Real-world evidence: the devil is in the detail

Much has been written about real-world evidence (RWE), a concept that offers an understanding of the effects of healthcare interventions using routine clinical data. The reflection of diverse real-world practices is a double-edged sword that makes RWE attractive but also opens doors to several biases that need to be minimised both in the design and analytical phases of non-experimental studies. Additionally, it is critical to ensure that researchers who conduct these studies possess adequate methodological expertise and ability to accurately implement these methods. Critical design elements to be considered should include a clearly defined research question using a causal inference framework, choice of a fit-for-purpose data source, inclusion of new users of a treatment with comparators that are as similar as possible to that group, accurately classifying person-time and deciding censoring approaches. Having taken measures to minimise bias ‘by design’, the next step is to implement appropriate analytical techniques (for example propensity scores) to minimise the remnant potential biases. A clear protocol should be provided at the beginning of the study and a report of the results after, including caveats to consider. We also point the readers to readings on some novel analytical methods as well as newer areas of application of RWE. While there is no one-size-fits-all solution to evaluating RWE studies, we have focused our discussion on key methods and issues commonly encountered in comparative observational cohort studies with the hope that readers are better equipped to evaluate non-experimental studies that they encounter in the future. Graphical abstract Graphical abstract


Introduction
Real-world evidence (RWE) remains one of the most enticing concepts in medicine, surrounded by much buzz. Recent developments, including the first-ever regulatory approval of label expansion of IBRANCE (palbociclib) for male breast cancer based on RWE, have brought in a new era in the applicability of RWE in healthcare [1]. RWE is defined as 'clinical evidence about the usage and potential benefits or risks of a medical product derived from analysing real-world data (RWD)' [2]. RWD are data relating to patient health status and/or the delivery of healthcare routinely collected from different sources and find application in many areas including therapeutic development to comparative effectiveness/safety, reimbursement, regulatory decision-making and clinical guideline development [2,3].
The reflection of 'diverse real-world practices' enhances the appeal of RWD making it more relatable than data from RCTs. However, this very element that makes RWD attractive also makes it challenging to work with. Additionally, inaccurate application of methods and shortage of adequate Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00125-020-05217-1) contains a slideset of the figures for download, which is available to authorised users. methodological know-how potentially threaten the validity of RWD studies [4]. In this paper we discuss commonly encountered issues and recommend key methodological considerations and potential solutions in the design, implementation and evaluation of real-world pharmacoepidemiological studies. This paper provides a general overview of a broad topic and because a detailed discussion on each subtopic is beyond the scope of this review, we have cited several references in relevant sections for interested readers to explore further.

Defining the research question using a causal inference framework
It is a misconception that the entire purpose of RWD is to reduce the cost or complexity of trials (although this is feasible and done in some settings) or simply to get evidence 'without randomisation'. RWE when done correctly is an important stand-alone source of evidence that complements RCTs and laboratory and other studies, which together inform decisionmaking. Understanding the research question is crucial to ensure that the right tools to generate robust RWE are employed.
Researchers should accurately describe the goals of realworld studies using a causal inference framework, like they would for an RCT, including any nuances (e.g. are we comparing initiation of treatment A vs treatment B or are we comparing patients switching from treatment A to treatment B vs patients staying on treatment A?) [5]. While RWE is inherently relevant to clinical practice, it examines a different pattern of care (i.e. RWE and RCTs ask different questions). However, imagining an RWE study as a hypothetical trial forces a more stringent thought process about the intervention, comparators, timelines, outcomes and confounders [6,7]. In estimating a causal effect, we ideally want to examine all potential outcomes in the same patients during the same time period, under contrasting treatments [8]. However, this is impossible, as for each patient the outcome can be observed only under one treatment. We therefore compare the outcomes of two groups: treatment A vs an 'exchangeable' substitute treatment B [9,10]. The validity of effect estimates depends on how valid the substitution is [10]. While there are no guarantees that an effect estimate can be causally interpreted, setting a causal goal for the study lays the foundation for robust design and analytical decisions [5][6][7][8]. Table 1 describes several data sources and provides examples of their application in diabetes research. RWD sources include administrative claims data [11][12][13], electronic health records [14,15] and disease or treatment registries [16,17].

Data sources
Additionally, patient-generated data from surveys, questionnaires, smartphone apps and social media are increasingly being considered for the purposes of pharmacovigilance, patient characterisation and disease understanding [11,18,19]. However, these need careful evaluation as not all health apps are thoroughly validated and their pace of growth is fast outpacing the vetting process [20]. Data linkages with appropriate safeguards offer opportunities to combine useful features from two or more data sources to conduct realworld studies [21].

Study design
Several classification schemes exist for real-world study designs [22] but, broadly, cohort studies, case-control studies and self-controlled case series are the three basic types [23]. Cohort studies follow patients from the treatment to the outcome. Case-control studies select disease cases and controls from the source population and compare treatment histories in the two groups, thereby introducing several avenues for biases. Cohort design is a direct analogue of an experiment and has generally become the standard design for observational studies unless an alternate design is dictated by the research question. Self-controlled methods compare treatments and outcomes within the same individual rather than across groups of individuals by looking at different treatment times within the same person. They are a good fit in settings with acute recurrent or non-recurrent events and intermittent exposures and transient effects, assuming availability of precise timings [24]. Choice of a study design depends on several factors including the research question of interest, rarity of the exposure/outcome and avenues for biases. We direct interested readers to publications by Rothman et al [23] and Hallas and Pottegård [25] for further reading on this subject. As cohort studies are most intuitive when assessing incidence, natural history or comparative effectiveness/safety, we will focus much of our further discussion with this design in mind. Recently, clear design diagrams have been proposed to intuitively visualise studies conducted using healthcare databases/ electronic medical records ( Fig. 1) [26].

Potential biases
The biggest criticism of real-world studies is their potential for systematic error (biases). These are broadly classified as confounding (due to lack of randomisation), selection bias (due to procedures used to select study population) and information bias (measurement error) [23].
Confounding Confounding is the distortion of the treatmentoutcome association when the groups being compared differ with respect to variables that influence the outcome. In  EHR, electronic health record comparing drug treatments, confounding by indication is a common issue that occurs because patients have an 'indication' for a particular drug [27]. As an example, comparing patients prescribed insulin vs oral glucose-lowering agents leads to confounding by indication as the two populations are imbalanced on the 'indication' (severe vs milder diabetes). When a treatment is known to be associated with an adverse event, confounding by contraindication is possible. In comparing thiazolidinediones with dipeptidyl peptidase-4 (DPP-4) inhibitors to assess the risk for heart failure, for example, patients with existing heart conditions are likely to be channelled away from thiazolidinediones.
Restricting the study population to those without prevalent heart failure will therefore minimise intractable confounding by contraindication [28].
In real-world studies confounding by frailty is possible. This is a particular problem in older adults, as frail, close-to-death patients are less likely to be treated with preventive treatments. Thus, when comparing users vs non-users of a particular drug to assess outcomes associated with frailty (e.g. mortality risk), the non-user group is likely to have higher mortality risk and make the drug look better than it really is [29,30].
Selection bias This bias occurs when the selected population is not representative of the target population to which inference is to be drawn (due to selective survival rate, differential losses to follow-up, non-response, etc.) [31]. Selection bias is sometimes intertwined with confounding depending on the setting in which it occurs (e.g. epidemiologists sometimes use the term selection bias to mean 'confounding by indication', others use the term selection bias when confounders are unmeasured) [32].
Information bias This arises due to inaccurate measurement or misclassification of treatments, outcome or confounders [23]. Its effect on results depends on whether misclassification is differential or non-differential across the treatments being compared. In a cohort study, non-differential exposure misclassification occurs when treatment status is equally misclassified among patients who develop or do not develop the outcome. As an illustration, if 10% of patients in both treatment A and treatment B groups received free drug samples (and therefore no prescription record in claims data), an equal proportion of patients in each group will be misclassified as 'unexposed'. Non-differential outcome misclassification in a cohort study occurs when patients who develop the outcome are equally misclassified in treatment A and treatment B groups (e.g. 15% of healthy patients receiving treatment A or treatment B are misclassified as having lung cancer). Differential misclassification occurs when misclassification of treatment status is uneven between individuals that have or do not have the outcome, or when misclassification of the outcome is not the same between treatment A and treatment B. While nondifferential misclassification of treatments and outcomes will generally bias estimates towards the null, differential misclassification can lead to spurious associations or can mask true effects. The effect of misclassification on results also depends on whether the results are reported as absolute or relative [23]. Absolute measures present difference in risk of the outcome in treatment A vs treatment B, while relative measures present the ratio of risk of outcome for treatment A vs treatment B. When misclassification is non-differential, studies reporting absolute measures should have outcome definitions with high sensitivity and specificity as low values for either can lead to bias. In studies reporting relative measures, near-perfect specificity, even at the cost of low sensitivity, is desired [33].
Another common criticism of RWD concerns 'missing data'. The commonly used strategy of excluding records with missing data can severely bias results. Multiple imputation methods for mitigating the effect of missing data have been shown to decrease bias and improve precision in a variety of disease areas including diabetes [34,35]. Methods for addressing missing data should be based on a careful consideration of reasons for missingness and availability of validation datasets needed for imputation methods [36].
Time-related biases These are biases that misclassify persontime attributed to the treatment. Immortal time bias is one such bias arising from misclassification of the time before the treatment during which a patient, by design, could not have experienced the outcome and the patients have to be event-free until treatment starts [37]. Misclassifying this time or excluding it from the analysis altogether leads to immortal time bias [37,38]. This is exacerbated in studies comparing treatment users vs non-users ( Fig. 2) but can occur when comparing active treatments without careful consideration of persontime. Consider an example comparing a sulfonylurea vs metformin, where metformin users consisted of patients with or without prior sulfonylurea use. For the metformin patients with prior sulfonylurea use, their time on sulfonylureas before metformin was misclassified as 'metformin-exposed' which led to immortal time bias and spuriously suggested the protective effect of metformin on mortality risk, since they had to survive to switch to metformin [39,40].
In studies assessing cancer outcomes, events occurring shortly after initiation may not be meaningfully attributed to the exposed period, particularly since carcinogenic exposures typically have long induction periods [41]. Not counting person-time and events during a predefined time-lag after drug initiation accounts for both these periods (Fig. 3). Similarly, it is unlikely that patients stop being 'at risk' on the day after drug discontinuation and a period of latency should also be considered to provide an opportunity to capture the outcome that was potentially present subclinically before treatment discontinuation [41]. As an example, a recent study exploring the incidence of breast cancer with insulin glargine vs intermediate-acting insulin used induction and lag periods to account for cancer latency [42].
Prevalent-user biases Prevalent users are patients already on treatment before follow-up starts and therefore more tolerant of the drug. Methodological problems due to inclusion of prevalent users are illustrated by inconsistent results from studies examining cancer incidence with insulin glargine, depending on the study design used [43,44]. However, the most striking and frequently cited example illustrating these issues is a series of studies highlighting the discrepancies in the estimated effects of hormone therapy on cardiovascular outcomes between new users and prevalent users in the same data [45][46][47][48]. The Nurses' Health cohort study reported a decreased risk of major CHD in prevalent users of oestrogen and progestin compared with non-users, in contrast to results from the RCT which showed an increased risk in the oestrogen + progestin arm relative to placebo [49,50]. A reanalysis of the Nurses' Health study cohort comparing new users of hormone therapy vs non-initiators demonstrated results in line with the RCT, highlighting the issues due to inclusion of prevalent users [51]. As the prevalent users have 'survived' treatment, any patients who experienced early events (susceptible patients) will be automatically excluded in prevalent-user studies, introducing substantial bias if the hazard for the outcome varies depending on time spent on treatment [48,52]. In studies with a mix of prevalent and incident users, the differential proportion of prevalent users across two groups being compared leads to selection bias and also obscures early events if the prevalent users contribute more person-time. Moreover, since confounders are affected by prior treatment, they are mediators in a causal pathway between the treatment and outcome, and any analytical adjustment would worsen the bias [48].

Active comparator new-user design
To avoid prevalent-user biases, new-user design has been recommended as almost a default strategy, except in settings where inclusion of prevalent users is preferable (e.g. describing burden of illness) [53]. This design includes initiators of a drug, after a washout period without that drug (treatmentnaivety not necessary) and provides an intuitive timeline to start follow-up [48]. Because new-user designs restrict the population to drug initiators, concerns have been expressed about reduced generalisability and precision at the cost of high internal validity. Modifications of the new-user design, such as the prevalent new-user designs, have recently been proposed to address this (e.g. while comparing new-tomarket vs older drugs) [54]. Such designs propose including patients switching from older to newer drugs to increase precision. However, precision gain needs to be carefully weighed against the mixing of research questions (initiation vs switching) and the potential for biases introduced by comparing switchers with patients who remain on treatment [55]. The merits of a new-user design are further amplified by comparing drugs in clinical equipoise [56]. Comparing treated and untreated patients opens the door to a host of biases (Fig.  2), which can be overcome by the active comparator new-user design comparing new users of therapeutically equivalent drugs (active comparators; Fig. 3). This design makes the two cohorts 'exchangeable' with respect to baseline disease severity and outcome risk and the follow-up can start from an intuitive, synchronised time point [57,58]. The demonstrated balance of measured characteristics may also increase the probability of balance of unmeasured covariates, although this cannot be empirically demonstrated [28,59]. Often there may be situations in diabetes research where an active comparator is not available (e.g. an RWE study emulating a placebocontrolled trial). In such cases, synchronising cohorts based on any healthcare encounters that make the two cohorts as substitutable as possible is still preferred over comparing with non-users [57]. In a recent example illustrating this principle, the risk of cardiovascular outcomes with the sodium-glucose cotransporter-2 (SGLT2) inhibitor canagliflozin was assessed relative to non-SGLT2-inhibitors rather than to non-users of canagliflozin (which could have led to inclusion of diabetes patients not on pharmacological therapy and therefore caused imbalance of patient characteristics) [60].
The active comparator new-user design is analogous to a head-to-head RCT comparing two drugs in equipoise. It allows following patients by ignoring treatment changes over time, analogous to the 'intent-to-treat' analyses in RCTs. This may introduce treatment misclassification bias towards the null and should be avoided, particularly in studies assessing harm, to avoid masking actual treatment-associated harm. Another option is the 'as-treated' approach where follow-up and is followed by induction and latent periods during which person-time and outcomes are not counted. Solid red lines represent this time after the first prescription. Follow-up, indicated by the dashed red lines, starts at the end of the latent period and ends at censoring. Note that patients' timelines for start of follow-up are intuitively synchronised by the active comparator new-user design, even though the patients can have variable start points of enrolment in the database or variable time points for end of follow-up/study end. a If censoring is due to drug discontinuation, a predefined lag period should be considered before stopping to count outcomes and person-time. This figure is available as part of a downloadable slideset is censored at treatment discontinuation, switching or augmentation. A caveat with the 'as-treated' approach is potential selection bias introduced because of informative censoring (i.e. patients censored because they made treatment changes are not representative of patients who remain on treatment). This needs to be addressed in the analysis using inverse probability of censoring weights [32]. Recent applications of these designs in diabetes research include new-user studies on SGLT2 inhibitors demonstrating no increased risk of amputations relative to non-SGLT2 inhibitors, but increased risk relative to the most appropriate DPP-4 inhibitor comparator using restrictive study criteria and robust analytic techniques [60,61].

Analysis
An example that naturally fits with the active comparator newuser study is the use of propensity scores, a powerful tool for controlling measured confounding [62][63][64][65][66]. A propensity score is a summary score estimating the probability of treatment A vs treatment B based on patients' baseline characteristics. Once estimated, propensity scores can be implemented by matching, weighting and stratification on the score [62,63,67,68], all of which allow empirical demonstration of covariate balance before and after implementation. Propensity scores can also be included in an outcome model, although this takes away the ability to empirically 'see' the adjustment and has other disadvantages so is therefore discouraged [67]. The choice of method used to implement propensity scores (matching, stratification, different types of weighting) depends on the target population to which inference needs to be drawn and the extent of unmeasured residual confounding [62,[69][70][71][72][73][74].
Other methods such as disease risk scores (summary scores based on baseline outcome risk) can have advantages in specific settings [75,76]. When substantial unmeasured confounding is expected, instrumental variable methods might be used to obtain unbiased effect estimates [77,78]. Instrumental variables are variables that affect treatment choice but not the outcome of interest other than through treatment. Examples include physicians' preference and any rapid change in treatments (e.g. due to market access, guideline changes, warnings about serious side effects). All of these methods, however, are based on a number of assumptions that should be evaluated when conducting and interpreting realworld studies. Further, more than one method can be considered as supplementary sensitivity analyses after clearly specifying the reasons a priori. Given the dynamic treatment patterns in routine clinical practice (discontinuation, re-initiation, switching treatment, etc.), analyses often need to account for time-varying treatments and confounders depending on the research question of interest.
Recently, the utility of machine learning in causal inference has been explored [79,80]. Machine learning algorithms have been shown to perform well in estimating propensity scores in certain settings by reducing model mis-specification [81,82] but can amplify bias in certain settings (e.g. if use of instrumental variables in propensity score estimation is encouraged) [83]. A concern with these methods is the lack of easy interpretability and the risk of being data-driven rather than being informed by substantive knowledge and therefore need careful consideration before being used.
Newer avenues for applicability of RWE RWD are increasingly being used to predict outcomes from clinical trials, which supports efficient resource management, faster drug approval times and making medicines available sooner for patients. A recent example is a study comparing linagliptin vs glimepiride using RWD from Medicare and commercial data [84]. While this study demonstrated linagliptin's 'non-inferiority' in line with the findings of the CAROLINA trial, the magnitude was smaller than that observed in the trial. This was likely due to differences in the nature of treatments being compared rather than a lack of robust methodology. Despite the difference in magnitude of results, this supports the value that RWD brings. Another application is the use of an RWD-based comparator for single-arm trials when using a randomised control arm is not feasible, as was done with BLINCYTO (blinatumomab) indicated for leukaemia treatment [2]. We use blinatumomab as a powerful example of use of RWD in regulatory decisionmaking. It is not inconceivable that RWD may find applications in the future in areas where randomised trials may be deemed unethical, such as treatment of heart failure without background SGLT2 inhibitor therapy, or for the prevention of rare events where sample sizes could become prohibitive. The main challenge to address here is the differences between trial participants vs patients in routine practice, including the potential for differential recording of characteristics, warranting deeper design and analytical considerations depending on the nature and extent of differences. Efforts are also ongoing to map the potential effects of RCT data to real-world populations, although we are not aware of examples of this in diabetes research. Pragmatic trials (that measure effectiveness of the treatment/intervention in routine clinical practice) including RWD are also increasingly being explored in a number of disease areas [85,86]. Finally, we may be at the verge of a paradigm shift with respect to classification of validity and hierarchy of study designs. The approach of prioritising internal validity (getting unbiased estimates) at the cost of external validity (generalisability or transportability of results), and our current thinking of internal validity as a prerequisite for external validity can negatively affect the value that RWE brings. Westreich et al recently proposed a joint measure of the validity of effect estimates (target validity) and defined target bias as any deviation of the estimated treatment effect from the true treatment effect in a target population rather than the current distinction between internal and external validity [87].

Conclusion
The value of RWE lies in going beyond the constraints of RCTs to understand the effects in real-world populations. However, the hopes of 'quick wins' with RWE need to be balanced with a knowledge of robust methodology. We have focused our discussion on key concepts, methods and recommendations in the hope that readers are better informed of the utility and limitations of a particular RWE study that they encounter. The following key points should be looked for when evaluating an RWE study: a clearly articulated research question; a fit-for-purpose data source; a state-of-the-art design including appropriate comparators; covariate balance; analysis methods including sensitivity analyses; and the likelihood of being able to reasonably replicate the study in another similar setting. Several guidelines have come into existence to assist investigators with proper conduct, interpretation and reporting of real-world studies [88][89][90]. As the field continues to grow, it is important for scientific journals and regulatory agencies to use peer reviewers with adequate methodological know-how to ensure dissemination of high-quality RWE and maximise its utility in decision-making.