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Evidence for risk of bias in cluster randomised trials: review of recent trials published in three general medical journals

BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7418.785 (Published 02 October 2003) Cite this as: BMJ 2003;327:785
  1. Suezann Puffer, research assistant1,
  2. David Torgerson (djt6{at}york.ac.uk), director1,
  3. Judith Watson, research fellow1
  1. 1 York Trials Unit, Department of Health Sciences, York University, York YO10 5DD
  1. Correspondence to: D J Torgerson
  • Accepted 10 July 2003

Abstract

Objective To examine the prevalence of a risk of bias associated with the design and conduct of cluster randomised controlled trials among a sample of recently published studies.

Design Retrospective review of cluster randomised trials published in the BMJ, Lancet, and New England Journal of Medicine from January 1997 to October 2002.

Main outcome measures Prevalence of secure randomisation of clusters, identification of participants before randomisation (to avoid foreknowledge of allocation), differential recruitment between treatment arms, differential application of inclusion and exclusion criteria, and differential attrition.

Results Of the 36 trials identified, 24 were published in the BMJ,11 in the Lancet, and a single trial in the New England Journal of Medicine. At the cluster level, 15 (42%) trials provided evidence for secure allocation and 25 (69%) used stratified allocation. Few trials showed evidence of imbalance at the cluster level. However, some evidence of susceptibility to risk of bias at the individual level existed in 14 (39%) studies.

Conclusions Some recently published cluster randomised trials may not have taken adequate precautions to guard against threats to the internal validity of their design.

Footnotes

  • Embedded Image Additional references appear on bmj.com

  • We thank Doug Altman, Diana Elbourne, Craig Ramsay, and Trevor Sheldon for their helpful comments on an earlier version of this manuscript.

  • Contributors DJT suggested the idea of the review and wrote the first draft. SP and JW did the searches and extracted data from the included papers; they also helped to write and comment on the draft manuscript. DJT is the guarantor.

  • Funding JW is trial coordinator of the SAPPHIRE trial funded by the Medical Research Council; SP and DJT are funded by the University of York.

  • Competing interests None declared.

  • Ethical approval Not needed.

  • Accepted 10 July 2003
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