Accounting for Noncompliance in the Design of Clinical Trials

Patient noncompliance with study regimens may greatly impact the interpretation of results from randomized clinical trials. Although much has been written about issues related to noncompliance, there has been little done to provide an overall framework for designing efficacy trials in a way that accommodates possible noncompliance. This paper is intended to help fill this gap. First, decisions directly related to the randomized treatment comparison, such as sample size and the number of study arms, are discussed. Next, the secondary or observational component of the design involving compliance monitoring is examined. Alternative methods for monitoring compliance, with their relative advantages and disadvantages, are reviewed. Subsampling of patients to be monitored, and the construction of a compliance score, are also addressed. Much work remains in developing and understanding methods of analysis that incorporate compliance data; nevertheless, compliance information may be crucial for optimizing the use of drugs in clinical practice and in developing more effective therapeutic regimens.