Dataset Information

Different ways to estimate treatment effects in randomised controlled trials.

ABSTRACT:

Background

Regarding the analysis of RCT data there is a debate going on whether an adjustment for the baseline value of the outcome variable should be made. When an adjustment is made, there is a lot of misunderstanding regarding the way this should be done. Therefore, the aims of this educational paper are: 1) to explain different methods used to estimate treatment effects in RCTs, 2) to illustrate the different methods with a real life example and 3) to give an advise on how to analyse RCT data.

Methods

Longitudinal analysis of covariance, repeated measures analysis in which also the baseline value is used as outcome and the analysis of changes were theoretically explained and applied to an example dataset investigating a systolic blood pressure lowering treatment.

Results

It was shown that differences at baseline should be taken into account and that regular repeated measures analysis and regular analysis of changes did not adjust for the baseline differences between the groups and therefore lead to biased estimates of the treatment effect. In the real life example, due to the differences at baseline between the treatment and control group, the different methods lead to different estimates of the treatment effect.

Conclusion

Regarding the analysis of RCT data, it is advised to use longitudinal analysis of covariance or a repeated measures analysis without the treatment variable, but with the interaction between treatment and time in the model.

SUBMITTER: J T

PROVIDER: S-EPMC5898524 | biostudies-literature | 2018 Jun

REPOSITORIES: biostudies-literature

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Publications

Different ways to estimate treatment effects in randomised controlled trials.

J Twisk T L Bosman B T Hoekstra H J Rijnhart R M Welten W M Heymans H

Contemporary clinical trials communications 20180328

<h4>Background</h4>Regarding the analysis of RCT data there is a debate going on whether an adjustment for the baseline value of the outcome variable should be made. When an adjustment is made, there is a lot of misunderstanding regarding the way this should be done. Therefore, the aims of this educational paper are: 1) to explain different methods used to estimate treatment effects in RCTs, 2) to illustrate the different methods with a real life example and 3) to give an advise on how to analys ...[more]

PMID: 29696162

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Project description:BACKGROUND:Findings regarding the impact of language bias on treatment effect estimates (TEE) are conflicting, and very few studies have assessed these impacts in rehabilitation. The purpose was to compare TEE between studies published in non-English language (SPNEL) and those published in English language (SPEL) included in a previously published meta-analysis assessing the effects of physical therapy on balance and postural control after stroke. METHODS:Six databases were searched until January 2019. Two independent reviewers selected randomised trials, extracted data, and assessed risk of bias. We conducted subgroup meta-analyses according to the language of study publication, then compared TEE between SPEL and SPNEL subgroups by using a random-effects meta-regression model. RESULTS:From 13,123 records, 132 SPEL (n = 5219) and 13 SPNEL (n = 693) were included. SPNEL had a weight in the pooled estimate (8.2%) significantly lower than SPEL (91.8%; p<0.001). Compared to SPEL, SPNEL had both significantly worse methodological quality (p = 0.002) and quality of reporting for blinding of outcome assessment (p<0.001); and a significantly worse quality of reporting for incomplete outcome data (p<0.001). SPNEL had a significantly worse precision (i.e. inverse of variance) of TEE than SPEL (p = 0.005). Overall, the TEE was not significantly different between SPNEL and SPEL (standardised mean difference -0.16, 95% confidence interval [-0.53; 0.22], heterogeneity I2 = 78%). However, when PT was compared to sham treatment or usual care, SPNEL significantly over-estimated treatment effects (SMD -0.68, 95%CI [-1.03; -0.33], I2 = 39%) compared to SPEL. Restriction of the search to SPEL only did not change the direction of TEE for 8 out of 9 comparisons. CONCLUSIONS:SPNEL had a worse methodological quality than SPEL and were likely to over-estimate treatment effect. If inclusion of SPNEL in a systematic review is considered to be relevant, the impact of such studies on TEE should be explored by sensitivity analyses to ensure the findings validity.

Project description:ObjectiveRandomised controlled trials (RCTs) are often considered as the gold standard for assessing new health interventions. Patients are randomly assigned to receive an intervention or control. The effect of the intervention can be estimated by comparing outcomes between groups, whose prognostic factors are expected to balance by randomisation. However, patients' non-compliance with their assigned treatment will undermine randomisation and potentially bias the estimate of treatment effect. Through simulation, we aim to compare common approaches in analysing non-compliant data under different non-compliant scenarios.SettingsBased on a real study, we simulated hypothetical trials by varying three non-compliant factors: the type, randomness and degree of non-compliance. We compared the intention-to-treat (ITT), as-treated (AT), per-protocol (PP), instrumental variable (IV) and complier average casual effect (CACE) analyses to estimate large (50% improvement over the control), moderate (25% improvement) and null (same as the control) treatment effects. Different approaches were compared by the bias of estimate, mean square error (MSE) and 95% coverage of the true value.ResultsFor a large or moderate treatment effect, the ITT estimate was considerably biased in all scenarios. The AT, PP, IV and CACE estimates were unbiased when non-compliant behaviours were random. The IV estimate was unbiased when non-compliant behaviours were symmetrically dependent on patients' conditions. The PP estimate was mostly unbiased when patients in the control group did not have access to the intervention. When the intervention was not different from the control, the ITT was less biased than the other approaches. Similar results were found when comparing the MSE and 95% coverage.ConclusionsThe standard ITT analysis under non-compliance is biased when the intervention has a moderate or large effect. Alternative analyses can provide unbiased or less biased estimates. Based on the results, we make some suggestions on choosing optimal approaches for analysing specific non-compliant scenarios.

Project description:BACKGROUND:Recent methodologic evidence suggests that lack of blinding in randomized trials can result in under- or overestimation of the treatment effect size. The objective of this study is to quantify the extent of bias associated with blinding in randomized controlled trials of oral health interventions. METHODS:We selected all oral health meta-analyses that included a minimum of five randomized controlled trials. We extracted data, in duplicate, related to nine blinding-related criteria, namely: patient blinding, assessor blinding, care-provider blinding, investigator blinding, statistician blinding, blinding of both patients and assessors, study described as "double blind", blinding of patients, assessors, and care providers concurrently, and the appropriateness of blinding. We quantified the impact of bias associated with blinding on the magnitude of effect size using a two-level meta-meta-analytic approach with a random effects model to allow for intra- and inter-meta-analysis heterogeneity. RESULTS:We identified 540 randomized controlled trials, included in 64 meta-analyses, analyzing data from 137,957 patients. We identified significantly larger treatment effect size estimates in trials that had inadequate patient blinding (difference in treatment effect size?=?0.12; 95% CI: 0.00 to 0.23), lack of blinding of both patients and assessors (difference?=?0.19; 95% CI: 0.06 to 0.32), and lack of blinding of patients, assessors, and care-providers concurrently (difference?=?0.14; 95% CI: 0.03 to 0.25). In contrast, assessor blinding (difference?=?0.06; 95% CI: -0.06 to 0.18), caregiver blinding (difference?=?0.02; 95% CI: -0.04 to 0.09), principal-investigator blinding (difference?=?-?0.02; 95% CI: -0.10 to 0.06), describing a trial as "double-blind" (difference?=?0.09; 95% CI: -0.05 to 0.22), and lack of an appropriate method of blinding (difference?=?0.06; 95% CI: -0.06 to 0.18) were not associated with over- or underestimated treatment effect size. CONCLUSIONS:We found significant differences in treatment effect size estimates between oral health trials based on lack of patient and assessor blinding. Treatment effect size estimates were 0.19 and 0.14 larger in trials with lack of blinding of both patients and assessors and blinding of patients, assessors, and care-providers concurrently. No significant differences were identified in other blinding criteria. Investigators of oral health systematic reviews should perform sensitivity analyses based on the adequacy of blinding in included trials.

Project description:ObjectiveTo identify factors and assess to what extent they impact the magnitude of the treatment effect of acupuncture therapies across therapeutic areas.Data sourceMedline, Embase, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, Wanfang Database, VIP Database, and China Biology Medicine disc, between 2015 and 2019.Study selectionThe inclusion criteria were trials with a total number of randomised patients larger than 100, at least one patient-important outcome and one of two sets of comparisons.Data analysisThe potential independent variables were identified by reviewing relevant literature and consulting with experts. We conducted meta-regression analyses with standardised mean difference (SMD) as effect estimate for the dependent variable. The analyses included univariable meta-regression and multivariable meta-regression using a three-level robust mixed model.Results1304 effect estimates from 584 acupuncture randomised controlled trials (RCTs) were analysed. The multivariable analyses contained 15 independent variables . In the multivariable analysis, the following produced larger treatment effects of large magnitude (>0.4): quality of life (difference of adjusted SMDs 0.51, 95% CI 0.24 to 0.77), or pain (0.48, 95% CI 0.27 to 0.69), or function (0.41, 95% CI 0.21 to 0.61) vs major events. The following produced larger treatment effects of moderate magnitude (0.2-0.4): single-centred vs multicentred RCTs (0.38, 95% CI 0.10 to 0.66); penetration acupuncture vs non-penetration types of acupuncture (0.34, 95% CI 0.15 to 0.53); non-pain symptoms vs major events (0.32, 95% CI 0.12 to 0.52). The following produced larger treatment effects of small magnitude (<0.2): high vs low frequency treatment sessions (0.19, 95% CI 0.03 to 0.35); pain vs non-pain symptoms (0.16, 95% CI 0.04 to 0.27); unreported vs reported funding (0.12, 95% CI 0 to 0.25).ConclusionPatients, clinicians and policy-makers should consider penetrating over non-penetrating acupuncture and more frequent treatment sessions when feasible and acceptable. When designing future acupuncture RCTs, trialists should consider factors that impact acupuncture treatment effects.

Dataset Information

Different ways to estimate treatment effects in randomised controlled trials.

Background

Methods

Results

Conclusion

Publications

Different ways to estimate treatment effects in randomised controlled trials.

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