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ENCePP Guide on Methodological Standards in Pharmacoepidemiology

 

5.8. Signal detection methodology and application

 
5.8.1. General aspects of signal detection
 

A general overview of methods for signal detection and recommendations for their application are provided in the report of the CIOMS Working Group VIII Practical aspects of signal detection in pharmacovigilance and empirical results on various aspects of signal detection obtained from the IMI PROTECT project have been summarised in Good signal detection practices: evidence from IMI PROTECT (Drug Saf 2016;39:469-90).

 

The EU Guideline on good pharmacovigilance practices (GVP) Module IX - Signal Management defines signal management as the set of activities performed to determine whether, based on an examination of individual case safety reports (ICSRs), aggregated data from active surveillance systems or studies, literature information or other data sources, there are new risks associated with an active substance or a medicinal product or whether risks have changed. Signal management covers all steps from detecting signals (signal detection), through their validation and confirmation, analysis, prioritisation and assessment to recommending action, as well as the tracking of the steps taken and of any recommendations made.

 

The FDA’s Guidance for Industry-Good Pharmacovigilance Practices and Pharmacoepidemiologic Assessment provides best practice for documenting, assessing and reporting individual case safety reports and case series and for identifying, evaluating, investigating and interpreting safety signals, including recommendations on data mining techniques and use of pharmacoepidemiological studies.

 

5.8.2. Methods of statistical signa detection

 

Quantitative analysis of spontaneous adverse drug reaction reports is routinely used in Drug Safety research. Quantitative signal detection using spontaneous ADR reporting (Pharmacoepidemiol Drug Saf 2009;18:427-36) describes the core concepts behind the most common methods, the proportional reporting ratio (PRR), reporting odds ratio (ROR), information component (IC) and empirical Bayes geometric mean (EBGM). The authors also discuss the role of Bayesian shrinkage in screening spontaneous reports and the importance of changes over time in screening the properties of the measures. Additionally, they discuss major areas of controversy (such as stratification and evaluation and implementation of methods) and give some suggestions as to where emerging research is likely to lead. Data mining for signals in spontaneous reporting databases: proceed with caution (Pharmacoepidemiol Drug Saf 2007;16(4):359–65) reviews data mining methodologies and their limitations and provides useful points to consider before incorporating data mining as a routine component of any pharmacovigilance program.

 

The revised guidance on Routine signal detection methods in EudraVigilance describes methods (statistical and clinical information based) for screening adverse reactions and used by the European Medicines Agency, national competent authorities and Marketing Authorisation Holders. For the methods recommended, it addresses elements of their interpretation, their potential advantages and limitations and the evidence behind. Areas of uncertainty, that require resolution before firm recommendations can be made, are also mentioned.

 

Methods such as multiple logistic regression (that may use propensity score-adjustment) have the theoretical capability to reduce masking and confounding by co-medication and underlying disease. The letter Logistic regression in signal detection: another piece added to the puzzle (Clin Pharmacol Ther 2013;94 (3):312) highlights the variability of results obtained in different studies based on this method and the daunting computational task it requires. More work is needed on its value for pharmacovigilance in the real world setting.

 

A more recent proposal involves a broadening of the basis for computational screening of individual case safety reports, by considering multiple aspects of the strength of evidence in a predictive model. This approach combines disproportionality analysis with features such as the number of well-documented reports, the number of recent reports and geographical spread of the case series (Improved statistical signal detection in pharmacovigilance by combining multiple strength-of-evidence aspects in vigiRank. Drug Saf 2014;37(8):617–28). In a similar spirit, logistic regression has been proposed to combine a disproportionality measure with a measure of unexpectedness for the time-to-onset distribution (Use of logistic regression to combine two causality criteria for signal detection in vaccine spontaneous report data, Drug Saf 2014;37(12):1047-57).

 

Disproportionality methods are usually calculated on the cumulative data and therefore do not provide a direct insight into temporal changes in frequency of reports. Methodologies to monitor changes in the frequency of reporting over time have been developed with the focus to enhance pharmacovigilance when databases are small, when drugs have established safety profiles and/or when product quality defects, medication errors and cases of abuse or misuse are of concern.

 

Automated method for detecting increases in frequency of spontaneous adverse event reports over time (J Biopharm Stat. 2013; 23(1):161-77) presents a regression method with both smooth trend and seasonal components, while in An algorithm to detect unexpected increases in frequency of reports of adverse events in EudraVigilance (Pharmacoepidemiol Drug Saf 2018;27(1):38-45) a model based on a negative binomial time-series regression model was tested on thirteen historical concerns. Additionally, a modification of the Information Component to screen for spatial-temporal disproportionality is described in Using VigiBase to Identify Substandard Medicines: Detection Capacity and Key Prerequisites (Drug Saf 2015; 38(4): 373–382). Despite the promising results of these methods, and even if theoretically they seem appealing, limited work has been performed to assess their effectiveness. Thus these methods might be implemented with ongoing quality control measures to ensure acceptable performance.

 

As understanding increases regarding the mechanisms at a molecular level that are involved in adverse effects of drugs it would be expected that this information will inform efforts to predict and detect Drug Safety problems. Such modeling is currently at an early stage, as presented in Data-driven prediction of drug effects and interactions (Sci Transl Med. 2012 14;4(125):125ra31), but should be a major focus of Drug Safety research activity. An example of an application of this concept is illustrated in the paper Cheminformatics-aided pharmacovigilance: application to Stevens-Johnson Syndrome (J Am Med Inform Assoc 2016; 23(5): 968–78) where the authors apply a Quantitative Structure-Activity Relationship (QSAR) model to predict the drugs associated with Stevens Johnson syndrome in a pharmacovigilance database.

 

5.8.3. Performance comparison of signal detection methods
 

The role of data mining in pharmacovigilance (Expert Opin Drug Saf 2005;4(5):929-48) explains how signal detection algorithms work and addresses questions regarding their validation, comparative performance, limitations and potential for use and misuse in pharmacovigilance.

 

An empirical evaluation of several disproportionality methods in a number of different spontaneous reporting databases is given in Comparison of statistical detection methods within and across spontaneous reporting databases (Drug Saf 2015; 38(6); 577-87).

 

Performance of pharmacovigilance signal detection algorithms for the FDA adverse event reporting system (Clin Pharmacol Ther 2013;93(6):539-46) describes the performance of signal-detection algorithms for spontaneous reports in the US FDA adverse event reporting system against a benchmark constructed by the Observational Medical Outcomes Partnership OMOP. It concludes that logistic regression performs better than traditional disproportionality analysis. Other studies have addressed similar or related questions, for examples Large-scale regression-based pattern discovery: The example of screening the WHO global Drug Safety database (Stat. Anal. Data Min 2010;3(4), 197–208), Are all quantitative postmarketing signal detection methods equal? Performance characteristics of logistic regression and Multi-item Gamma Poisson Shrinker (Pharmacoepidemiol. Drug Saf 2012; 21(6):622–630 and Data-driven prediction of drug effects and interactions (Sci. Transl. Med. 2012; 4(125):125ra31).

 

5.8.4. Stratification and sub-group analyses

 

Many statistical signal detection algorithms disregard the underlying diversity and give equal weight to reports on all patients when computing the expected number of reports for a drug-event pair. This may render them vulnerable to confounding and distortions due to effect modification, and could result in true signals being masked or false associations being flagged as potential signals. Stratification and/or subgroup analyses might address these issues, and whereas stratification is implemented in some standard software packages, routine use of subgroup analyses is less common. Performance of stratified and subgrouped disproportionality analyses in spontaneous databases (Drug Saf 2016; 39(4):355-364) performed a comparison across a range of spontaneous report databases and covariates and found  subgroup analyses to improve first pass signal detection, whereas stratification did not; subgroup analyses by patient age and country of origin were found to bring greatest value.

 

5.8.5. Masking

 

Masking is a statistical issue by which true signals of disproportionate reporting are hidden by the presence of other products in the database. While it is not currently perfectly understood, publications have described methods assessing the extent and impact of the masking effect of measures of disproportionality. They include A conceptual approach to the masking effect of measures of disproportionality (Pharmacoepidemiol Drug Saf 2014;23(2):208-17), with an application described in Assessing the extent and impact of the masking effect of disproportionality analyses on two spontaneous reporting systems databases (Pharmacoepidemiol Drug Saf 2014;23(2):195-207), Outlier removal to uncover patterns in adverse drug reaction surveillance - a simple unmasking strategy (Pharmacoepidemiol Drug Saf 2013;22(10):1119-29) and A potential event-competition bias in safety signal detection: results from a spontaneous reporting research database in France (Drug Saf 2013;36(7):565-72). The value of these methods in practice needs to be further investigated.

 

5.8.6. Complementary role of databases

 

A time-consuming step in signal detection of adverse reactions is the determination of whether an effect is already recorded in the product information. A database which can be searched for this information allows filtering or flagging reaction monitoring reports for signals related to unlisted reactions, thus improving considerably the efficiency of the signal detection process by restricting attention to those drugs and adverse event not already considered causally related. In research, it permits an evaluation of the effect of background restriction on the performance of statistical signal detection. An example of such database is the PROTECT Database of adverse drug reactions (EU SPC ADR database), a structured Excel database of all adverse drug reactions (ADRs) listed in Chapter 4.8 of the Summary of Product Characteristics (SPC) of medicinal products authorised in the European Union (EU) according to the centralised procedure, based exclusively on the Medical Dictionary for Regulatory Activities (MedDRA) terminology.

 

Other large observational databases such as claims and electronic medical records databases are potentially useful as part of a larger signal detection and refinement strategy. Modern methods of pharmacovigilance: detecting adverse effects of drugs (Clin Med 2009;9(5):486-9) describes the strengths and weaknesses of different data sources for signal detection (spontaneous reports, electronic patient records and cohort-event monitoring). A number of studies have considered the use of observational data in electronic systems that complement existing methods of safety surveillance e.g. the PROTECT, OHDSI and Sentinel projects.

 

 

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