Robust analysis of stepped wedge trials using cluster‐level summaries within periods

• Published in: Statistics in medicine 2018-07, Vol.37 (16), p.2487-2500
• Main Authors: Thompson, J.A., Davey, C., Fielding, K., Hargreaves, J.R., Hayes, R.J.
• Format: Article
• Language: English
• Subjects: Cluster Analysis; cluster randomised trial; Computer Simulation; confidence interval coverage; Data Interpretation, Statistical; Humans; Medical research; permutation test; Randomized Controlled Trials as Topic - methods; simulation study; Statistics, Nonparametric; stepped wedge trial; Time Factors
• ISSN: 0277-6715; 1097-0258
• DOI: 10.1002/sim.7668

In stepped‐wedge trials (SWTs), the intervention is rolled out in a random order over more than 1 time‐period. SWTs are often analysed using mixed‐effects models that require strong assumptions and may be inappropriate when the number of clusters is small. We propose a non‐parametric within‐period method to analyse SWTs. This method estimates the intervention effect by comparing intervention and control conditions in a given period using cluster‐level data corresponding to exposure. The within‐period intervention effects are combined with an inverse‐variance‐weighted average, and permutation tests are used. We present an example and, using simulated data, compared the method to (1) a parametric cluster‐level within‐period method, (2) the most commonly used mixed‐effects model, and (3) a more flexible mixed‐effects model. We simulated scenarios where period effects were common to all clusters, and when they varied according to a distribution informed by routinely collected health data. The non‐parametric within‐period method provided unbiased intervention effect estimates with correct confidence‐interval coverage for all scenarios. The parametric within‐period method produced confidence intervals with low coverage for most scenarios. The mixed‐effects models' confidence intervals had low coverage when period effects varied between clusters but had greater power than the non‐parametric within‐period method when period effects were common to all clusters. The non‐parametric within‐period method is a robust method for analysing SWT. The method could be used by trial statisticians who want to emphasise that the SWT is a randomised trial, in the common position of being uncertain about whether data will meet the assumptions necessary for mixed‐effect models.