Objective: Heterogeneity of patients is a common problem in randomized controlled trials (RCTs) in various fields of clinical research. We aimed to investigate the potential benefits of different approaches for dealing with heterogeneity in a case study on traumatic brain injury (TBI). Design and Setting: Statistical modeling studies in three surveys and six randomized controlled trials. Patients: Individual patient data (n = 8033) from the IMPACT database. Interventions: We investigated the statistical power and efficiency of randomized controlled trials (RCTs) in relation to (1) selection according to baseline characteristics, (2) prognostic targeting (i.e., excluding those with a relatively extreme prognosis), and (3) covariate-adjusted analysis. Statistical power was expressed as the required sample size for obtaining 80% power and efficiency as the relative change in study duration, reflecting both gains in power and adverse effects on recruitment. Uniform and targeted treatment effects were simulated for 6 month unfavorable outcome. Results: For a uniform treatment effect, selection resulted in a sample size reduction of 33% in the surveys and 5% in the RCTs, but decreased recruitment by 65% and 41%, respectively. Hence, the relative study duration was prolonged (surveys: +95%; RCTs: +60%). Prognostic targeting resulted in sample size reductions of 28% and 17%, and increased relative study duration by +5% in surveys and +11% in the RCTs. Covariate adjustment reduced sample sizes by 30% and 16%, respectively, and did not affect recruitment. For a targeted treatment effect, the sample size reductions by selection (surveys: 47%; RCTs: 20%) and prognostic targeting (surveys: 49%; RCTs: 41%) were larger and adverse effects on recruitment smaller. Conclusions: The benefits of selection and prognostic targeting in terms of statistical power are reversed by adverse effects on recruitment. Covariate adjusted analysis in a broadly selected group of patients is advisable if a uniform treatment effect is assumed, since there is no decrease in recruitment.

Covariate adjustment, Heterogeneity, Randomized controlled trials, Selection criteria, Statistical power, Traumatic brain injury
dx.doi.org/10.1097/CCM.0b013e3181ab85ec, hdl.handle.net/1765/24709
Critical Care Medicine
Erasmus MC: University Medical Center Rotterdam

Roozenbeek, B, Maas, A.I.R, Butcher, I, Lu, J, Marmarou, A, McHugh, G.S, … Steyerberg, E.W. (2009). Baseline characteristics and statistical power in randomized controlled trials: Selection, prognostic targeting, or covariate adjustment?. Critical Care Medicine, 37(10), 2683–2690. doi:10.1097/CCM.0b013e3181ab85ec