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BACKGROUND: Modulator therapies that seek to correct the underlying defect in cystic fibrosis (CF) have revolutionized the clinical landscape. Given the heterogeneous nature of lung disease progression in the post-modulator era, there is a need to develop prediction models that are robust to modulator uptake.METHODS: We conducted a retrospective longitudinal cohort study of the CF Foundation Patient Registry (N = 867 patients carrying the G551D mutation who were treated with ivacaftor from 2003 to 2018). The primary outcome was lung function (percent predicted forced expiratory volume in 1 s or FEV1pp). To characterize the association between ivacaftor initiation and lung function, we developed a dynamic prediction model through covariate selection of demographic and clinical characteristics. The ability of the selected model to predict a decline in lung function, clinically known as an FEV1-indicated exacerbation signal (FIES), was evaluated both at the population level and individual level.RESULTS: Based on the final model, the estimated improvement in FEV1pp after ivacaftor initiation was 4.89% predicted (95% confidence interval [CI]: 3.90 to 5.89). The rate of decline was reduced with ivacaftor initiation by 0.14% predicted/year (95% CI: 0.01 to 0.27). More frequent outpatient visits prior to study entry and being male corresponded to a higher overall FEV1pp. Pancreatic insufficiency, older age at study entry, a history of more frequent pulmonary exacerbations, lung infections, CF-related diabetes, and use of Medicaid insurance corresponded to lower FEV1pp. The model had excellent predictive accuracy for FIES events with an area under the receiver operating characteristic curve of 0.83 (95% CI: 0.83 to 0.84) for the independent testing cohort and 0.90 (95% CI: 0.89 to 0.90) for 6-month forecasting with the masked cohort. The root-mean-square errors of the FEV1pp predictions for these cohorts were 7.31% and 6.78% predicted, respectively, with sta

The joint modeling of longitudinal and time-to-event outcomes has become a popular tool in follow-up studies. However, fitting Bayesian joint models to large datasets, such as patient registries, can require extended computing times. To speed up sampling, we divided a patient registry dataset into subsamples, analyzed them in parallel, and combined the resulting Markov chain Monte Carlo draws into a consensus distribution. We used a simulation study to investigate how different consensus strategies perform with joint models. In particular, we compared grouping all draws together with using equal- and precision-weighted averages. We considered scenarios reflecting different sample sizes, numbers of data splits, and processor characteristics. Parallelization of the sampling process substantially decreased the time required to run the model. We found that the weighted-average consensus distributions for large sample sizes were nearly identical to the target posterior distribution. The proposed algorithm has been made available in an R package for joint models, JMbayes2. This work was motivated by the clinical interest in investigating the association between ppFEV1, a commonly measured marker of lung function, and the risk of lung transplant or death, using data from the US Cystic Fibrosis Foundation Patient Registry (35,153 individuals with 372,366 years of cumulative follow-up). Splitting the registry into five subsamples resulted in an 85% decrease in computing time, from 9.22 to 1.39 hours. Splitting the data and finding a consensus distribution by precision-weighted averaging proved to be a computationally efficient and robust approach to handling large datasets under the joint modeling framework.