Randomized controlled trials (RCTs) are gold standards for assessing intervention efficacy. Yet, generalizing evidence from classical RCTs can be challenging and sometimes problematic due to their limited external validity under stringent eligibility criteria and inadequate statistical power resulting from limited sample sizes under budgetary constraints. "Digital clinical trial," which utilizes digital technology and electronic medical records (EMRs) to expand eligibility criteria and enhance data collection efficiency, offers a promising concept for solving the above-mentioned conundrums encountered in classical RCTs. In this paper, we propose two novel digital clinical trial design strategies assisted by EMRs collected from diverse patient populations. On the one hand, leveraging digital technologies, our design strategies adaptively modify both the eligibility criteria and treatment assignment mechanism to enhance data collection efficiency. As a result, evidence gathered from our design can possess greater statistical power. On the other hand, since EMRs capture diverse patient populations and provide large sample sizes, our design not only broadens the trial’s eligibility criteria but also enhances its statistical power, enabling us to collect more generalizable evidence with boosted statistical power for evaluating intervention efficacy than classical RCTs. We demonstrate the validity and merit of the proposed designs with detailed theoretical investigation, simulation studies, and a synthetic case study.

Identifying subgroups with differential responses to treatment is pivotal in randomized clinical trials, as tailoring treatments to specific subgroups can advance personalized medicine. Upon trial completion, identifying best-performing subgroups–those with the most beneficial treatment effects–is crucial for optimizing resource allocation or mitigating adverse treatment effects. However, traditional clinical trials are not customized for the goal of identifying best-performing subgroups because they typically pre-define subgroups at the beginning of the trial and adhere to a fixed subgroup treatment allocation rule, leading to inefficient use of experimental efforts. While some adaptive experimental strategies exist for the identification of the single best subgroup, they commonly do not enable the identification of the best set of subgroups. To address these challenges, we propose a dynamic subgroup identification covariate-adjusted response-adaptive randomization (CARA) design strategy with the following key features: (i) Our approach is an adaptive experimental strategy that allows the dynamic identification of the best subgroups and the revision of treatment allocation towards the goal of correctly identifying the best subgroups based on collected experimental data. (ii) Our design handles ties between subgroups effectively, merging those with similar treatment effects to maximize experimental efficiency. In the theoretical investigations, we demonstrate that our design has a higher probability of correctly identifying the best set of subgroups compared to conventional designs. Additionally, we prove the statistical validity of our estimator for the best subgroup treatment effect, demonstrating its asymptotic normality and semiparametric efficiency. Finally, we validate our design using synthetic data from a clinical trial on cirrhosis.

Covariate-adjusted response-adaptive randomization (CARA) designs are gaining increasing attention. These designs combine the advantages of randomized experiments with the ability to adaptively revise treatment allocations based on data collected across multiple stages, enhancing estimation efficiency. Yet, CARA designs often assume that primary outcomes are immediately observable, which is not the case in many clinical scenarios where there is a delay in observing primary outcomes. This assumption can lead to significant missingness and inefficient estimation of treatment effects. To tackle this practical challenge, we propose a CARA experimental strategy integrating delayed primary outcomes with immediately observed surrogate outcomes. Surrogate outcomes are intermediate clinical outcomes that are predictive or correlated with the primary outcome of interest. Our design goal is to improve the estimation efficiency of the average treatment effect (ATE) of the primary outcome utilizing surrogate outcomes. From a methodological perspective, our approach offers two benefits: First, we accommodate arm and covariates-dependent delay mechanisms without imposing any parametric modeling assumptions on the distribution of outcomes. Second, when primary outcomes are not fully observed, surrogate outcomes can guide the adaptive treatment allocation rule. From a theoretical standpoint, we prove the semiparametric efficiency bound of estimating ATE under delayed primary outcomes while incorporating surrogate outcomes. We show that the ATE estimator under our proposed design strategy attains this semiparametric efficiency bound and achieves asymptotic normality. Through theoretical investigations and a synthetic HIV study, we show that our design is more efficient than the design without incorporating any surrogate information.

Randomized experiments have been the gold standard for assessing the effectiveness of a treatment, policy, or intervention, spanning various fields, including social sciences, biomedical studies, and e-commerce. The classical complete randomization approach assigns treatments based on a pre-specified probability and may lead to inefficient use of data. Adaptive experiments improve upon complete randomization by sequentially learning and updating treatment assignment probabilities using accrued evidence during the experiment. Hence, they can help achieve efficient data use and higher estimation efficiency. However, their application can also raise fairness and equity concerns, as assignment probabilities may vary drastically across groups of participants. Furthermore, when treatment is expected to be extremely beneficial to certain groups of participants, it is more appropriate to expose many of these participants to favorable treatment. In response to these challenges, we propose a fair adaptive experiment strategy that simultaneously enhances data use efficiency, achieves an ``envy-free'' treatment assignment guarantee, and improves the overall welfare of participants. An important feature of our proposed strategy is that we do not impose parametric modeling assumptions on the outcome variables, making it more versatile and applicable to a wider array of applications. Through our theoretical investigation, we characterize the convergence rate of the estimated treatment effects and the associated standard deviations at the group level and further prove that our adaptive treatment assignment algorithm, despite not having a closed-form expression, approaches the optimal allocation rule asymptotically. Our proof strategy takes into account the fact that the allocation decisions in our design depend on sequentially accumulated data, which poses a significant challenge in characterizing the properties and conducting statistical inference of our method. We further provide simulation evidence and two synthetic data studies to showcase the performance of our fair adaptive experiment strategy.