Dataset Information

Covariate-constrained randomization for cluster randomized trials in the long-term care setting: Application to the TRAIN-AD trial.

ABSTRACT: Little has been reported on strategies to ensure key covariate balance in cluster randomized trials in the nursing home setting. Facilities vary widely on key characteristics, small numbers may be randomized, and staggered enrollment is often necessary. A covariate-constrained algorithm was used to randomize facilities in the Trial to Reduce Antimicrobial use In Nursing home residents with Alzheimer's Disease and other Dementias (TRAIN-AD), an ongoing trial in Boston-area facilities (14 facilities/arm). Publicly available 2015 LTCfocus.org data were leveraged to inform the distribution of key facility-level covariates. The algorithm was applied in waves (2-8 facilities/wave) June 2017-March 2019. To examine the algorithm's general performance, simulations calculated an imbalance score (minimum 0) for similar trial designs. The algorithm provided good balance for profit status (Arm 1, 7 facilities; Arm 2, 6 facilities). Arm 2 was allocated more nursing homes with the number of severely cognitive impaired residents above the median (Arm 1, 7 facilities; Arm 2, 10 facilities), resulting in an imbalance in total number of residents enrolled (Arm 1, 196 residents; Arm 2, 228 residents). Facilities with number of black residents above the median were balanced (7 facilities/arm), while the numbers of black residents enrolled differed slightly between arms (Arm 1, 26 residents (13%); Arm 2, 22 residents (10%)). Simulations showed the median imbalance for TRAIN-AD's original randomization scheme (score = 3), was similar to the observed imbalance (score = 4). Covariate-constrained randomization flexibly accommodates logistical complexities of cluster trials in the nursing home setting, where LTCfocus.org is a valuable source of baseline data.

Trial registration number and trial register

ClinicalTrials.gov Identifier: NCT03244917.

SUBMITTER: Shaffer ML

PROVIDER: S-EPMC7110330 | biostudies-literature | 2020 Jun

REPOSITORIES: biostudies-literature

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Covariate-constrained randomization for cluster randomized trials in the long-term care setting: Application to the TRAIN-AD trial.

Shaffer Michele L ML D'Agata Erika M C EMC Habtemariam Daniel D Mitchell Susan L SL

Contemporary clinical trials communications 20200317

Little has been reported on strategies to ensure key covariate balance in cluster randomized trials in the nursing home setting. Facilities vary widely on key characteristics, small numbers may be randomized, and staggered enrollment is often necessary. A covariate-constrained algorithm was used to randomize facilities in the Trial to Reduce Antimicrobial use In Nursing home residents with Alzheimer's Disease and other Dementias (TRAIN-AD), an ongoing trial in Boston-area facilities (14 faciliti ...[more]

PMID: 32258819

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Project description:BackgroundIn cluster-randomized controlled trials (C-RCTs), covariate-constrained randomization (CCR) methods efficiently control imbalance in multiple baseline cluster-level variables, but the choice of imbalance metric to define the subset of "adequately balanced" possible allocation schemes for C-RCTs involving more than two arms and continuous variables is unclear. In an ongoing three-armed C-RCT, we chose the min(three Kruskal-Wallis [KW] test P values) > 0.30 as our metric. We use simulation studies to explore the performance of this and other metrics of baseline variable imbalance in CCR.MethodsWe simulated three continuous variables across three arms under varying allocation ratios and assumptions. We compared the performance of min(analysis of variance [ANOVA] P value) > 0.30, min(KW P value) > 0.30, multivariate analysis of variance (MANOVA) P value > 0.30, min(nine possible t test P values) > 0.30, and min(Wilcoxon rank-sum [WRS] P values) > 0.30.ResultsPairwise comparison metrics (t test and WRS) tended to be the most conservative, providing the smallest subset of allocation schemes (10%-13%) meeting criteria for acceptable balance. Sensitivity of the min(t test P values) > 0.30 for detecting non-trivial imbalance was 100% for both hypothetical and resampled simulation scenarios. The KW criterion maintained higher sensitivity than both the MANOVA and ANOVA criteria (89% to over 99%) but was not as sensitive as pairwise criteria.ConclusionsOur criterion, the KW P value > 0.30, to signify "acceptable" balance was not the most conservative, but it appropriately identified imbalance in the majority of simulations. Since all are related, CCR algorithms involving any of these imbalance metrics for continuous baseline variables will ensure robust simultaneous control over multiple continuous baseline variables, but we recommend care in determining the threshold of "acceptable" levels of (im)balance.Trial registrationThis trial is registered on ClinicalTrials.gov (initial post: December 1, 2016; identifier: NCT02979444 ).

Project description:BackgroundCluster randomised trials often randomise a small number of units, putting them at risk of poor balance of covariates across treatment arms. Covariate constrained randomisation aims to reduce this risk by removing the worst balanced allocations from consideration. This is known to provide only a small gain in power over that averaged under simple randomisation and is likely influenced by the number and prognostic effect of the covariates. We investigated the performance of covariate constrained randomisation in comparison to the worst balanced allocations, and considered the impact on the power of the prognostic effect and number of covariates adjusted for in the analysis.MethodsUsing simulation, we examined the Monte Carlo type I error rate and power of cross-sectional, two-arm parallel cluster-randomised trials with a continuous outcome and four binary cluster-level covariates, using either simple or covariate constrained randomisation. Data were analysed using a small sample corrected linear mixed-effects model, adjusted for some or all of the binary covariates. We varied the number of clusters, intra-cluster correlation, number and prognostic effect of covariates balanced in the randomisation and adjusted in the analysis, and the size of the candidate set from which the allocation was selected. For each scenario, 20,000 simulations were conducted.ResultsWhen compared to the worst balanced allocations, covariate constrained randomisation with an adjusted analysis provided gains in power of up to 20 percentage points. Even with analysis-based adjustment for those covariates balanced in the randomisation, the type I error rate was not maintained when the intracluster correlation is very small (0.001). Generally, greater power was achieved when more prognostic covariates are restricted in the randomisation and as the size of the candidate set decreases. However, adjustment for weakly prognostic covariates lead to a loss in power of up to 20 percentage points.ConclusionsWhen compared to the worst balanced allocations, covariate constrained randomisation provides moderate to substantial improvements in power. However, the prognostic effect of the covariates should be carefully considered when selecting them for inclusion in the randomisation.

Project description:Background and aimSome parallel-group cluster-randomized trials use covariate-constrained rather than simple randomization. This is done to increase the chance of balancing the groups on cluster- and patient-level baseline characteristics. This study assessed how well two covariate-constrained randomization methods balanced baseline characteristics compared with simple randomization.MethodsWe conducted a mock 3-year cluster-randomized trial, with no active intervention, that started April 1, 2014, and ended March 31, 2017. We included a total of 11,832 patients from 72 hemodialysis centers (clusters) in Ontario, Canada. We randomly allocated the 72 clusters into two groups in a 1:1 ratio on a single date using individual- and cluster-level data available until April 1, 2013. Initially, we generated 1000 allocation schemes using simple randomization. Then, as an alternative, we performed covariate-constrained randomization based on historical data from these centers. In one analysis, we restricted on a set of 11 individual-level prognostic variables; in the other, we restricted on principal components generated using 29 baseline historical variables. We created 300,000 different allocations for the covariate-constrained randomizations, and we restricted our analysis to the 30,000 best allocations based on the smallest sum of the penalized standardized differences. We then randomly sampled 1000 schemes from the 30,000 best allocations. We summarized our results with each randomization approach as the median (25th and 75th percentile) number of balanced baseline characteristics. There were 156 baseline characteristics, and a variable was balanced when the between-group standardized difference was ≤ 10%.ResultsThe three randomization techniques had at least 125 of 156 balanced baseline characteristics in 90% of sampled allocations. The median number of balanced baseline characteristics using simple randomization was 147 (142, 150). The corresponding value for covariate-constrained randomization using 11 prognostic characteristics was 149 (146, 151), while for principal components, the value was 150 (147, 151).ConclusionIn this setting with 72 clusters, constraining the randomization using historical information achieved better balance on baseline characteristics compared with simple randomization; however, the magnitude of benefit was modest.

Project description:This paper studies inference for the average treatment effect in randomized controlled trials with covariate-adaptive randomization. Here, by covariate-adaptive randomization, we mean randomization schemes that first stratify according to baseline covariates and then assign treatment status so as to achieve "balance" within each stratum. Our main requirement is that the randomization scheme assigns treatment status within each stratum so that the fraction of units being assigned to treatment within each stratum has a well behaved distribution centered around a proportion ? as the sample size tends to infinity. Such schemes include, for example, Efron's biased-coin design and stratified block randomization. When testing the null hypothesis that the average treatment effect equals a pre-specified value in such settings, we first show the usual two-sample t-test is conservative in the sense that it has limiting rejection probability under the null hypothesis no greater than and typically strictly less than the nominal level. We show, however, that a simple adjustment to the usual standard error of the two-sample t-test leads to a test that is exact in the sense that its limiting rejection probability under the null hypothesis equals the nominal level. Next, we consider the usual t-test (on the coefficient on treatment assignment) in a linear regression of outcomes on treatment assignment and indicators for each of the strata. We show that this test is exact for the important special case of randomization schemes with ?=12 , but is otherwise conservative. We again provide a simple adjustment to the standard errors that yields an exact test more generally. Finally, we study the behavior of a modified version of a permutation test, which we refer to as the covariate-adaptive permutation test, that only permutes treatment status for units within the same stratum. When applied to the usual two-sample t-statistic, we show that this test is exact for randomization schemes with ?=12 and that additionally achieve what we refer to as "strong balance." For randomization schemes with ??12 , this test may have limiting rejection probability under the null hypothesis strictly greater than the nominal level. When applied to a suitably adjusted version of the two-sample t-statistic, however, we show that this test is exact for all randomization schemes that achieve "strong balance," including those with ??12 . A simulation study confirms the practical relevance of our theoretical results. We conclude with recommendations for empirical practice and an empirical illustration·.

Dataset Information

Covariate-constrained randomization for cluster randomized trials in the long-term care setting: Application to the TRAIN-AD trial.

Trial registration number and trial register

Publications

Covariate-constrained randomization for cluster randomized trials in the long-term care setting: Application to the TRAIN-AD trial.

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