Determination of power and sample size in the design of clinical trials with failure-time endpoints and interim analyses

Design of a randomized trial to evaluate the influence of mobile phone reminders on adherence to first line antiretroviral treatment in South India--the HIVIND study protocol

BACKGROUND

Poor adherence to antiretroviral treatment has been a public health challenge associated with the treatment of HIV. Although different adherence-supporting interventions have been reported, their long term feasibility in low income settings remains uncertain. Thus, there is a need to explore sustainable contextual adherence aids in such settings, and to test these using rigorous scientific designs. The current ubiquity of mobile phones in many resource-constrained settings, make it a contextually appropriate and relatively low cost means of supporting adherence. In India, mobile phones have wide usage and acceptability and are potentially feasible tools for enhancing adherence to medications. This paper presents the study protocol for a trial, to evaluate the influence of mobile phone reminders on adherence to first-line antiretroviral treatment in South India.

METHODS/DESIGN

600 treatment naïve patients eligible for first-line treatment as per the national antiretroviral treatment guidelines will be recruited into the trial at two clinics in South India. Patients will be randomized into control and intervention arms. The control arm will receive the standard of care; the intervention arm will receive the standard of care plus mobile phone reminders. Each reminder will take the form of an automated call and a picture message. Reminders will be delivered once a week, at a time chosen by the patient. Patients will be followed up for 24 months or till the primary outcome i.e. virological failure, is reached, whichever is earlier. Self-reported adherence is a secondary outcome. Analysis is by intention-to-treat. A cost-effectiveness study of the intervention will also be carried out.

DISCUSSION

Stepping up telecommunications technology in resource-limited healthcare settings is a priority of the World Health Organization. The trial will evaluate if the use of mobile phone reminders can influence adherence to first-line antiretrovirals in an Indian context.

Estimating sample size in critical care clinical trials

Estimating the required sample size for a study is necessary during the design phase to ensure that it will have maximal efficiency to answer the primary question of interest. Clinicians require a basic understanding of the principles underlying sample size calculation to interpret and apply research findings. This article reviews the critical components of sample size calculation, including the selection of a primary outcome, specification of the acceptable types I and II error rates, identification of the minimal clinically important difference, and estimation of the error associated with measuring the primary outcome. The relationship among confidence intervals, precision, and study power is also discussed.

Designing complex group sequential survival trials

This paper presents methodology for designing complex group sequential survival trials when the survival curves will be compared using the logrank statistic. The method can be applied to any treatment and control survival curves as long as each hazard function can be approximated by a piecewise linear function. The approach allows arbitrary accrual patterns and permits adjustment for varying rates of non-compliance, drop-in and loss to follow-up. The calendar-time-information-time transformation is derived under these complex assumptions. This permits the exploration of the operating characteristics of various interim analysis plans, including sample size and power. By using the calendar-time-information-time transformation, information fractions corresponding to desired calendar times can be determined. In this way, the interim analyses can be scheduled in information time, assuring the desired power and realization of the spending function, while the interim analyses will take place according to the desired calendar schedule.