Covariate adjustment" in the randomized trial context refers to an estimator of the average treatment effect that adjusts for chance imbalances between study arms in baseline variables (called “covariates"). The baseline variables could include, e.g., age, sex, disease severity, and biomarkers. According to two surveys of clinical trial reports, there is confusion about the statistical properties of covariate adjustment. We focus on the ANCOVA estimator, which involves fitting a linear model for the outcome given the treatment arm and baseline variables, and trials with equal probability of assignment to treatment and control. We prove the following new (to the best of our knowledge) robustness property of ANCOVA to arbitrary model misspecification: Not only is the ANCOVA point estimate consistent (as proved by Yang and Tsiatis (2001)) but so is its standard error. This implies that confidence intervals and hypothesis tests conducted as if the linear model were correct are still valid even when the linear model is arbitrarily misspecified, e.g., when the baseline variables are nonlinearly related to the outcome or there is treatment effect heterogeneity. We also give a simple, robust formula for the variance reduction (equivalently, sample size reduction) from using ANCOVA. By re-analyzing completed randomized trials for mild cognitive impairment, schizophrenia, and depression, we demonstrate how ANCOVA can reduce variance, reduce bias conditional on chance imbalance, and increase power even when by chance there is perfect balance across arms in the baseline variables.


Biostatistics | Statistical Methodology

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