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Rolf H.H. Groenwold, MD, PhD
Causality in pharmacoepidemiologic research
what are the challenges?
“Pharmacoepidemiology is the study of the use of
and the effects of drugs in large numbers of
people”
“Pharmacoepidemiology is the bridge between
pharmacology and epidemiology”
“Pharmacoepidemiology studies the effects of
drugs”
Wikipedia:
http://en.wikipedia.org/wiki/Pharmacoepidemiology
... are the paradigm to assess the effects of drug, yet…
… are very expensive
… require a lot of men power
… answer (at most) only 1 question
… are little informative about (rare) side-effects
… have limited duration of follow-up
Randomized trials….
… are MUCH LESS expensive
… require LESS men power
… answer MORE than 1 question
… are MORE informative about (rare) side-effects
… have ENDLESS duration of follow-up, yet…
... are NOT the paradigm to assess the effects of drug, because …
Non-randomized trials….
VS.
Confounding – an example of EPO
“Studies naar het effect
van vaccinatie tegen
griep deugen vaak
methodologisch niet.” (www.nos.nl, 24-10-2011)
“Effectiviteit griepprik nooit
bewezen” (Elsevier, 24-10-2011)
An example of influenza vaccination
The everlasting challenge in pharmacoepidemiology
- can be addressed by comparing like with like
- E.g. compare treated men with untreated men and
treated women with untreated women
- all methods to control for confounding are based
on this principle
Confounding
1. (non-)positivity
2. Dynamic treatment
3. Validity and completeness of registries
Some challenges:
Study of OC use in medical students:
Study of β-blocker use in adults
(non-)positivity – example
Confounder
Oral contraceptive
use
No oral
contraceptive use
Females 95% 5%
Males 0% 100%
Confounder
β-blocker use No β-blocker use
Hypertension 30% 70%
No hypertension 0.5% 99.5%
• non-positivity shortly after drug comes to the market
(selective groups switch treatment)
• second choice drugs
(non-respondents switch treatment)
• strict indication
(yet unrecorded)
1. (non-)positivity in pharmacoepi
Treatment is often not a constant
• time-varying dosage
• on demand treatment (e.g. SABA, NSAIDs)
• ‘ever vs never’ or dynamic regimes
(where does our interest lie?)
2. Dynamic treatment in pharmacoepi
Validity and completeness of registries
• prescription ≠ actual drug use
• only measured confounders can be adjusted
• time-varying confounding
(how frequent have confounders been measured?)
Shouldn’t we anticipated future research in
designing our registries? (which are key confounders?)
3. Registries in pharmacoepi
Pharmacoepidemiology is an ideal playing field to
study methods for causal inference.
A lot of opportunities and challenges.
Causality in pharmacoepidemiology
Thank you for your attention
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