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Post-randomisation exclusions: the intention to treat principle and excluding patients from analysis
Open accessAbstract
When is it legitimate to exclude randomised patients from the analysis of data in clinical trials? Basing their analysis on the desirability of minimising bias and random error, the authors consider the circumstances when it may be possible to exclude patients, even in an intention to treat trial
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“The effect of assignment to intervention should be estimated by an intention-to-treat analysis that includes all randomised participants. 17”
From RoB 2: a revised tool for assessing risk of bias in randomised trials (2019) · cites this paper as [17]
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“Despite this, this style of analysis is less likely to show a positive treatment effect [94].”
From Consumer-based wearable activity trackers increase physical activity participation: systematic review and meta-analysis (2019) · cites this paper as [94]
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“Methods used to deal with this are generally inadequate, potentially leading to bias.(21) Performing an ITT analysis in a systematic review is not straightforward since review authors must decide how to handle outcome data missing from the contributing trials.”
MethodWiberg, S. C., Kjærgaard, J., Møgelvang, R., Møller, C. H., Kandler, K., Ravn, H. B., Hassager, C., Køber, L., & Nilsson, J. C. (2021) · BMJ Open · doi:10.1136/bmjopen-2021-052340 · Cited by 5
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“If a participant is identified as ineligible after randomisation and prior Plant protein, physical activity and appetite to baseline assessment due to error in screening (53) , a participant of the same sex will be randomised to the group the ineligible participant was allocated to.”
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“On the other hand, our sample size – though relatively large – can easily result in type II errors (existing differences are not detected), also because we used intention-to-treat analysis (Sommer & Zeger, 1991; Rubin, 1998; both cited in Fergusson et al., 2002).”
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“Hence, we also report results from the per-protocol (PP) method (Fergusson et al., 2002), where we restrict the treatment group to only those Award employees that received the wage premium cut, or those Award employers that imposed the wage premium cut.”
MethodKlitgaard, T. L., Schjørring, O. L., Severinsen, M. T., Perner, A., & Rasmussen, B. S. (2022) · BJA Open · doi:10.1016/j.bjao.2022.100090 · Cited by 4
“All analyses were performed according to the intention-totreat principle.(26) All-cause mortality at 90 days and 1 year, and the proportion of patients with one ormore SAE in the ICU were evaluated using a generalised linear model adjusted for COPD with a binomial error distribution and a log-link to produce a relativ…”
MethodNielsen, F. M., Klitgaard, T. L., Bruun, N. H., Møller, M. H., Schjørring, O. L., & Rasmussen, B. S. (2023) · Acta Anaesthesiologica Scandinavica · doi:10.1111/aas.14220 · Cited by 4
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“…date \ 21 days from enrolment (if actual time from enrolment to surgery was \ 21 days, patients were not excluded); postrandomization exclusion 18 occurred if patients did not undergo surgery, or if their tumour was deemed to be nonresectable at the time of surgery (per their surgeon, who was…”
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“9 13 The direction of the bias is unpredictable, but in a systematic review of 43 meta-analyses including 310 RCTs, Abraha and colleagues compared the point estimates obtained by ITT versus mITT trials, and found that mITT trials reported treatment effects that were inflated by 17% (95% CI 3% to…”
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“After randomisation, one patient was excluded from the trial as she did not meet the inclusion criteria (Fergusson et al., 2002).”
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“Trial investigators excluded this patient’s data from analysis according to the literature [12], without risk of bias.”
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“We argue that given the triple-blinded character of the study, post-randomisation exclusion of clusters with no SARS-CoV-2-negative contacts (exclusion due to excessively broad eligibility criteria [23]) will be random and will not lead into bias [24, 25].”
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Cuesta‐Lozano, D., López‐Alcalde, J., Molina, F. J. C., García-Sastre, M., Herrera, P. M., Muriel, A., Esteve, Á. L. A., Díaz, N. Á., Martín, D. M., & Montero, A. C. (2022) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd014532 · Cited by 2
Longitudinal study: Pros and cons, study design, and classic examples
Sadighian, M. J., Hakam, N., Shaw, N. M., & Breyer, B. N. (2024) · Elsevier eBooks · doi:10.1016/b978-0-323-90186-4.00052-3 · Cited by 1
Interventions for improving adherence to amblyopia treatments in children
Chen, D. M. L., Han, S., Summers, A. I., Wang, J., Rice, M. L., Mallios, J., Leslie, L., Harb, E. N., Qureshı, R., & supported by the Cochrane Eyes and Vision Group (2025) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd015820.pub2 · Cited by 1
Shear-wave elastography-guided transthoracic biopsy for lung lesions: a randomised controlled trial
Kuo, Y.-W., Chen, Y., Chen, Y., Chang, Y., Jan, I., Wu, C., Hsieh, M., Huang, C.-K., Wu, H., Fang, C., et al. (2025) · European Respiratory Journal · doi:10.1183/13993003.02370-2024 · Cited by 1
Automated Modes to Improve Mechanical Ventilation Outcomes—The Ghost in the Machine
Sklar, M. C., & Ferguson, N. D. (2025) · JAMA · doi:10.1001/jama.2025.24401 · Cited by 1
O’Toole, R. V., Carlini, A. R., Schrank, G. M., O’Hara, N. N., Chung, S., Gary, J. L., Obremskey, W. T., Matuszewski, P. E., Teague, D., Natoli, R. M., et al. (2025) · OTA International The Open Access Journal of Orthopaedic Trauma · doi:10.1097/oi9.0000000000000459 · Cited by 1
Li, M., Wu, Z., Lu, X., Zalesky, A., Cheng, X., Zhang, Y., Cash, R. F. H., Jin, F., Jia, S., Xiao, Y., et al. (2026) · American Journal of Psychiatry · doi:10.1176/appi.ajp.20251084 · Cited by 2
Paredes, G. R., de Cárdenas, J. D. V., & Chavarría, E. J. (2011) · Cirugía Española (English Edition) · doi:10.1016/s2173-5077(11)70043-6 · Cited by 1
Análisis crítico de ensayos clínicos. ¿Es oro todo lo que reluce?
Etxeberría, A., del Campo, R. R., & Morán-Barrios, J. (2008) · Hipertensión y Riesgo Vascular · doi:10.1016/s1889-1837(08)71737-9 · Cited by 1
Periasamy, U., Sidik, S. M., Rampal, L. R. G., & Ismail, S. I. F. (2014) · Cited by 1
Cohort Studies, Meta-analyses, and Clinical Trials in Childhood Hypertension
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Exploring the effectiveness of a brief health promotion intervention in an urgent treatment centre
Chacha-Mannie, C. U., Pallikadavath, S., Dewey, A., Kandala, N.-B., & Daniels, P. (2020) · Primary Health Care · doi:10.7748/phc.2020.e1608 · Cited by 1
Ramos, M. F. K. P., & Takeda, F. R. (2020) · JAMA Surgery · doi:10.1001/jamasurg.2020.5180 · Cited by 1
Análisis crítico de ensayos clínicos. ¿Es oro todo lo que reluce?
Etxeberría, A., del Campo, R. R., & Morán-Barrios, J. (2008) · Hipertensión · doi:10.1016/s0212-8241(08)70872-7 · Cited by 1
A SuperLearner-enforced approach for the estimation of treatment effect in pediatric trials
Azzolina, D., Comoretto, R. I., Dalt, L. D., Bressan, S., & Gregori, D. (2023) · Digital Health · doi:10.1177/20552076231191967 · Cited by 1
“Post-randomization events, including poor compliance with treatment and missing follow-up, could alter the balance of patient characteristics, demystifying the merits of a well-conducted randomization procedure.(35) The gold standard for an RCT analysis is historically represented by the Intention To Treat principle;…”
MethodHaas, Y., Williams, O., Masià, J., Pons, G., Taylor, E. M., Katapodi, M. C., Staub, D., Eisenhardt, S. U., Visconti, G., Longo, B., et al. (2025) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd016019 · Cited by 1
Sugimoto, D. (2013) · UKnowledge (University of Kentucky) · Cited by 1
Avaliação crítica e implementação prática de ensaios clínicos aleatorizados
Azevedo, L. F., & Costa‐Pereira, A. (2009) · Nascer e crescer · Cited by 1
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Metadata
- Authors
- Fergusson, D., Aaron, S. D., Guyatt, G., & Hébert, P.
- Affiliations
- McMaster University (CA)
- Corresponding author
- Fergusson, Dean
- Venue
- BMJ
- Publisher
- BMJ
- Published
- 2002-09-21
- Volume
- 325
- Issue
- 7365
- Pages
- 652-654
- ISSN
- 0007-1447 (ISSN-L)
- 0959-8138
- 1468-5833
- PMC
- PMC1124168
- OpenAlex
- W2000522086
- Cited by
- 708
- References
- 19
- Citations by year
- 2026: 22 · 2025: 26 · 2024: 30 · 2023: 24 · 2022: 46 · 2021: 59 · 2020: 36 · 2019: 37 · 2018: 35 · 2017: 40 · 2016: 34 · 2015: 40 · 2014: 34 · 2013: 27 · 2012: 21
- FWCI
- 17.26
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- www.bmj.com/company/legal-information/terms-conditions/legal-information/tdm-licencepolicy (tdm)
- Locations
- BMJ (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- DigitalGeorgetown (Georgetown University Library) (submittedVersion)
- Topics
- Physical Sciences › Mathematics › Statistics and Probability › Statistical Methods in Clinical Trials
- Physical Sciences › Mathematics › Statistics and Probability › Advanced Causal Inference Techniques
- Social Sciences › Decision Sciences › Statistics, Probability and Uncertainty › Meta-analysis and systematic reviews
- Keywords
- intention-to-treat analysis, randomized controlled trials, random error, statistical analysis of clinical trials
- MeSH terms
- Data Interpretation, Statistical, Humans, Randomized Controlled Trials as Topic, Patient Selection
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