Increased risk of type I errors in cluster randomised trials with small or medium numbers of clusters: a review, reanalysis, and simulation study

Kahan, Brennan C.; Forbes, Gordon; Ali, Yunus; Jairath, Vipul; Bremner, Stephen; Harhay, Michael O.; Hooper, Richard; Wright, Neil; Eldridge, Sandra M.; Leyrat, Clémence

doi:10.1186/s13063-016-1571-2

Cited by 185Statistical Methods in Clinical TrialsStatistical Methods and Bayesian InferenceMeta-analysis and systematic reviews

Increased risk of type I errors in cluster randomised trials with small or medium numbers of clusters: a review, reanalysis, and simulation study

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Kahan, Brennan C., Forbes, Gordon, Ali, Yunus, Jairath, Vipul, Bremner, Stephen, Harhay, Michael O., Hooper, Richard, Wright, Neil +2 more·2016·Trials

DOI 10.1186/s13063-016-1571-2PMC PMC5013635

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Abstract

BACKGROUND: Cluster randomised trials (CRTs) are commonly analysed using mixed-effects models or generalised estimating equations (GEEs). However, these analyses do not always perform well with the small number of clusters typical of most CRTs. They can lead to increased risk of a type I error (finding a statistically significant treatment effect when it does not exist) if appropriate corrections are not used. METHODS: We conducted a small simulation study to evaluate the impact of using small-sample corrections for mixed-effects models or GEEs in CRTs with a small number of clusters. We then reanalysed data from TRIGGER, a CRT with six clusters, to determine the effect of using an inappropriate analysis method in practice. Finally, we reviewed 100 CRTs previously identified by a search on PubMed in order to assess whether trials were using appropriate methods of analysis. Trials were classified as at risk of an increased type I error rate if they did not report using an analysis method which accounted for clustering, or if they had fewer than 40 clusters and performed an individual-level analysis without reporting the use of an appropriate small-sample correction. RESULTS: Our simulation study found that using mixed-effects models or GEEs without an appropriate correction led to inflated type I error rates, even for as many as 70 clusters. Conversely, using small-sample corrections provided correct type I error rates across all scenarios. Reanalysis of the TRIGGER trial found that inappropriate methods of analysis gave much smaller P values (P ≤ 0.01) than appropriate methods (P = 0.04-0.15). In our review, of the 99 trials that reported the number of clusters, 64 (65 %) were at risk of an increased type I error rate; 14 trials did not report using an analysis method which accounted for clustering, and 50 trials with fewer than 40 clusters performed an individual-level analysis without reporting the use of an appropriate correction. CONCLUSIONS: CRTs with a small or medium number of clusters are at risk of an inflated type I error rate unless appropriate analysis methods are used. Investigators should consider using small-sample corrections with mixed-effects models or GEEs to ensure valid results.

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Authors: Kahan, B. C., Forbes, G., Ali, Y., Jairath, V., Bremner, S., Harhay, M. O., Hooper, R., Wright, N., Eldridge, S. M., & Leyrat, C.
Affiliations: Queen Mary University of London (GB)
Western University (CA)
Brighton and Sussex Medical School (GB)
University of Pennsylvania (US)
Inserm (FR)
Corresponding author: Kahan, Brennan C.
ORCID: Kahan, Brennan C.
Forbes, Gordon
Jairath, Vipul
Bremner, Stephen
Harhay, Michael O.
Hooper, Richard
Wright, Neil
Eldridge, Sandra M.
Leyrat, Clémence
Venue: Trials
Publisher: Springer Science and Business Media LLC
Published: 2016-09-06
Volume: 17
Issue: 1
Pages: 438-438
ISSN: 1745-6215 (ISSN-L)
DOI: 10.1186/s13063-016-1571-2
PMC: PMC5013635
OpenAlex: W2515120484
Cited by: 185
References: 29
Citations by year: 2026: 10 · 2025: 11 · 2024: 22 · 2023: 12 · 2022: 16 · 2021: 35 · 2020: 26 · 2019: 16 · 2018: 13 · 2017: 15 · 2016: 9
FWCI: 17.86
Type: journal article
Language: en
Open access: gold
doi.org
Licence: cc-by
www.springer.com/tdm (unspecified)
Locations: Trials (publishedVersion, cc-by)
PubMed Central (publishedVersion, cc-by)
PubMed (publishedVersion)
LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
Sussex Research Online (University of Sussex) (submittedVersion, cc-by)
Figshare (submittedVersion, cc-by)
Research Portal (King's College London) (submittedVersion, other-oa)
Queen Mary Research Online (Queen Mary University of London) (submittedVersion, cc-by)
Funders: National Institute for Health and Care Research (NIHR-CTF-2014-03-05)
National Institutes of Health
National Heart, Lung, and Blood Institute (F31HL127947)
Topics: Physical Sciences › Mathematics › Statistics and Probability › Statistical Methods in Clinical Trials
Physical Sciences › Mathematics › Statistics and Probability › Statistical Methods and Bayesian Inference
Social Sciences › Decision Sciences › Statistics, Probability and Uncertainty › Meta-analysis and systematic reviews
Keywords: type I error, small sample correction, mixed models, generalized estimating equations, small number of clusters, clustering, statistical power
MeSH terms: Computer Simulation, Data Interpretation, Statistical, Humans, Risk, Cluster Analysis, Randomized Controlled Trials as Topic

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Increased risk of type I errors in cluster randomised trials with small or medium numbers of clusters: a review, reanalysis, and simulation study

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