Using audit information to adjust parameter estimates for data errors in clinical trials.

Background: Audits are often performed to assess the quality of clinical trial data, but beyond detecting fraud or sloppiness, the audit data are generally ignored. In an earlier study, using data from a nonrandomized study, Shepherd and Yu developed statistical methods to incorporate audit results into study estimates and demonstrated that audit data could be used to eliminate bias.
Purpose: In this article, we examine the usefulness of audit-based error-correction methods in clinical trial settings where a continuous outcome is of primary interest.
Methods: We demonstrate the bias of multiple linear regression estimates in general settings with an outcome that may have errors and a set of covariates for which some may have errors and others, including treatment assignment, are recorded correctly for all subjects. We study this bias under different assumptions, including independence between treatment assignment, covariates, and data errors (conceivable in a double-blinded randomized trial) and independence between treatment assignment and covariates but not data errors (possible in an unblinded randomized trial). We review moment-based estimators to incorporate the audit data and propose new multiple imputation estimators. The performance of estimators is studied in simulations.
Results: When treatment is randomized and unrelated to data errors, estimates of the treatment effect using the original error-prone data (i.e., ignoring the audit results) are unbiased. In this setting, both moment and multiple imputation estimators incorporating audit data are more variable than standard analyses using the original data. In contrast, in settings where treatment is randomized but correlated with data errors and in settings where treatment is not randomized, standard treatment-effect estimates will be biased. And in all settings, parameter estimates for the original, error-prone covariates will be biased. The treatment and covariate effect estimates can be corrected by incorporating audit data using either the multiple imputation or moment-based approaches. Bias, precision, and coverage of confidence intervals improve as the audit size increases.
Limitations: The extent of bias and the performance of methods depend on the extent and nature of the error as well as the size of the audit. This study only considers methods for the linear model. Settings much different than those considered here need further study.
Conclusions: In randomized trials with continuous outcomes and treatment assignment independent of data errors, standard analyses of treatment effects will be unbiased and are recommended. However, if treatment assignment is correlated with data errors or other covariates, naive analyses may be biased. In these settings, and when covariate effects are of interest, approaches for incorporating audit results should be considered.