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VOLUME 53 | NUMBER 3 | JUNE 2018

Comparing the Effectiveness of Dynamic Treatment Strategies Using Electronic Health Records: An Application of the Parametric g-Formula to Anemia Management Strategies

Objective: To compare the effectiveness of dynamic anemia management strategies by applying the parametric gformula to electronic health records.

Data Source/Study Setting: Patients with endstage renal disease from the US Renal Data System who had congestive heart failure or ischemic heart disease and were undergoing hemodialysis in outpatient dialysis facilities between 2006 and 2010.

Study Design: We explicitly emulated a target trial of three ‎erythropoietin dosing strategies (aimed at achieving a low, middle, or high hematocrit) and estimated the observational analog of the perprotocol effect.

Results: Of 156,945 eligible patients, 41,970 died during the 18month followup. Compared to the lowhematocrit strategy, the estimated risk of death was 4.6 (95% CI 4.4–4.9) percentage points higher under the highhematocrit strategy and 1.8 (95% CI 1.7–1.9) percentage points higher under the midhematocrit strategy. The corresponding risk differences for a composite outcome of death and myocardial infarction were similar.

Conclusion: An explicit emulation of a target trial using electronic health records, combined with the parametric gformula, allowed comparison of realworld dynamic strategies that have not been compared in randomized trials.

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