A flip of a coin does not result in an exact 50-50 chance of heads or tails. It depends a lot on how the coin is flipped, of course, but there is a bias. This article explains when, why, and how much bias there is. Continue reading
When I wrote a book about Evidence Based Medicine back in 2006, I talked about empirical evidence to support the use of certain research methodologies like blinding and allocation concealment. Since that time, many more studies have appeared, more than you or I could easily keep track of. Thankfully, the folks at the Agency for Healthcare Research and Quality commissioned a report to look at studies that empirically evaluate the bias reduction of several popular approaches used in randomized trials. These include
selection bias through randomization (sequence generation and allocation concealment); confounding through design or analysis; performance bias through fidelity to the protocol, avoidance of unintended interventions, patient or caregiver blinding and clinician or provider blinding; detection bias through outcome assessor and data analyst blinding and appropriate statistical methods; detection/performance bias through double blinding; attrition bias through intention-to-treat analysis or other approaches to accounting for dropouts; and reporting bias through complete reporting of all prespecified outcomes.
The general finding was that failure to use these bias reduction approaches tended to exaggerate treatment effects, but the magnitude and precision of these exaggerated effects was inconsistent. Continue reading
I was attending a short course taught by Susanne May on clinical trials (very good, by the way) and she mentioned an interesting publication. It talks about the “random high” bias. Continue reading
This is a commentary on a 2011 Cochrane Review that found substantial differences between studies that were adequately randomized and those that were not adequately randomized. The direction of the difference was not predictable, however, meaning that there was not a consistent bias on average towards overstating the treatment effect or a consistent bias on average towards understating the treatment effect. This leads the authors of the Cochrane review to conclude that “the unpredictability of random allocation is the best protection against the unpredictability of the extent to which non-randomised studies may be biased.” The authors of the commentary provide a critique of this conclusion on several grounds. Continue reading
This is an overview of some of the ethical controversies associated with randomization. It includes an interesting story of an early trial by Archie Cochrane that raised a lot of fuss at the time because it was attacking one of the “sacred cows” of medicine. Continue reading
Dean Ornish contirbutes his response to a series of invited essays on the topic “What Scientific Idea is Ready for Retirement?” His choice is the large randomized controlled trial. While I believe his criticism is too one-sided, he does raise some interesting points about the difficulty in using large trials to assess behavioral interventions. Continue reading