, given its sample size.

Data synthesis: For the most robust of 3 models, the probability that the mean defibrillator effect (in the population of trials) is beneficial is greater than 0.999. In that model, about 5% of trials in the population of trials would have a detrimental effect. Despite the moderate amount of heterogeneity across the trials, there was stability of conclusions after the first 3 of the 12 total trials had been conducted. This stability enabled reasonable predictions for the results of future trials.

Limitations: Inability to assess treatment effects within subsets of patients.

Conclusions: Bayesian meta-analyses based on literature surveys can effectively inform coverage decisions. Bayesian modeling for endpoints such as mortality can elucidate treatment effects over time. The Bayesian approach used in a sequential manner over time can predict results and help assess the utility of future clinical trials.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Bayes Theorem*
  • Centers for Medicare and Medicaid Services, U.S. / organization & administration*
  • Clinical Trials as Topic
  • Comparative Effectiveness Research / methods*
  • Defibrillators, Implantable
  • Humans
  • Insurance Coverage / organization & administration*
  • Meta-Analysis as Topic*
  • United States