Accounting for uncertainty in the expected treatment effect substantially increases the sample size required for randomised trials: implications for the feasibility of clinical trials in anaesthesia and critical care

Background Multicentre trials in anaesthesia and critical care report low rates of statistically significant differences. This finding may partly reflect conventional sample size methods, which assume a fixed treatment effect. Assurance methods use a design prior to represent uncertainty in the expected treatment effect, which may provide a more realistic way of estimating sample sizes. Methods We calculated power curves across a range of effect sizes, design priors, and sample sizes using frequentist and Bayesian assurance methods and compared the sample sizes required to achieve 80% and 90% power to the conventional method. We standardised the design priors across effect sizes using the coefficient of variation. We derived a theoretical limit for achievable power. We validated a normal approximation to the Bayesian posterior distribution. Results Frequentist and Bayesian assurance methods produced similar power curves across all scenarios. At a coefficient of variation of 0.5 - reflecting realistic prior uncertainty in the expected effect size - both methods required sample sizes that were approximately 1.5 to 3.5 times larger than the conventional method. The theoretical power limit depends only on the coefficient of variation of the design prior and holds true across all effect sizes. The normal approximation to the Bayesian posterior distribution matched the results obtained from Markov chain Monte Carlo sampling. Conclusions Incorporating clinical uncertainty in the expected effect size substantially increases the sample size required to achieve adequate power, which has important implications for the feasibility of randomised trials in anaesthesia and critical care.