Abstract
IMPORTANCE AND OBJECTIVES: The current medical paradigm of evidence-based medicine relies on clinical guidelines derived from randomized clinical trials (RCTs), but these guidelines often overlook individual variations in treatment effects. Approaches have been proposed to develop models predicting the effects of individualized management, such as predictive allocation, individualizing treatment allocation. It is currently unknown whether widespread implementation of predictive allocation could result in better population-level outcomes over guideline-based therapy. We sought to simulate the potential effect of predictive allocation using data from previously conducted RCTs. METHODS AND RESULTS: Data from 3 RCTs (positive trial, negative trial, trial stopped for futility) in pediatric cardiology were used in a computational simulation study to quantify the potential benefits of a personalized approach based on predictive allocation. Outcomes were compared when using a universal approach vs predictive allocation where each patient was allocated to the treatment associated with the lowest predicted probability of negative outcome. Compared to results from RCTs, predictive allocation yielded absolute risk reductions of 13.8% (95% confidence interval [CI] -1.9 to 29.5), 13.9% (95% CI 4.5-23.2), and 15.6% (95% CI 1.5-29.6), respectively, corresponding to a number needed to treat of 7.3, 7.2, and 6.4. The net benefit of predictive allocation was directly proportional to the performance of the prediction models and disappeared as model performance degraded below an area under the curve of 0.55. DISCUSSION: These findings highlight that predictive allocation could result in improved group-level outcomes, particularly when highly predictive models are available. These findings will need to be confirmed in simulations of other trials with varying conditions and eventually in RCTs of predictive vs guideline-based treatment allocation.