
Across research disciplines, cluster randomized trials (CRTs) are commonly implemented to evaluate interventions delivered to groups of participants, such as communities and clinics. Despite advances in the design and analysis of CRTs, several challenges remain. First, there are many possible ways to specify the causal effect of interest (eg, at the individual‐level or at the cluster‐level). Second, the theoretical and practical performance of common methods for CRT analysis remain poorly understood. Here, we present a general framework to formally define an array of causal effects in terms of summary measures of counterfactual outcomes. Next, we provide a comprehensive overview of CRT estimators, including thet‐test, generalized estimating equations (GEE), augmented‐GEE, and targeted maximum likelihood estimation (TMLE). Using finite sample simulations, we illustrate the practical performance of these estimators for different causal effects and when, as commonly occurs, there are limited numbers of clusters of different sizes. Finally, our application to data from the Preterm Birth Initiative (PTBi) study demonstrates the real‐world impact of varying cluster sizes and targeting effects at the cluster‐level or at the individual‐level. Specifically, the relative effect of the PTBi intervention was 0.81 at the cluster‐level, corresponding to a 19% reduction in outcome incidence, and was 0.66 at the individual‐level, corresponding to a 34% reduction in outcome risk. Given its flexibility to estimate a variety of user‐specified effects and ability to adaptively adjust for covariates for precision gains while maintaining Type‐I error control, we conclude TMLE is a promising tool for CRT analysis.
FOS: Computer and information sciences, Epidemiology, Social Sciences, Cluster (spacecraft), Sample size determination, Estimator, Social psychology, Mathematical Sciences, Applications of statistics to biology and medical sciences; meta analysis, data-adaptive adjustment, Estimating equations, Methods for Handling Missing Data in Statistical Analysis, Psychological intervention, Observational study, Cluster Analysis, Psychology, clustered data, Gee, Randomized Controlled Trials as Topic, Psychiatry, Statistics, Mixed-Effects Models, Covariate, Programming language, Causality, FOS: Psychology, Economics, Econometrics and Finance, stat.ME, Counterfactual thinking, Physical Sciences, Cluster randomised controlled trial, Public Health and Health Services, Premature Birth, Medicine, Female, Economics of Health Care Systems and Policies, Health and social care services research, Statistics and Probability, Economics and Econometrics, 330, Methods for Causal Inference in Observational Studies, Statistics & Probability, Flexibility (engineering), 610, Article, Methodology (stat.ME), FOS: Economics and business, Health Sciences, FOS: Mathematics, Humans, Computer Simulation, Econometrics, Hierarchical data, Statistics - Methodology, Infant, Newborn, Infant, Newborn, cluster randomized trials, Computer science, Type I and type II errors, 8.4 Research design and methodologies (health services), Good Health and Well Being, group randomized trials, Sample Size, hierarchical data, Generic health relevance, Generalized estimating equation, targeted maximum likelihood estimation, Mathematics, Causal inference
FOS: Computer and information sciences, Epidemiology, Social Sciences, Cluster (spacecraft), Sample size determination, Estimator, Social psychology, Mathematical Sciences, Applications of statistics to biology and medical sciences; meta analysis, data-adaptive adjustment, Estimating equations, Methods for Handling Missing Data in Statistical Analysis, Psychological intervention, Observational study, Cluster Analysis, Psychology, clustered data, Gee, Randomized Controlled Trials as Topic, Psychiatry, Statistics, Mixed-Effects Models, Covariate, Programming language, Causality, FOS: Psychology, Economics, Econometrics and Finance, stat.ME, Counterfactual thinking, Physical Sciences, Cluster randomised controlled trial, Public Health and Health Services, Premature Birth, Medicine, Female, Economics of Health Care Systems and Policies, Health and social care services research, Statistics and Probability, Economics and Econometrics, 330, Methods for Causal Inference in Observational Studies, Statistics & Probability, Flexibility (engineering), 610, Article, Methodology (stat.ME), FOS: Economics and business, Health Sciences, FOS: Mathematics, Humans, Computer Simulation, Econometrics, Hierarchical data, Statistics - Methodology, Infant, Newborn, Infant, Newborn, cluster randomized trials, Computer science, Type I and type II errors, 8.4 Research design and methodologies (health services), Good Health and Well Being, group randomized trials, Sample Size, hierarchical data, Generic health relevance, Generalized estimating equation, targeted maximum likelihood estimation, Mathematics, Causal inference
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