Randomized Controlled Trial

Randomized controlled trial
https://en.wikipedia.org/wiki/Randomized_controlled_trial
A randomized controlled trial (or randomized control trial;[2] RCT) is a type of scientific (often
medical) experiment which aims to reduce bias when testing a new treatment. The people
participating in the trial are randomly allocated to either the group receiving the treatment under
investigation or to a group receiving standard treatment (or placebo treatment) as the
control. Randomization minimises selection bias and the different comparison groups allow the
researchers to determine any effects of the treatment when compared with the no treatment (control)
group, while other variables are kept constant. The RCT is often considered the gold standard for
a clinical trial. RCTs are often used to test the efficacy or effectiveness of various types of
medical intervention and may provide information about adverse effects, such as drug
reactions. Random assignment of intervention is done after subjects have been assessed for
eligibility and recruited, but before the intervention to be studied begins.
Random allocation in real trials is complex, but conceptually the process is like tossing a coin. After
randomization, the two (or more) groups of subjects are followed in exactly the same way and the
only differences between them is the care they receive. For example, in terms of procedures, tests,
outpatient visits, and follow-up calls, should be those intrinsic to the treatments being compared. The
most important advantage of proper randomization is that it minimizes allocation bias, balancing both
known and unknown prognostic factors, in the assignment of treatments. [3]
The terms "RCT" and randomized trial are sometimes used synonymously, but the
methodologically sound practice is to reserve the "RCT" name only for trials that
contain control groups, in which groups receiving the experimental treatment are compared with
control groups receiving no treatment (a placebo-controlled study) or a previously tested treatment
(a positive-control study). The term "randomized trials" omits mention of controls and can describe
studies that compare multiple treatment groups with each other (in the absence of a control group).
[4]
Similarly, although the "RCT" name is sometimes expanded as "randomized clinical trial" or
"randomized comparative trial", the methodologically sound practice, to avoid ambiguity in
the scientific literature, is to retain "control" in the definition of "RCT" and thus reserve that name only
for trials that contain controls. Not all randomized clinical trials are randomized controlled trials (and
some of them could never be, in cases where controls would be impractical or unethical to institute).
The term randomized controlled clinical trials is a methodologically sound alternate expansion for
"RCT" in RCTs that concern clinical research;[5][6][7] however, RCTs are also employed in other
research areas, including many of the social sciences.
Contents
[hide]
1History
2Ethics
o 2.1Trial registration
3Classifications of RCTs
o 3.1By study design
o 3.2By outcome of interest (efficacy vs. effectiveness)
o 3.3By hypothesis (superiority vs. noninferiority vs. equivalence)
4Randomization
o 4.1Randomization procedures
4.1.1Simple randomization
4.1.2Restricted randomization
4.1.3Adaptive
o 4.2Allocation concealment
o 4.3Sample size
5Blinding
6Analysis of data from RCTs
7Reporting of RCT results
o 7.1Relative importance of RCTs and observational studies
o 7.2Interpretation of statistical results
8Advantages
9Disadvantages
o 9.1Limitations of external validity
o 9.2Time and Costs
o 9.3Conflict of interest dangers
o 9.4Ethics
10Randomized controlled trials in social science
o 10.1Transport science
o 10.2International development
o 10.3Criminology
o 10.4Education
11See also
12References
13Further reading
14External links
History[edit]
The first reported clinical trial was conducted by James Lind in 1747 to identify treatment for scurvy.
[8]
Randomized experiments appeared in psychology, where they were introduced by Charles
Sanders Peirce,[9] and in education.[10][11][12] Later, randomized experiments appeared in agriculture, due
to Jerzy Neyman[13] and Ronald A. Fisher. Fisher's experimental research and his writings
popularized randomized experiments.[14]
The first published RCT in medicine appeared in the 1948 paper entitled "Streptomycin treatment of
pulmonary tuberculosis", which described a Medical Research Councilinvestigation.[15][16][17] One of the
authors of that paper was Austin Bradford Hill, who is credited as having conceived the modern RCT.
[18]
By the late 20th century, RCTs were recognized as the standard method for "rational therapeutics" in
medicine.[19] As of 2004, more than 150,000 RCTs were in the Cochrane Library.[18] To improve the
reporting of RCTs in the medical literature, an international group of scientists and editors
published Consolidated Standards of Reporting Trials(CONSORT) Statements in 1996, 2001 and
2010, and these have become widely accepted.[1][3] Randomization is the process of assigning trial
subjects to treatment or control groups using an element of chance to determine the assignments in
order to reduce the bias.
Ethics[edit]
Although the principle of clinical equipoise ("genuine uncertainty within the expert medical
community... about the preferred treatment") common to clinical trials [20] has been applied to RCTs,
the ethics of RCTs have special considerations. For one, it has been argued that equipoise itself is
insufficient to justify RCTs.[21] For another, "collective equipoise" can conflict with a lack of personal
equipoise (e.g., a personal belief that an intervention is effective).[22] Finally, Zelen's design, which
has been used for some RCTs, randomizes subjects before they provide informed consent, which
may be ethical for RCTs of screening and selected therapies, but is likely unethical "for most
therapeutic trials."[23][24]
Although subjects almost always provide informed consent for their participation in an RCT, studies
since 1982 have documented that RCT subjects may believe that they are certain to receive
treatment that is best for them personally; that is, they do not understand the difference between
research and treatment.[25][26] Further research is necessary to determine the prevalence of and ways
to address this "therapeutic misconception".[26]
The RCT method may also create cultural effects that have not been well understood. [27] For
example, patients with terminal illness may join trials in the hope of being cured, even when
treatments are unlikely to be successful.
Trial registration[edit]
In 2004, the International Committee of Medical Journal Editors (ICMJE) announced that all trials
starting enrolment after July 1, 2005 must be registered prior to consideration for publication in one
of the 12 member journals of the committee.[28] However, trial registration may still occur late or not at
all.[29][30] Medical journals have been slow in adapting policies requiring mandatory clinical trial
registration as a prerequisite for publication.[31]
Classifications of RCTs[edit]
By study design[edit]
One way to classify RCTs is by study design. From most to least common in the healthcare
literature, the major categories of RCT study designs are:[32]
Parallel-group each participant is randomly assigned to a group, and all the participants in
the group receive (or do not receive) an intervention.
Crossover over time, each participant receives (or does not receive) an intervention in a
random sequence.[33][34]
Cluster pre-existing groups of participants (e.g., villages, schools) are randomly selected to
receive (or not receive) an intervention.
Factorial each participant is randomly assigned to a group that receives a particular

combination of interventions or non-interventions (e.g., group 1 receives vitamin X and vitamin Y,
group 2 receives vitamin X and placebo Y, group 3 receives placebo X and vitamin Y, and group
4 receives placebo X and placebo Y).
An analysis of the 616 RCTs indexed in PubMed during December 2006 found that 78% were
parallel-group trials, 16% were crossover, 2% were split-body, 2% were cluster, and 2% were
factorial.[32]
By outcome of interest (efficacy vs. effectiveness)[edit]
RCTs can be classified as "explanatory" or "pragmatic." [35] Explanatory RCTs test efficacy in a
research setting with highly selected participants and under highly controlled conditions. [35] In
contrast, pragmatic RCTs test effectiveness in everyday practice with relatively unselected
participants and under flexible conditions; in this way, pragmatic RCTs can "inform decisions about
practice."[35]
By hypothesis (superiority vs. noninferiority vs. equivalence)[edit]
Another classification of RCTs categorizes them as "superiority trials," "noninferiority trials," and
"equivalence trials," which differ in methodology and reporting. [36] Most RCTs are superiority trials, in
which one intervention is hypothesized to be superior to another in a statistically significant way.
[36]
Some RCTs are noninferiority trials "to determine whether a new treatment is no worse than a
reference treatment."[36] Other RCTs are equivalence trials in which the hypothesis is that two
interventions are indistinguishable from each other.[36]
Randomization[edit]
The advantages of proper randomization in RCTs include:[37]
"It eliminates bias in treatment assignment," specifically selection bias and confounding.
"It facilitates blinding (masking) of the identity of treatments from investigators, participants,
and assessors."
"It permits the use of probability theory to express the likelihood that any difference in
outcome between treatment groups merely indicates chance."
There are two processes involved in randomizing patients to different interventions. First is choosing
a randomization procedure to generate an unpredictable sequence of allocations; this may be a
simple random assignment of patients to any of the groups at equal probabilities, may be
"restricted," or may be "adaptive." A second and more practical issue is allocation concealment,
which refers to the stringent precautions taken to ensure that the group assignment of patients are
not revealed prior to definitively allocating them to their respective groups. Non-random "systematic"
methods of group assignment, such as alternating subjects between one group and the other, can
cause "limitless contamination possibilities" and can cause a breach of allocation concealment. [38]
However empirical evidence that adequate randomization changes outcomes relative to inadequate
randomization has been difficult to detect empirically.[39]
Randomization procedures[edit]
The treatment allocation is the desired proportion of patients in each treatment arm.
An ideal randomization procedure would achieve the following goals:[40]
Maximize statistical power, especially in subgroup analyses. Generally, equal group sizes
maximize statistical power, however, unequal groups sizes maybe more powerful for some
analyses (e.g., multiple comparisons of placebo versus several doses using Dunnetts
procedure[41] ), and are sometimes desired for non-analytic reasons (e.g., patients maybe more
motivated to enroll if there is a higher chance of getting the test treatment, or regulatory
agencies may require a minimum number of patients exposed to treatment). [42]
Minimize selection bias. This may occur if investigators can consciously or unconsciously
preferentially enroll patients between treatment arms. A good randomization procedure will be
unpredictable so that investigators cannot guess the next subject's group assignment based on
prior treatment assignments. The risk of selection bias is highest when previous treatment
assignments are known (as in unblinded studies) or can be guessed (perhaps if a drug has
distinctive side effects).
Minimize allocation bias (or confounding). This may occur when covariates that affect the
outcome are not equally distributed between treatment groups, and the treatment effect is
confounded with the effect of the covariates (i.e., an "accidental bias"[37][43]). If the randomization
procedure causes an imbalance in covariates related to the outcome across groups, estimates
of effect may be biased if not adjusted for the covariates (which may be unmeasured and
therefore impossible to adjust for).
However, no single randomization procedure meets those goals in every circumstance, so

researchers must select a procedure for a given study based on its advantages and disadvantages.
Simple randomization[edit]
This is a commonly used and intuitive procedure, similar to "repeated fair coin-tossing." [37] Also
known as "complete" or "unrestricted" randomization, it is robust against both selection and
accidental biases. However, its main drawback is the possibility of imbalanced group sizes in small
RCTs. It is therefore recommended only for RCTs with over 200 subjects.[44]
Restricted randomization[edit]
To balance group sizes in smaller RCTs, some form of "restricted" randomization is recommended.
[44]
The major types of restricted randomization used in RCTs are:
Permuted-block randomization or blocked randomization: a "block size" and "allocation

ratio" (number of subjects in one group versus the other group) are specified, and subjects are
allocated randomly within each block.[38] For example, a block size of 6 and an allocation ratio of
2:1 would lead to random assignment of 4 subjects to one group and 2 to the other. This type of
randomization can be combined with "stratified randomization", for example by center in
a multicenter trial, to "ensure good balance of participant characteristics in each group." [3] A
special case of permuted-block randomization is random allocation, in which the entire sample is
treated as one block.[38] The major disadvantage of permuted-block randomization is that even if
the block sizes are large and randomly varied, the procedure can lead to selection bias.
[40]
Another disadvantage is that "proper" analysis of data from permuted-block-randomized RCTs
requires stratification by blocks.[44]
Adaptive biased-coin randomization methods (of which urn randomization is the most
widely known type): In these relatively uncommon methods, the probability of being assigned to
a group decreases if the group is overrepresented and increases if the group is
underrepresented.[38] The methods are thought to be less affected by selection bias than
permuted-block randomization.[44]
Adaptive[edit]
At least two types of "adaptive" randomization procedures have been used in RCTs, but much less
frequently than simple or restricted randomization:
Covariate-adaptive randomization, of which one type is minimization: The probability of

being assigned to a group varies in order to minimize "covariate imbalance." [44]Minimization is
reported to have "supporters and detractors"[38] because only the first subject's group assignment
is truly chosen at random, the method does not necessarily eliminate bias on unknown factors. [3]
Response-adaptive randomization, also known as outcome-adaptive randomization:

The probability of being assigned to a group increases if the responses of the prior patients in
the group were favorable.[44] Although arguments have been made that this approach is more
ethical than other types of randomization when the probability that a treatment is effective or
ineffective increases during the course of an RCT, ethicists have not yet studied the approach in
detail.[45]
Allocation concealment[edit]
"Allocation concealment" (defined as "the procedure for protecting the randomization process so that
the treatment to be allocated is not known before the patient is entered into the study") is important
in RCTs.[46] In practice, clinical investigators in RCTs often find it difficult to maintain impartiality.
Stories abound of investigators holding up sealed envelopes to lights or ransacking offices to
determine group assignments in order to dictate the assignment of their next patient. [38] Such
practices introduce selection bias andconfounders (both of which should be minimized by
randomization), thereby possibly distorting the results of the study.[38] Adequate allocation
concealment should defeat patients and investigators from discovering treatment allocation once a
study is underway and after the study has concluded. Treatment related side-effects or adverse
events may be specific enough to reveal allocation to investigators or patients thereby introducing
bias or influencing any subjective parameters collected by investigators or requested from subjects.
Some standard methods of ensuring allocation concealment include sequentially numbered, opaque,
sealed envelopes (SNOSE); sequentially numbered containers; pharmacy controlled randomization;
and central randomization.[38] It is recommended that allocation concealment methods be included in
an RCT's protocol, and that the allocation concealment methods should be reported in detail in a
publication of an RCT's results; however, a 2005 study determined that most RCTs have unclear
allocation concealment in their protocols, in their publications, or both. [47] On the other hand, a 2008
study of 146 meta-analyses concluded that the results of RCTs with inadequate or unclear allocation
concealment tended to be biased toward beneficial effects only if the RCTs' outcomes
were subjective as opposed to objective.[48]
Sample size[edit]
Main article: Sample size determination
The number of treatment units (subjects or groups of subjects) assigned to control and treatment
groups, affects an RCT's reliability. If the effect of the treatment is small, the number of treatment
units in either group may be insufficient for rejecting the null hypothesis in the respective statistical
test. The failure to reject the null hypothesis would imply that the treatment shows no statistically
significant effect on the treated in a given test. But as the sample size increases, the same RCT may
be able to demonstrate a significant effect of the treatment, even if this effect is small. [49]
Blinding[edit]
An RCT may be blinded, (also called "masked") by "procedures that prevent study participants,
caregivers, or outcome assessors from knowing which intervention was received." [48] Unlike allocation
concealment, blinding is sometimes inappropriate or impossible to perform in an RCT; for example, if
an RCT involves a treatment in which active participation of the patient is necessary (e.g., physical
therapy), participants cannot be blinded to the intervention.
Traditionally, blinded RCTs have been classified as "single-blind," "double-blind," or "triple-blind";

however, in 2001 and 2006 two studies showed that these terms have different meanings for
different people.[50][51] The 2010 CONSORT Statement specifies that authors and editors should not
use the terms "single-blind," "double-blind," and "triple-blind"; instead, reports of blinded RCT should
discuss "If done, who was blinded after assignment to interventions (for example, participants, care
providers, those assessing outcomes) and how."[3]
RCTs without blinding are referred to as "unblinded",[52] "open",[53] or (if the intervention is a
medication) "open-label".[54] In 2008 a study concluded that the results of unblinded RCTs tended to
be biased toward beneficial effects only if the RCTs' outcomes were subjective as opposed to
objective;[48] for example, in an RCT of treatments for multiple sclerosis, unblinded neurologists (but
not the blinded neurologists) felt that the treatments were beneficial. [55] In pragmatic RCTs, although
the participants and providers are often unblinded, it is "still desirable and often possible to blind the
assessor or obtain an objective source of data for evaluation of outcomes." [35]
Analysis of data from RCTs[edit]
The types of statistical methods used in RCTs depend on the characteristics of the data and include:
For dichotomous (binary) outcome data, logistic regression (e.g., to predict sustained
virological response after receipt of peginterferon alfa-2a for hepatitis C[56]) and other methods
can be used.
For continuous outcome data, analysis of covariance (e.g., for changes in blood lipid levels
after receipt of atorvastatin after acute coronary syndrome[57]) tests the effects of predictor
variables.
For time-to-event outcome data that may be censored, survival analysis (e.g., KaplanMeier
estimators and Cox proportional hazards models for time to coronary heart disease after receipt
of hormone replacement therapy in menopause[58]) is appropriate.
Regardless of the statistical methods used, important considerations in the analysis of RCT data
include:
Whether an RCT should be stopped early due to interim results. For example, RCTs may be
stopped early if an intervention produces "larger than expected benefit or harm," or if
"investigators find evidence of no important difference between experimental and control
interventions."[3]
The extent to which the groups can be analyzed exactly as they existed upon randomization
(i.e., whether a so-called "intention-to-treat analysis" is used). A "pure" intention-to-treat analysis
is "possible only when complete outcome data are available" for all randomized subjects; [59] when
some outcome data are missing, options include analyzing only cases with known outcomes and
using imputed data.[3] Nevertheless, the more that analyses can include all participants in the
groups to which they were randomized, the less bias that an RCT will be subject to. [3]
Whether subgroup analysis should be performed. These are "often discouraged"

because multiple comparisons may produce false positive findings that cannot be confirmed by
other studies.[3]
Reporting of RCT results[edit]
The CONSORT 2010 Statement is "an evidence-based, minimum set of recommendations for
reporting RCTs."[60] The CONSORT 2010 checklist contains 25 items (many with sub-items) focusing
on "individually randomised, two group, parallel trials" which are the most common type of RCT.[1] For
other RCT study designs, "CONSORT extensions" have been published. [1]
Relative importance of RCTs and observational studies[edit]
Two studies published in The New England Journal of Medicine in 2000 found that observational
studies and RCTs overall produced similar results.[61][62] The authors of the 2000 findings questioned
the belief that "observational studies should not be used for defining evidence-based medical care"
and that RCTs' results are "evidence of the highest grade."[61][62] However, a 2001 study published
in Journal of the American Medical Association concluded that "discrepancies beyond chance do
occur and differences in estimated magnitude of treatment effect are very common" between
observational studies and RCTs.[63]
Two other lines of reasoning question RCTs' contribution to scientific knowledge beyond other types
of studies:
If study designs are ranked by their potential for new discoveries, then anecdotal
evidence would be at the top of the list, followed by observational studies, followed by RCTs. [64]
RCTs may be unnecessary for treatments that have dramatic and rapid effects relative to the
expected stable or progressively worse natural course of the condition treated. [65][66] One example
is combination chemotherapy including cisplatin for metastatic testicular cancer, which increased
the cure rate from 5% to 60% in a 1977 non-randomized study.[66][67]
Interpretation of statistical results[edit]
Like all statistical methods, RCTs are subject to both type I ("false positive") and type II ("false
negative") statistical errors. Regarding Type I errors, a typical RCT will use 0.05 (i.e., 1 in 20) as the
probability that the RCT will falsely find two equally effective treatments significantly different.
[68]
Regarding Type II errors, despite the publication of a 1978 paper noting that the sample sizes of
many "negative" RCTs were too small to make definitive conclusions about the negative results, [69] by
2005-2006 a sizeable proportion of RCTs still had inaccurate or incompletely reported sample size
calculations.[70]
Advantages[edit]
RCTs are considered to be the most reliable form of scientific evidence in the hierarchy of
evidence that influences healthcare policy and practice because RCTs reduce spurious causality and
bias. Results of RCTs may be combined in systematic reviews which are increasingly being used in
the conduct of evidence-based practice. Some examples of scientific organizations' considering
RCTs or systematic reviews of RCTs to be the highest-quality evidence available are:
As of 1998, the National Health and Medical Research Council of Australia designated "Level
I" evidence as that "obtained from a systematic review of all relevant randomised controlled
trials" and "Level II" evidence as that "obtained from at least one properly designed randomised
controlled trial."[71]
Since at least 2001, in making clinical practice guideline recommendations the United States
Preventive Services Task Force has considered both a study's design and itsinternal validity as
indicators of its quality.[72] It has recognized "evidence obtained from at least one properly
randomized controlled trial" with good internal validity (i.e., a rating of "I-good") as the highest
quality evidence available to it.[72]
The GRADE Working Group concluded in 2008 that "randomised trials without important
limitations constitute high quality evidence."[73]
For issues involving "Therapy/Prevention, Aetiology/Harm", the Oxford Centre for Evidence-
based Medicine as of 2011 defined "Level 1a" evidence as a systematic review of RCTs that are
consistent with each other, and "Level 1b" evidence as an "individual RCT (with
narrow Confidence Interval)."[74]
Notable RCTs with unexpected results that contributed to changes in clinical practice include:
After Food and Drug Administration approval, the antiarrhythmic

agents flecainide and encainide came to market in 1986 and 1987 respectively.[75] The non-
randomized studies concerning the drugs were characterized as "glowing", [76] and their sales
increased to a combined total of approximately 165,000 prescriptions per month in early 1989.
[75]
In that year, however, a preliminary report of an RCT concluded that the two drugs increased
mortality.[77] Sales of the drugs then decreased.[75]
Prior to 2002, based on observational studies, it was routine for physicians to prescribe
hormone replacement therapy for post-menopausal women to prevent myocardial infarction.[76] In
2002 and 2004, however, published RCTs from the Women's Health Initiative claimed that
women taking hormone replacement therapy with estrogen plus progestin had a higher rate of
myocardial infarctions than women on a placebo, and that estrogen-only hormone replacement
therapy caused no reduction in the incidence of coronary heart disease. [58][78] Possible
explanations for the discrepancy between the observational studies and the RCTs involved
differences in methodology, in the hormone regimens used, and in the populations studied. [79]
[80]
The use of hormone replacement therapy decreased after publication of the RCTs. [81]
Disadvantages[edit]
Many papers discuss the disadvantages of RCTs.[65][82] Among the most frequently cited drawbacks
are:
Limitations of external validity[edit]
The extent to which RCTs' results are applicable outside the RCTs varies; that is, RCTs' external
validity may be limited.[65][83] Factors that can affect RCTs' external validity include:[83]
Where the RCT was performed (e.g., what works in one country may not work in another)
Characteristics of the patients (e.g., an RCT may include patients whose prognosis is better
than average, or may exclude "women, children, the elderly, and those with common medical
conditions"[84])
Study procedures (e.g., in an RCT patients may receive intensive diagnostic procedures and
follow-up care difficult to achieve in the "real world")
Outcome measures (e.g., RCTs may use composite measures infrequently used in clinical
practice)
Incomplete reporting of adverse effects of interventions
However, all research suffers from limitations of external validity, whether observational or
experimental, quantitative, or qualitative, since it is limited necessarily by the context in which it
takes place.
Time and Costs[edit]
RCTs can be expensive;[82] one study found 28 Phase III RCTs funded by the National Institute of
Neurological Disorders and Stroke prior to 2000 with a total cost of US$335 million,[85] for
a mean cost of US$12 million per RCT. Nevertheless, the return on investment of RCTs may be high,
in that the same study projected that the 28 RCTs produced a "net benefit to society at 10-years" of
46 times the cost of the trials program, based on evaluating a quality-adjusted life year as equal to
the prevailing mean per capita gross domestic product.[85]
The conduct of an RCT takes several years until being published, thus data is restricted from the
medical community for long years and may be of less relevance at time of publication. [86]
It is costly to maintain RCTs for the years or decades that would be ideal for evaluating some
interventions.[65][82]
Interventions to prevent events that occur only infrequently (e.g., sudden infant death syndrome) and
uncommon adverse outcomes (e.g., a rare side effect of a drug) would require RCTs with extremely
large sample sizes and may therefore best be assessed by observational studies. [65]
Due to the costs of running RCTs, these usually only inspect one variable or very few variables,
rarely reflecting the full picture of a complicated medical situation; whereas thecase report, for
example, can detail many aspects of the patients medical situation (e.g. patient history, physical
examination, diagnosis, psychosocial aspects, follow up).[86]
Conflict of interest dangers[edit]
A 2011 study done to disclose possible conflicts of interests in underlying research studies used for
medical meta-analyses reviewed 29 meta-analyses and found that conflicts of interests in the
studies underlying the meta-analyses were rarely disclosed. The 29 meta-analyses included 11 from
general medicine journals; 15 from specialty medicine journals, and 3 from the Cochrane Database
of Systematic Reviews. The 29 meta-analyses reviewed an aggregate of 509 randomized controlled
trials (RCTs). Of these, 318 RCTs reported funding sources with 219 (69%) industry funded. 132 of
the 509 RCTs reported author conflict of interest disclosures, with 91 studies (69%) disclosing
industry financial ties with one or more authors. The information was, however, seldom reflected in
the meta-analyses. Only two (7%) reported RCT funding sources and none reported RCT author-
industry ties. The authors concluded without acknowledgment of COI due to industry funding or
author industry financial ties from RCTs included in meta-analyses, readers understanding and
appraisal of the evidence from the meta-analysis may be compromised. [87]
Some RCTs are fully or partly funded by the health care industry (e.g., the pharmaceutical industry)
as opposed to government, nonprofit, or other sources. A systematic review published in 2003 found
four 1986-2002 articles comparing industry-sponsored and nonindustry-sponsored RCTs, and in all
the articles there was a correlation of industry sponsorship and positive study outcome. [88] A 2004
study of 1999-2001 RCTs published in leading medical and surgical journals determined that
industry-funded RCTs "are more likely to be associated with statistically significant pro-industry
findings."[89] One possible reason for the pro-industry results in industry-funded published RCTs
is publication bias.[89] Other authors have cited the differing goals of academic and industry
sponsored research as contributing to the difference. Commercial sponsors may be more focused
on performing trials of drugs that have already shown promise in early stage trials, and on replicating
previous positive results to fulfill regulatory requirements for drug approval. [90]
Ethics[edit]
If a 'disruptive' innovation in medical (or other) technology is developed, it may be difficult to test this
ethically in an RCT if it becomes 'obvious' that the control subjects have poorer outcomes either
due to other foregoing testing, or within the initial phase of the RCT itself. Ethically it may be
necessary to abort the RCT prematurely, and getting ethics approval (and patient agreement) to
withhold the innovation from the control group in future RCT's may not be feasible.
An alternative to RCT are historical control trails (HCT) which exploit the data of previous RCTs to
reduce the sample size. However, these approaches are controversial in the scientific community
and must be handled with care.[91]
Randomized controlled trials in social science[edit]
Due to the recent emergence of RCTs in social science, the use of RCTs in social sciences is a
contested issue. Some writers from a medical or health background have argued that existing
research in a range of social science disciplines lacks rigour, and should be improved by greater use
of randomized control trials.
Transport science[edit]
Researchers in transport science argue that public spending on programmes such as school travel
plans could not be justified unless their efficacy is demonstrated by randomized controlled trials.
[92]
Graham-Rowe and colleagues[93] reviewed 77 evaluations of transport interventions found in the
literature, categorising them into 5 "quality levels". They concluded that most of the studies were of
low quality and advocated the use of randomized controlled trials wherever possible in future
transport research.
Melia[94] took issue with these conclusions, arguing that claims about the advantages of RCTs, in
establishing causality and avoiding bias, have been exaggerated. He proposed the following 8
criteria for the use of RCTs in contexts where interventions must change human behaviour to
be effective:
The intervention:
1. Has not been applied to all members of a unique group of people (e.g. the population of a
whole country, all employees of a unique organisation etc.)
2. Is applied in a context or setting similar to that which applies to the control group
3. Can be isolated from other activities and the purpose of the study is to assess this isolated
effect
4. Has a short timescale between its implementation and maturity of its effects
And the causal mechanisms:
1 Are either known to the researchers, or else all possible alternatives can be tested
2 Do not involve significant feedback mechanisms between the intervention group and
external environments
3 Have a stable and predictable relationship to exogenous factors
4 Would act in the same way if the control group and intervention group were reversed
International development[edit]
RCTs are currently being used by a number of international development experts to measure the
impact of development interventions worldwide. Development economists at research organizations
including Abdul Latif Jameel Poverty Action Lab (J-PAL)[95][96][97] and Innovations for Poverty
Action[98] have used RCTs to measure the effectiveness of poverty, health, and education programs in
the developing world. While RCTs can be useful in policy evaluation, it is necessary to exercise care
in interpreting the results in social science settings. For example, interventions can inadvertently
induce socioeconomic and behavioral changes that can confound the relationships (Bhargava,
2008).
For some development economists, the main benefit to using RCTs compared to other research
methods is that randomization guards against selection bias, a problem present in many current
studies of development policy. In one notable example of a cluster RCT in the field of development
economics, Olken (2007) randomized 608 villages in Indonesia in which roads were about to be built
into six groups (no audit vs. audit, and no invitations to accountability meetings vs. invitations to
accountability meetings vs. invitations to accountability meetings along with anonymous comment
forms).[99] After estimating "missing expenditures" (a measure of corruption), Olken concluded that
government audits were more effective than "increasing grassroots participation in monitoring" in
reducing corruption.[99] Overall, it is important in social sciences to account for the intended as well as
the unintended consequences of interventions for policy evaluations.
Criminology[edit]
A 2005 review found 83 randomized experiments in criminology published in 1982-2004, compared

with only 35 published in 1957-1981.[100] The authors classified the studies they found into five
categories: "policing", "prevention", "corrections", "court", and "community". [100] Focusing only on
offending behavior programs, Hollin (2008) argued that RCTs may be difficult to implement (e.g., if
an RCT required "passing sentences that would randomly assign offenders to programmes") and
therefore that experiments withquasi-experimental design are still necessary.[101]
Education[edit]
RCTs have been used in evaluating a number of educational interventions. For example, a 2009
study randomized 260 elementary school teachers' classrooms to receive or not receive a program
of behavioral screening, classroom intervention, and parent training, and then measured the
behavioral and academic performance of their students.[102]Another 2009 study randomized
classrooms for 678 first-grade children to receive a classroom-centered intervention, a parent-
centered intervention, or no intervention, and then followed their academic outcomes through age
19.[103]
See also[edit]
Drug development
Hypothesis testing
Impact evaluation
Jadad scale
Statistical inference
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Further reading[edit]
Berger, M. P. F.; Wong, W. K. (2009). An Introduction to Optimal Designs for Social and Biomedical
Research. John Wiley & Sons. p. 346. ISBN 978-0-470-69450-3.
Bhargava Alok (2008). "Randomized controlled experiments in health and social sciences: Some
conceptual issues".Economics and Human Biology 6: 293298.doi:10.1016/j.ehb.2008.01.001.
Domanski MJ, McKinlay S. Successful randomized trials: a handbook for the 21st century.
Philadelphia: Lippincott Williams & Wilkins, 2009. ISBN 978-0-7817-7945-6.
Jadad AR, Enkin M. Randomized controlled trials: questions, answers, and musings. 2nd ed. Malden,
Mass.: Blackwell, 2007. ISBN 978-1-4051-3266-4.
Matthews JNS. Introduction to randomized controlled clinical trials. 2nd ed. Boca Raton, Fla.: CRC
Press, 2006. ISBN 1-58488-624-2.
Nezu AM, Nezu CM. Evidence-based outcome research: a practical guide to conducting randomized
controlled trials for psychosocial interventions. Oxford: Oxford University Press, 2008. ISBN 978-0-19-
530463-3.
Solomon PL, Cavanaugh MM, Draine J. Randomized controlled trials: design and implementation for
community-based psychosocial interventions. New York: Oxford University Press, 2009. ISBN 978-0-19-
533319-0.
Torgerson DJ, Torgerson C. Designing randomised trials in health, education and the social sciences:
an introduction. Basingstoke, England, and New York: Palgrave Macmillan, 2008. ISBN 978-0-230-53735-
4.
External links[edit]
Bland M. Directory of randomisation software and services. University of York, 2008 March
19.
Evans I, Thornton H, Chalmers I. Testing treatments: better research for better health
care. London: Pinter & Martin, 2010. ISBN 978-1-905177-35-6.
Gelband H. The impact of randomized clinical trials on health policy and medical practice:
background paper. Washington, DC: U.S. Congress, Office of Technology Assessment, 1983.
(Report OTA-BP-H-22.)
REFLECT (Reporting guidElines For randomized controLled trials for livEstoCk and food
safeTy) Statement
Wathen JK, Cook JD. Power and bias in adaptively randomized clinical trials. M. D.
Anderson Cancer Center, University of Texas, 2006 July 12.

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Randomized Controlled Trial

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Randomized controlled trial

o 3.1By study design

o 3.2By outcome of interest (efficacy vs. effectiveness)

o 3.3By hypothesis (superiority vs. noninferiority vs. equivalence)

6Analysis of data from RCTs

7Reporting of RCT results

o 7.1Relative importance of RCTs and observational studies

o 7.2Interpretation of statistical results

o 9.1Limitations of external validity

o 9.2Time and Costs

o 9.3Conflict of interest dangers

Factorial each participant is randomly assigned to a group that receives a particular

By outcome of interest (efficacy vs. effectiveness)[edit]

By hypothesis (superiority vs. noninferiority vs. equivalence)[edit]

The advantages of proper randomization in RCTs include:[37]

An ideal randomization procedure would achieve the following goals:[40]

However, no single randomization procedure meets those goals in every circumstance, so

Permuted-block randomization or blocked randomization: a "block size" and "allocation

Covariate-adaptive randomization, of which one type is minimization: The probability of

Response-adaptive randomization, also known as outcome-adaptive randomization:

Traditionally, blinded RCTs have been classified as "single-blind," "double-blind," or "triple-blind";

Analysis of data from RCTs[edit]

Whether subgroup analysis should be performed. These are "often discouraged"

Reporting of RCT results[edit]

After Food and Drug Administration approval, the antiarrhythmic

Limitations of external validity[edit]

Incomplete reporting of adverse effects of interventions

Time and Costs[edit]

Conflict of interest dangers[edit]

Randomized controlled trials in social science[edit]

And the causal mechanisms:

3 Have a stable and predictable relationship to exogenous factors

A 2005 review found 83 randomized experiments in criminology published in 1982-2004, compared

14. Jump up^ According to Conniffe (1991, p. 87),

Mann, H. B. (1949). Analysis and design of experiments: Analysis of variance and

70. Jump up^ Charles P, Giraudeau B, Dechartres A, Baron G, Ravaud P (2009-05-

95. Jump up^ "Introduction to evaluations", J-PAL, Massachusetts Institute of Technology

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