title: Concordance of Results from Randomized and Observational Analyses within the Same Study: A Re-Analysis of the Women's Health Initiative Limited-Access Dataset.
abstract: BACKGROUND
  Observational studies (OS) and randomized controlled trials (RCTs) often report discordant results. In the Women's Health Initiative Calcium and Vitamin D (WHI CaD) RCT, women were randomly assigned to CaD or placebo, but were permitted to use personal calcium and vitamin D supplements, creating a unique opportunity to compare results from randomized and observational analyses within the same study.
  
  
  METHODS
  WHI CaD was a 7-year RCT of 1g calcium/400IU vitamin D daily in 36,282 post-menopausal women. We assessed the effects of CaD on cardiovascular events, death, cancer and fracture in a randomized design- comparing CaD with placebo in 43% of women not using personal calcium or vitamin D supplements- and in a observational design- comparing women in the placebo group (44%) using personal calcium and vitamin D supplements with non-users. Incidence was assessed using Cox proportional hazards models, and results from the two study designs deemed concordant if the absolute difference in hazard ratios was ≤0.15. We also compared results from WHI CaD to those from the WHI Observational Study(WHI OS), which used similar methodology for analyses and recruited from the same population.
  
  
  RESULTS
  In WHI CaD, for myocardial infarction and stroke, results of unadjusted and 6/8 covariate-controlled observational analyses (age-adjusted, multivariate-adjusted, propensity-adjusted, propensity-matched) were not concordant with the randomized design results. For death, hip and total fracture, colorectal and total cancer, unadjusted and covariate-controlled observational results were concordant with randomized results. For breast cancer, unadjusted and age-adjusted observational results were concordant with randomized results, but only 1/3 other covariate-controlled observational results were concordant with randomized results. Multivariate-adjusted results from WHI OS were concordant with randomized WHI CaD results for only 4/8 endpoints.
  
  
  CONCLUSIONS
  Results of randomized analyses in WHI CaD were concordant with observational analyses for 5/8 endpoints in WHI CaD and 4/8 endpoints in WHI OS.
authors.affiliation: Department of Medicine, University of Auckland, Auckland, New Zealand.
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Bolland
authors.affiliation: Department of Medicine, University of Auckland, Auckland, New Zealand.
authors.forename: Andrew
authors.initials: A
authors.lastname: Grey
authors.affiliation: Department of Medicine, University of Auckland, Auckland, New Zealand.
authors.forename: Greg D
authors.initials: GD
authors.lastname: Gamble
authors.affiliation: Department of Medicine, University of Auckland, Auckland, New Zealand.
authors.forename: Ian R
authors.initials: IR
authors.lastname: Reid
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D008875:Middle Aged; D050071:Bone Density Conservation Agents / Q000008:administration & dosage; D002118:Calcium / Q000008:administration & dosage; D019587:Dietary Supplements; D006620:Hip Fractures / Q000453:epidemiology; D015994:Incidence; D064887:Observational Studies as Topic; D017698:Postmenopause; D016032:Randomized Controlled Trials as Topic; D015203:Reproducibility of Results; D012107:Research Design; D012307:Risk Factors; D014807:Vitamin D / Q000008:administration & dosage; D016387:Women's Health
chemical_list: D050071:Bone Density Conservation Agents; D002118:Calcium; D014807:Vitamin D