1. Sample Size and Power Steven R. Cummings, MD Director, S.F. Coordinating Center

2. The Secret of Long Life Resveratrol Resveratrol In the skin of red grapes In the skin of red grapes Makes mice Makes mice  Run faster  Live longer

3. What I want to show Consuming reservatrol prolongs healthy life Consuming reservatrol prolongs healthy life

4. Sample Size Ingredients Testable hypothesis Testable hypothesis Type of study Type of study Statistical test Statistical test  Type of variables Effect size (and its variance) Effect size (and its variance) Power and alpha Power and alpha

5. Sample Size Ingredients Testable hypothesis Testable hypothesis Type of study Type of study Statistical test Statistical test  Type of variables Effect size (and its variance) Effect size (and its variance) Power and alpha Power and alpha

6. My research question I need to plan the study I need to plan the study My question is My question is Does consuming reservatrol lead to a long and healthy life?

7. What’s wrong with the question? I need to plan the study I need to plan the study My question is My question is Does consuming reservatrol lead to a long and healthy life?

8. What’s wrong with the question? Does consuming resveratrol lead to a long and healthy life? Vague Vague Must be measurable Must be measurable

9. “Consuming resveratrol” Most rigorous design: randomized placebo- controlled trial Most rigorous design: randomized placebo- controlled trial Comparing red wine to placebo would be difficult Comparing red wine to placebo would be difficult But resveratrol supplements are widely available But resveratrol supplements are widely available

10. Measurable (specific) outcome “Consuming resevertrol” = taking resveratrol supplements vs. taking placebo “Consuming resevertrol” = taking resveratrol supplements vs. taking placebo “Prolong healthy life” = “Prolong healthy life” =

11. Measurable (specific) outcome “Consuming resevertrol” = taking resveratrol supplements vs. taking placebo “Consuming resevertrol” = taking resveratrol supplements vs. taking placebo “Prolong healthy life” = reduces all-cause mortality “Prolong healthy life” = reduces all-cause mortality Do people randomized to get a resveratrol supplement have a lower mortality rate than those who get a placebo?

12. In whom? Elderly men and women (≥70 years) Elderly men and women (≥70 years)

13. The research hypothesis Men and women > age 70 years randomized to get a resveratrol supplement have a lower mortality rate than those who get a placebo.

14. The research hypothesis The ‘alternative’ hypothesis Men and women > age 70 years randomized to get a resveratrol supplement have a lower mortality rate than those who get a placebo. Cannot be tested statistically Cannot be tested statistically Statistical tests only reject null hypothesis - that there is no effect Statistical tests only reject null hypothesis - that there is no effect

15. The Null Hypothesis Men and women > age 70 years randomized to receive a resveratrol supplement do not have lower mortality rate than those who receive placebo. Can be rejected by statistical tests Can be rejected by statistical tests

16. Ingredients for Sample Size  Testable hypothesis Type of study Type of study Statistical test Statistical test  Type of variables Effect size (and its variance) Effect size (and its variance) Power and alpha Power and alpha

17. Type of study Descriptive Descriptive  Only one variable / measurements What proportion of centenarians take resveratrol supplements? What proportion of centenarians take resveratrol supplements?  Confidence interval for proportions What is the mean red wine intake of centenarians? What is the mean red wine intake of centenarians?  Confidence interval for the mean

18. Sample size for a descriptive study For example: “What proportion of centenarians (>100 years old) take resveratrol supplements?” “What proportion of centenarians (>100 years old) take resveratrol supplements?” How much precision do you want? How much precision do you want?  Sample size is based on the width of the confidence interval (Table 6D and 6E) I assume that 20% of centenarians take resveratrol I assume that 20% of centenarians take resveratrol  Conventional 95% C.I.  I want to be confident that the truth is within ±10%  Total width of the C.I. = 0.20

20. Analytical studies Analytical means a comparison Analytical means a comparison  Cross-sectional  Mean red wine intake in centenarians vs. 60-80 year olds  Randomized trial  Elders who get resveratrol have lower mortality than those who get placebo

21. Ingredients for Sample Size  Testable hypothesis  Type of study: analytical (RCT) Statistical test Statistical test  Type of variables Effect size (and its variance) Effect size (and its variance) Power and alpha Power and alpha

22. Type of statistical tests Depends on the types of variables This works for most study planning

23. The types of variables? Men and women > age 70 years randomized to receive a resveratrol supplement do not have lower mortality rate than those who receive placebo Dichotomous: resveratrol or placebo Dichotomous: resveratrol or placebo Continuous: mortality rate Continuous: mortality rate What’s wrong?

24. The types of variables? Men and women > age 70 years randomized to receive a resveratrol supplement do not have lower mortality rate than those who receive placebo Dichotomous: reseveratrol or placebo Dichotomous: reseveratrol or placebo Continuous: mortality rate Continuous: mortality rate  It is a proportion at certain times  For example, 3% at 1 year

25. The appropriate test for this randomized trial for mortality

26. Ingredients for Sample Size  Testable hypothesis  Type of study: analytical (RCT)  Statistical test  Type of variables Effect size (and its variance) Effect size (and its variance) Power and alpha Power and alpha

27. Estimating the effect size For randomized trials, Start with the expected rate in the placebo Start with the expected rate in the placebo Usually available from population or cohort studies Usually available from population or cohort studies In this case, we know the mortality rates by age: In this case, we know the mortality rates by age: 3-4% per year*; for a 3 year study: 10% 3-4% per year*; for a 3 year study: 10% * ~ mean annual female/males @ 78 yrs

28. Effect size the hardest part What should I assume for the effect of resveratrol on mortality?

29. Effect size the hardest part Ways to choose an effect size: What is likely, based on other data? What is likely, based on other data? Do a pilot study Do a pilot study Estimate based on effect on biomarkers Estimate based on effect on biomarkers What difference is important to detect? What difference is important to detect?  “We don’t want to miss a __%_ difference” What can we afford? What can we afford?

30. The effect of resveratrol on mortality rate? What is likely, based on other data? What is likely, based on other data? Do a pilot study Do a pilot study Estimate based on effect on biomarkers Estimate based on effect on biomarkers What difference is important to detect? What difference is important to detect?  “We don’t want to miss a __%_ difference” What can we afford? What can we afford?

31. Resveratrol pronged survival of mice fed high calorie diet Baur, Nature 2006 ~ 25%

32. The effect of resveratrol on mortality rate? What is likely, based on other data? What is likely, based on other data? Pilot study? What endpoint? Pilot study? What endpoint? No reliable markers for the effect on death No reliable markers for the effect on death What difference is important to detect? What difference is important to detect?  “We don’t want to miss a ____ difference” What can we afford to find? What can we afford to find?

33. The effect of resveratrol on mortality rate? What is likely, based on other data? What is likely, based on other data? Do a pilot study Do a pilot study Estimate based on biomarkers Estimate based on biomarkers What difference is important to detect? What difference is important to detect?  “We don’t want to miss a _1%_ difference” What can we afford? What can we afford?  1%: too big & expensive  5%: small and cheap

34. The effect of resveratrol on mortality rate? Finding a smaller effect is important to health Finding a smaller effect is important to health Allowing a larger effect is important for your budget Allowing a larger effect is important for your budget

35. Effect size Men and women > age 70 years randomized to receive a resveratrol supplement do not have lower mortality rate than those who receive placebo It would be important to find (I don’t want to miss) a 20% decrease It would be important to find (I don’t want to miss) a 20% decrease Placebo rate: 10% Placebo rate: 10% Resveratrol rate: 8% Resveratrol rate: 8%

36. Ingredients for Sample Size  Testable hypothesis  Type of study: analytical (RCT)  Statistical test  Type of variables  Effect size (and its variance) Power and alpha Power and alpha

37.  (alpha) The probability of finding a ‘significant’ result if nothing is going on

38. I will need to convince people Customarily, a result is ‘statistically significant’ if P<0.05 Customarily, a result is ‘statistically significant’ if P<0.05 In other words, Probability of a type I error = 5% Probability of a type I error = 5%  (alpha) = 0.05  (alpha) = 0.05

39. I will need to convince skeptics Very small chance that a positive result is an error Very small chance that a positive result is an error  (alpha) = 0.01 P<0.01 A smaller  means larger sample size A smaller  means larger sample size

40. Two-sided vs. one-sided   A 2-sided  assumes that the result could go either way A 2-sided  assumes that the result could go either way  Recognizes that you have two chances of finding something that isn’t really there  Resveratrol decreases mortality  Resveratrol increases mortality A 1-sided hypothesis reduces sample size (somewhat) A 1-sided hypothesis reduces sample size (somewhat)  A one-sided  of 0.05 corresponds to a two-sided  of 0.10 It assumes that the result could, plausibly, go only one way It assumes that the result could, plausibly, go only one way

41. Two-sided vs. one-sided   You may believe that your effect could only go one way! You may believe that your effect could only go one way!  Resveratrol is ‘natural.’ It could not increase mortality! Be humble. Be humble.  The history of research is filled with results that contradicted expectations  Vitamin D trial (JAMA 2010):  To everyone’s surprise, ~1500 IU of vitamin D/d increased the risk of falls and fractures in elderly women and men A 1-sided test is almost never the best choice A 1-sided test is almost never the best choice

42.  (beta) The probability of missing this effect size in this sample, if it is really true in the populations

43. Power (1-  ) The probability of finding this effect size in this sample, if it is really true in the population

44. If it’s true, I don’t want to miss it The chance of missing the effect (  ) The chance of missing the effect (  ) is “customarily” 20% In other words Probability of a type II error = 0.20 Probability of a type II error = 0.20  (beta) = 0.20  (beta) = 0.20 Power = 1-  0.80 Power = 1-  0.80

45. I really don’t want to miss it  =.10  =.10 Power (1-  ) = 0.90 Power (1-  ) = 0.90 Greater power requires a larger sample size Greater power requires a larger sample size

46. We have all of the ingredients  Testable hypothesis  Type of study: analytical (RCT)  Statistical test: Chi-squared  Effect size 10% vs 8%  Power: 0.90; alpha: 0.20

47. From Table 6B.2 Comparing two proportions

49. From Table 6B.2 Sample size: 4,401 Sample size: 4,401 Per group Per group Total: 8,802 Total: 8,802 Does not include drop-outs Does not include drop-outs  20% drop-out: 11,002 total sample size!

50. Alternatives Tweak  one-sided Tweak  one-sided  Almost never appropriate Tweak the power: 0.80 Tweak the power: 0.80

51. From Table 6B.2 Comparing two proportions

52. Alternatives Tweak  one-sided Tweak  one-sided  Almost never appropriate Tweak the power: 0.80 Tweak the power: 0.80 Modest effect: 3,308 (6,616 total) Modest effect: 3,308 (6,616 total)

53. Alternatives Increase the effect size Increase the effect size  10% vs. 6%

54. From Table 6B.2 Comparing two proportions

55. Increasing the effect size 10% vs. 6% 10% vs. 6% Makes a big difference! Makes a big difference! 769 / group; 1,538 total (no dropouts) 769 / group; 1,538 total (no dropouts) However, still large (and not affordable) However, still large (and not affordable) Not believable Not believable

56. Alternatives: a new hypothesis Change the outcome measure Change the outcome measure  Continuous measurement  A precise measurement A ‘surrogate’ for mortality rate A ‘surrogate’ for mortality rate  Strongly associated with mortality rate  Likely to be influenced by resveratrol Walking speed Walking speed

57. Mice on resveratrol Mice fed resveratrol Mice fed resveratrol  Live 25% longer  Are significantly faster  Have greater endurance

58. Increased gait speed (0.1 m/s) in 1 year and survival over 8 years Faster by ≥0.1 m/s Slower ~20% decreased mortality rate

59. The new ingredients  New testable hypothesis  Type of study: RCT Statistical test: t-test Statistical test: t-test  Continuous variable (walking speed)  Difference between means (pbo vs. tx) > Effect size and variance: E/S Power and alpha Power and alpha

60. E/S For t-scores (dichotomous predictor, continuous outcome) For t-scores (dichotomous predictor, continuous outcome) Sample size depends on the ratio of E/S Sample size depends on the ratio of E/S  E: Effect size (difference in means)  S: Standard deviation for measurement You need smaller sample size if You need smaller sample size if  Greater effect (E)  More precise measurement (lower SD)

61. What we need to determine E/S for our RCT Effect size (E) for change in walking speed Effect size (E) for change in walking speed  Mean baseline value = 1.0 m/s  Change in the placebo group = 0  Change with resveratrol = +0.1 m/s Standard deviation (S) Standard deviation (S)  Standard deviation of the change

62. S Standard deviation for the measurement Standard deviation for the measurement  Cross-sectional data: 0.25 m / sec However, we are interested in change However, we are interested in change Standard deviation of change in speed? Standard deviation of change in speed?  Often more difficult to find because cross-sectional surveys are more common than longitudinal studies

63. What if you don’t know the SD? Standard deviation of change in speed? Standard deviation of change in speed? If you cannot find data from other studies If you cannot find data from other studies Alternatives Alternatives  Pilot study: measure change in 3 or 6 mo.s

64. What if you don’t know the SD? Standard deviation of change in speed? Standard deviation of change in speed? If you cannot find data from other studies If you cannot find data from other studies Alternatives Alternatives  Pilot study: measure change in 3 or 6 mo.s  Or, a well educated guess

65. Estimating an S.D. the 1/4 rule ~ 4 S.D.s across a ‘usual’ range of values So, 1 S.D. will = 1/4 of the range

66. Estimating S.D. for change in walking speed the 1/4 rule Range of changes over 1 year* Range of changes over 1 year* +0.2 m/sec to -0.6 m/sec +0.2 m/sec to -0.6 m/sec Range = 0.8 m/sec Range = 0.8 m/sec 1/4 of the range = 0.2 m/sec 1/4 of the range = 0.2 m/sec * Single short, 6 meter walk

67. E/S Effect size: 0.1 m/sec difference in change Effect size: 0.1 m/sec difference in change Standard deviation: 0.2 m/sec Standard deviation: 0.2 m/sec E/S = 0.5 E/S = 0.5

68. The new ingredients  New testable hypothesis  Type of study: analytical (RCT)  Statistical test: t-test  Continuous variable  Difference between means  Effect size 1.0 vs. 1.1 m/sec; E/S = 0.5  Power: 0.80; alpha: 0.20

70. The new ingredients  New testable hypothesis  Type of study: analytical (RCT)  T-test  Effect size 1.0 vs.1.1 m/sec; E/S: 0.5  Power: 0.80; alpha: 0.20 Sample size: 64 per group; 128 total With 20% drop out: 160 total

71. Improving precision of the outcome measurement Increased precision (decreased SD) will decrease the sample size Increased precision (decreased SD) will decrease the sample size For example For example  Mean of repeated walks  Longer, 400 m walk  Standard deviation may improve from 0.2 m/sec to 0.15 m/sec E/S improves from 0.5 to 0.1÷ 0.15 = 0.7 E/S improves from 0.5 to 0.1÷ 0.15 = 0.7

72. A modest improvement in precision reduced sample size by 1/2

73. Summary Estimate sample size early Estimate sample size early Systematically collect the ingredients Systematically collect the ingredients Effect size is the most difficult - and important - judgement Effect size is the most difficult - and important - judgement Alternatives that reduce sample size Alternatives that reduce sample size  Compromise power  Increase effect size  Precise continuous outcomes