Clinical design

Experimental design in clinical trials

• Statistical applications are of utmost importance for the design and
analysis of clinical trials.
• Principles and procedures of experimental design, particularly as
applied to clinical studies.
• Involvement of –
• FDA
• Public health
• Preventive measures
• Pharmaceutical industry
• Clinical studies must be carefully devised and documented to meet
the clinical objectives.
• Clinical studies designed to “prove” or demonstrate efficacy and/or
safety for FDA approval should be controlled studies.
• A controlled study is one in which an adequate control group is
present(placebo or active control), and in which measures are taken
to avoid bias.
General principles
1. Clearly state the objective(s).
2. Document the procedure used for randomization.
3. Include a suitable number of patients (subjects) according to statistical
principles.
4. Include concurrently studied comparison (control) groups.
5. Use appropriate blinding techniques to avoid patient and physician bias.
6. Use objective measurements when possible.
7. Define the response variable.
8. Describe and document the statistical methods used for data analysis.
Important factors to consider while
designing clinical studies
1. Absence of bias
2. Absence of systematic errors
3. Adequate precision
4. Choice of patient
5. Simplicity and symmetry
6. Randomization
7. Intent to treat
Observational studies
Observational studies
• Observational studies are an important category of study designs.
• To address some investigative questions in plastic surgery, randomized
controlled trials are not always indicated or ethical to conduct.
• Instead, observational studies may be the next best method to address these
types of questions.
• Well-designed observational studies have been shown to provide results similar
to randomized controlled trials, challenging the belief that observational
studies are second-rate.
• Cohort studies and case-control studies are two primary types of observational
studies that aid in evaluating associations between diseases and exposures.
Levels of Evidence Based Medicine
Level of Qualifying Studies
Evidence
I High-quality, multicenter or single-center, randomized controlled trial with adequate
power; or systematic review of these studies

II Lesser quality, randomized controlled trial; prospective cohort study; or systematic review
of these studies

III Retrospective comparative study; case-control study; or systematic review of these studies

IV Case-series
V Expert opinion; case report or clinical example; or evidence based on physiology, bench
research, or “first principles”
Definition
• Observational studies fall under the category of analytic study designs
and are further sub-classified as observational or experimental study
designs.
• The goal of analytic studies is to identify and evaluate causes or risk
factors of diseases or health-related events.
• The differentiating characteristic between observational and
experimental study designs is that in the latter, the presence or absence
of undergoing an intervention defines the groups.
• By contrast, in an observational study, the investigator does not
intervene and rather simply “observes” and assesses the strength of the
relationship between an exposure and disease variable.
• Three types of observational studies include cohort studies, case-
control studies, and cross-sectional studies.
• Case-control and cohort studies offer specific advantages by measuring
disease occurrence and its association with an exposure by offering a
temporal dimension (i.e. prospective or retrospective study design).
• Cross-sectional studies, also known as prevalence studies, examine the
data on disease and exposure at one particular time point. Because the
temporal relationship between disease occurrence and exposure
cannot be established, cross-sectional studies cannot assess the cause
and effect relationship.
Temporal Design of Observational
Studies
• Cross-sectional studies are known as prevalence studies and do not
have an inherent temporal dimension.
• These studies evaluate subjects at one point in time, the present
time.
• By contrast, cohort studies can be either retrospective or prospective.

• Retrospective studies “look back” in time contrasting with prospective

studies, which “look ahead” to examine causal associations.
• Case-control study designs are also retrospective and assess the
history of the subject for the presence or absence of an exposure.
Cohort Studies
Definition
• Cohort studies are important in research design.
• The term “cohort” is derived from the Latin word “Cohors” – “a group
of soldiers.”
• It is a type of non-experimental or observational study design. The term
“cohort” refers to a group of people who have been included in a study
by an event that is based on the definition decided by the researcher.
• For example, a cohort of people born in Mumbai in the year 1980.
• This will be called a “birth cohort.” Another example of the cohort will
be people who smoke. Some other terms which may be used for these
studies are “prospective studies” or “longitudinal studies.”
Etymology
• The term “cohort” is derived from the Latin word cohors.
• Roman legions were composed of ten cohorts. During battle each cohort, or
military unit, consisting of a specific number of warriors and commanding
centurions, were traceable.
• The word “cohort” has been adopted into epidemiology to define a set of
people followed over a period of time. W.H. Frost, an epidemiologist from the
early 1900s, was the first to use the word “cohort” in his 1935 publication
assessing age-specific mortality rates and tuberculosis.
• The modern epidemiological definition of the word now means a “group of
people with defined characteristics who are followed up to determine incidence
of, or mortality from, some specific disease, all causes of death, or some other
outcome.”
• Cohort design is a type of non-experimental or observational study design.
• It is a longitudinal study in research design involving repeated observations of the
same variables over a period of time.
• In a cohort study, the participants do not have the outcome of interest to begin with.
• They are selected based on the exposure status of the individual.
• They are then followed over time to evaluate for the occurrence of the outcome of
interest.
• Some examples of cohort studies are (1) Framingham Cohort study, (2) Swiss HIV
Cohort study, and (3) The Danish Cohort study of psoriasis and depression.
• These studies may be prospective, retrospective, or a combination of both of these
types.
Characteristics
• The participants do not have the outcome of interest to begin with.
• They are selected based on the exposure status of the individual.
Thus, some of the participants may have the exposure and others do
not have the exposure at the time of initiation of the study.
• They are then followed over time to evaluate for the occurrence of
the outcome of interest.
• At baseline, some of the study participants have exposure (defined as
exposed) and others do not have the exposure (defined as
unexposed).
• Over the period of follow-up, some of the exposed individuals will
develop the outcome and some unexposed individuals will develop
the outcome of interest.
• We will compare the outcomes in these two groups.
Framingham cohort study
• (https://www.framinghamheartstudy.org/index.php)
• This cohort study was initiated in 1948 in Framingham.
• Framingham, at the time of initiation of the cohort, was an industrial town 21 miles west of
Boston with a population of 28,000.
• This Framingham Heart Study recruited 5209 men and women (30–62-year-old) in the study
to assess the factors associated with cardiovascular disease (CVD).
• The researchers also recruited second generation participants (children of original
participants) in 1971 and the third general participants in 2002.
• This has been one of the landmark cohort studies and has contributed immensely to our
knowledge of some of the important risk factors for CVD.
• The investigators have published 3064 publications using the Framingham Heart Study data.
Swiss HIV cohort study
• (http://www.shcs.ch/)
• This cohort study was initiated in 1988.
• It was a longitudinal study of HIV-infected individuals to conduct research on HIV
pathogenesis, treatment, immunology, and coinfections.
• They also work on the social aspects of the disease and management of HIV-infected
pregnant women.
• The study started with a recruitment of individuals ≥16 years.
• The cohort was gradually expanded to include the Swiss Mother and Child HIV Cohort
Study.
• The cohort has provided useful information on various aspects of HIV and published
542 manuscripts on these aspects.
The Danish cohort study of psoriasis
and depression (Jensen, 2015)
• This is another large cohort study that evaluated the association between psoriasis and
onset of depression.
• The participants in the cohort were enrolled from national registries in Denmark.
• None of the included participants had psoriasis or depression at baseline.
• The outcome of interest was the initiation of antidepressants or hospitalization for
depression.
• The authors compared the incidence rates of hospitalization for depression in psoriasis
and reference population.
• The psoriasis group was further classified as mild and moderate psoriasis.
• The authors found that psoriasis was an independent risk factor for new-onset depression
in young people.
• However, in the elderly, it was mediated through comorbid conditions.
TYPES
• Prospective cohort study
• Retrospective cohort study
Prospective cohort study
• In this type of cohort study, all the data are collected prospectively.
• The investigator defines the population that will be included in the cohort.
• They then measure the potential exposure of interest.
• The participants are then classified as exposed or unexposed by the investigator.
• The investigator then follows these participants.
• At baseline and during follow-up, the investigator also collects information on
other variables that are important for the study (such as confounding variables).
• The investigator then assesses the outcome of interest in these individuals. Some
of these outcomes may only occur once (for example, death), and some may
occur multiple times (for example, conditions which may recur in the same
individual – diarrhea, wheezing episodes, etc.).
Retrospective cohort study
• In this type of cohort study, the data are collected from records.
• Thus, the outcomes have occurred in the past.
• Even though the outcomes have occurred in the past, the basic study
design is essentially the same.
• Thus, the investigator starts with the exposure and other variables at
baseline and at follow-up and then measures the outcome during the
follow-up period.
Mixed
• Sometimes, the direction may not be as well defined as prospective
and retrospective.
• One may analyze retrospective data on a group of people well as
collect prospective data from the same individuals.
Outcomes
• A cohort study may have different types of outcomes.
• Some of the outcomes may occur only once. In the above mentioned
retrospective study, if we assess the mortality in these individuals,
then the outcome will occur only once.
• Other outcomes in the cohort study may be measured more than
once.
• For instance, if we assess CD4 counts in the same retrospective study,
then the values of CD4 counts may change at every visit.
• Thus, the outcome will be measured at every visit.
Strengths of a Cohort Study
• Temporality: Since at the time of entry into the cohort study, the individuals do not
have outcome, the temporality between exposure and outcome is well defined.
• A cohort study helps us to study multiple outcomes in the same exposure. For
example, if we follow patients of hypercholesterolemia, we can study the incidence
of melasma or psoriasis in them. Thus, there is one exposure
(hypercholesterolemia) and multiple outcomes (melasma and psoriasis). However,
we have to ensure that none of the individuals have any of the outcomes at the
baseline
• If the exposure is rare, then a cohort design is an efficient method to study the
relation between exposure and outcomes.
Strengths of a Cohort Study-cont..
• It is generally said that a cohort design may not be efficient for rare
outcomes (a case-control design is preferred). However, if the rare
outcome is common in some exposures, then it may be useful to follow
a cohort design.
• For example, melanoma is not a common condition in India. Hence, if
we follow individuals to study the incidence of melanoma, then it may
not be efficient. However, if we know that, theoretically, a particular
chemical may be associated with melanoma, then we should follow a
cohort of individuals exposed to this chemical (in occupational settings
or otherwise) and study the incidence of melanoma in this group
Strengths of a Cohort Study-cont..
• In a prospective cohort study, the exposure variable, other variables,
and outcomes may be measured more accurately.
• This is important to maintain uniformity in the measurement of
exposures and outcomes.
• This is also useful for exposures that may require subjective
assessment or recall by the patient. For example, dietary history,
smoking history, or alcoholic history, etc.
• This may help in reducing the bias in measurement of exposure.
Strengths of a Cohort Study-cont..
• A retrospective cohort study can be completed fast and is relatively
inexpensive compared with a prospective cohort study. However, it
also has other strengths of the prospective cohort study.
Limitations of a Cohort Study
• One major limitation of a prospective cohort design is that is time consuming
and costly. For example, if we have to study the incidence of cardiovascular
patients in patients of psoriasis, we may have to follow them up for many
years before the outcome occurs
• In a retrospective cohort study, the exposure and the outcome variables are
collected before the study has been initiated. Thus, the measurements may
not be very accurate or according to our requirements. In addition, the
some of the exposures may have been assessed differently for various
members of the cohort.
• Cohort studies may not be very efficient for rare outcomes except in some
conditions.
Advantages and Disadvantages of the
Cohort Study
Advantages
Gather data regarding sequence of events; can assess causality
Examine multiple outcomes for a given exposure
Good for investigating rare exposures
Can calculate rates of disease in exposed and unexposed individuals over time (e.g. incidence, relative risk)

Disadvantages
Large numbers of subjects are required to study rare exposures
Susceptible to selection bias
Prospective Cohort Study
May be expensive to conduct
May require long durations for follow-up
Maintaining follow-up may be difficult
Susceptible to loss to follow-up or withdrawals
Retrospective Cohort Study
Susceptible to recall bias or information bias
Less control over variables
Attrition Bias (Loss to follow-up)
• Because prospective cohort studies may require long follow-up periods, it is important to
minimize loss to follow-up.
• Loss to follow-up is a situation in which the investigator loses contact with the subject,
resulting in missing data.
• If too many subjects are loss to follow-up, the internal validity of the study is reduced.
• A general rule of thumb requires that the loss to follow-up rate not exceed 20% of the
sample.
• Any systematic differences related to the outcome or exposure of risk factors between
those who drop out and those who stay in the study must be examined, if possible, by
comparing individuals who remain in the study and those who were loss to follow-up or
dropped out.
• It is therefore important to select subjects who can be followed for the entire duration of
the cohort study. Methods to minimize loss to follow-up are listed in.
Methods to Minimize Loss to Follow-Up
During enrollment

Exclude subjects likely to be lost

Planning to move
Non-committal
Obtain information to allow future tracking
Collect subject's contact information (e.g. mailing addresses, telephone numbers, and email
addresses)
Collect social security and/or Medicare numbers

During follow-up

Maintain periodic contact

By telephone: may require calls during the weekends and/or evenings
By mail: repeated mailings by e-mail or with stamped, self-addressed return envelopes
Other: newsletters or token gifts with study logo
Practical aspects
• Project management
• The investigator should remember that conducting a large-scale prospective cohort
study requires proper project management.
• Follow-up of participants
• The investigator should devise strategies to ensure proper follow-up of individuals at
the designated time intervals. A computer program should be put in place at the start
of the prospective study. The program should indicate the number of participants due
for a visit every day. If the individual does not visit for the next week, a reminder should
be sent to the individual. This can be performed through texting or a phone call to the
individual. Some investigators hire field workers or outreach workers to ensure follow-
up of study participants.
• It is important that we include only patients with permanent addresses in the area for
long-term cohort studies. Details about the stay (permanent address, temporary
address, and duration of residence in the current address) should be a part of the
inclusion criteria.
Practical aspects
• Data management
• The investigator should prioritize data management in these studies. The data entry
program should be installed at the start of the project. In addition, data entry and
cleaning should be done as soon as data are collected. This will help us to identify the
lacunae in the existing data, loss of follow-ups, and missing data points.
• Missing data
• It is very important to address missing data in cohort studies.
• There are statistical methods to handle missing data in studies – such as complete
case analysis, available case analysis, single imputation, or multiple imputations.
• The investigator should work with a statistician to address missing data in the
dataset. These methods should also be described in the statistical analysis section of
the manuscript.
• Losses during follow-up are an important source of bias in cohort
studies; thus, measures to ensure follow-up of participants should be
included in the design of a prospective cohort study.
Future prospects
• Advanced modeling techniques are useful to analyze longitudinal data
and are preferred in cohort studies.
Case control
Background
• Case-control studies were historically borne out of interest in disease
etiology.
• The conceptual basis of the case-control study is similar to taking a
history and physical; the diseased patient is questioned and
examined, and elements from this history taking are knitted together
to reveal characteristics or factors that predisposed the patient to the
disease.
• In fact, the practice of interviewing patients about behaviors and
conditions preceding illness dates back to the Hippocratic writings of
the 4th century B.C.
Background
• An important distinction lies between cohort studies and case-series.
• The distinguishing feature between these two types of studies is the presence of a control,
or unexposed, group.
• Contrasting with epidemiological cohort studies, case-series are descriptive studies
following one small group of subjects. In essence, they are extensions of case reports.
• Usually the cases are obtained from the authors' experiences, generally involve a small
number of patients, and more importantly, lack a control group.
• There is often confusion in designating studies as “cohort studies” when only one group of
subjects is examined. Yet, unless a second comparative group serving as a control is
present, these studies are defined as case-series.
• The next step in strengthening an observation from a case-series is selecting appropriate
control groups to conduct a cohort or case-control study, the latter which is discussed in
the following section about case-control studies.
Case control
• Reasons of practicality and feasibility inherent in the study design
typically dictate whether a cohort study or case-control study is
appropriate.
• This study design was first recognized in Janet Lane-Claypon's study of
breast cancer in 1926, revealing the finding that low fertility rate raises
the risk of breast cancer.
• In the ensuing decades, case-control study methodology crystallized with
the landmark publication linking smoking and lung cancer in the 1950s.
• Since that time, retrospective case-control studies have become more
prominent in the biomedical literature with more rigorous
methodological advances in design, execution, and analysis.
Study design
• Case-control studies identify subjects by outcome status at the outset of the
investigation.
• Outcomes of interest may be whether the subject has undergone a specific type
of surgery, experienced a complication, or is diagnosed with a disease.
• Once outcome status is identified and subjects are categorized as cases, controls
(subjects without the outcome but from the same source population) are
selected.
• Data about exposure to a risk factor or several risk factors are then collected
retrospectively, typically by interview, abstraction from records, or survey.
• Case-control studies are well suited to investigate rare outcomes or outcomes
with a long latency period because subjects are selected from the outset by their
outcome status.
• Thus in comparison to cohort studies, case-control studies are quick, relatively
inexpensive to implement, require comparatively fewer subjects, and allow for
multiple exposures or risk factors to be assessed for one outcome.
Case control
Advantages and Disadvantages of the Case-
Control Study
Advantages

Good for examining rare outcomes or outcomes with long latency

Relatively quick to conduct
Relatively inexpensive
Requires comparatively few subjects
Existing records can be used
Multiple exposures or risk factors can be examined

Disadvantages

Susceptible to recall bias or information bias

Difficult to validate information
Control of extraneous variables may be incomplete
Selection of an appropriate comparison group may be difficult
Rates of disease in exposed and unexposed individuals cannot be determined
Methodological Issues -Selection of
Cases
• Sampling in a case-control study design begins with selecting the cases.
• In a case-control study, it is imperative that the investigator has explicitly defined inclusion
and exclusion criteria prior to the selection of cases.
• For example, if the outcome is having a disease, specific diagnostic criteria, disease
subtype, stage of disease, or degree of severity should be defined. Such criteria ensure
that all the cases are homogenous.
• Second, cases may be selected from a variety of sources, including hospital patients, clinic
patients, or community subjects.
• Many communities maintain registries of patients with certain diseases and can serve as a
valuable source of cases. However, despite the methodologic convenience of this method,
validity issues may arise. For example, if cases are selected from one hospital, identified
risk factors may be unique to that single hospital. This methodological choice may weaken
the generalizability of the study findings.
• Another example is choosing cases from the hospital versus the
community; most likely cases from the hospital sample will represent
a more severe form of the disease than those in the community.
• Finally, it is also important to select cases that are representative of
cases in the target population to strengthen the study's external
validity.
• Potential reasons why cases from the original target population
eventually filter through and are available as cases (study
participants) for a case-control study are illustrated in the next figure.
Methodological Issues - Selection of
Controls
• Selecting the appropriate group of controls can be one of the most
demanding aspects of a case-control study.
• An important principle is that the distribution of exposure should be
the same among cases and controls; in other words, both cases and
controls should stem from the same source population.
• The investigator may also consider the control group to be an at-risk
population, with the potential to develop the outcome.
• Because the validity of the study depends upon the comparability of
these two groups, cases and controls should otherwise meet the
same inclusion criteria in the study.
Methodological Issues - Matching
• Matching is a method used in an attempt to ensure comparability between
cases and controls and reduces variability and systematic differences due to
background variables that are not of interest to the investigator.
• Each case is typically individually paired with a control subject with respect to
the background variables.
• The exposure to the risk factor of interest is then compared between the
cases and the controls. This matching strategy is called individual matching.
• Age, sex, and race are often used to match cases and controls because they
are typically strong confounders of disease.
• Confounders are variables associated with the risk factor and may potentially
be a cause of the outcome.
Advantages and Disadvantages for Using a
Matching Strategy
Advantages Disadvantages
Eliminate influence of measurable confounders (e.g. May be time-consuming and expensive
age, sex)
Eliminate influence of confounders that are difficult to Decision to match and confounding variables to match
measure upon are decided at the outset of the study
May be a sampling convenience, making it easier to Matched variables cannot be examined in the study
select the controls in a case-control study
May improve study efficiency (i.e. smaller sample size) Requires a matched analysis
Vulnerable to overmatching: when matching variable
has some relationship with the outcome
Methodological Issues - Multiple
Controls
• Investigations examining rare outcomes may have a limited number of
cases to select from, whereas the source population from which
controls can be selected is much larger.
• In such scenarios, the study may be able to provide more information
if multiple controls per case are selected.
• This method increases the “statistical power” of the investigation by
increasing the sample size.
• The precision of the findings may improve by having up to about
three or four controls per case.
Bias in Case-Control Studies
• Information about exposure is typically collected by self-report, interview, or from
recorded information, it is susceptible to recall bias, interviewer bias, or will rely on
the completeness or accuracy of recorded information, respectively.
• These biases decrease the internal validity of the investigation and should be carefully
addressed and reduced in the study design.
• Recall bias occurs when a differential response between cases and controls occurs.
• The common scenario is when a subject with disease (case) will unconsciously recall
and report an exposure with better clarity due to the disease experience.
• Interviewer bias occurs when the interviewer asks leading questions or has an
inconsistent interview approach between cases and controls.
• A good study design will implement a standardized interview in a non-judgemental
atmosphere with well-trained interviewers to reduce interviewer bias.
The STROBE Statement: The Strengthening the
Reporting of Observational Studies in Epidemiology
Statement

• In 2004, the first meeting of the Strengthening the Reporting of Observational Studies
in Epidemiology (STROBE) group took place in Bristol, UK.
• The aim of the group was to establish guidelines on reporting observational research
to improve the transparency of the methods, thereby facilitating the critical appraisal
of a study's findings.
• A well-designed but poorly reported study is disadvantaged in contributing to the
literature because the results and generalizability of the findings may be difficult to
assess.
• Thus a 22-item checklist was generated to enhance the reporting of observational
studies across disciplines.
• This checklist is also located at the following website: www.strobe-statement.org. This
statement is applicable to cohort studies, case-control studies, and cross-sectional
studies.
The STROBE Statement: The Strengthening the
Reporting of Observational Studies in Epidemiology
Statement

• In fact, 18 of the checklist items are common to all three types of

observational studies, and 4 items are specific to each of the 3
specific study designs.
• In an effort to provide specific guidance to go along with this
checklist, an “explanation and elaboration” article was published for
users to better appreciate each item on the checklist.
• Due to the limitations in carrying out RCTs in surgical investigations,
observational studies are becoming more popular to investigate the
relationship between exposures, such as risk factors or surgical
interventions, and outcomes, such as disease states or complications.
Recognizing that well-designed observational studies can provide valid
results is important among the plastic surgery community, so that
investigators can both critically appraise and appropriately design
observational studies to address important clinical research questions.
The investigator planning an observational study can certainly use the
STROBE statement as a tool to outline key features of a study as well as
coming back to it again at the end to enhance transparency in
methodology reporting.