Interactions in the 2×2×2 factorial randomised clinical STEPCARE trial and the potential effects on conclusions: a protocol for a simulation study

Markus Harboe Olsen*, Aksel Karl Georg Jensen, Josef Dankiewicz, Markus B. Skrifvars, Matti Reinikainen, Marjaana Tiainen, Manoj Saxena, Anders Aneman, Christian Gluud, Susann Ullén, Niklas Nielsen, Janus Christian Jakobsen

*Corresponding author for this work

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Background: Randomised clinical trials with a factorial design may assess the effects of multiple interventions in the same population. Factorial trials are carried out under the assumption that the trial interventions have no interactions on outcomes. Here, we present a protocol for a simulation study investigating the consequences of different levels of interactions between the trial interventions on outcomes for the future 2×2×2 factorial designed randomised clinical Sedation, TEmperature, and Pressure after Cardiac Arrest and REsuscitation (STEPCARE) trial in comatose patients after out-of-hospital cardiac arrest. Methods: By simulating a multisite trial with 50 sites and 3278 participants, and a presumed six-month all-cause mortality of 60% in the control population, we will investigate the validity of the trial results with different levels of interaction effects on the outcome. The primary simulation outcome of the study is the risks of type-1 and type-2 errors in the simulated scenarios, i.e. at what level of interaction is the desired alpha and beta level exceeded. When keeping the overall risk of type-1 errors ≤ 5% and the risk of type-2 errors ≤ 10%, we will quantify the maximum interaction effect we can accept if the planned sample size is increased by 5% to take into account possible interaction between the trial interventions. Secondly, we will assess how interaction effects influence the minimal detectable difference we may confirm or reject to take into account 5% (small interaction effect), 10% (moderate), or 15% (large) positive interactions in simulations with no ‘true’ intervention effect (type-1 errors) and small (5%), moderate (10%), or large negative interactions (15%) in simulations with ‘true’ intervention effects (type-2 errors). Moreover, we will investigate how much the sample size must be increased to account for a small, moderate, or large interaction effects. Discussion: This protocol for a simulation study will inform the design of a 2×2×2 factorial randomised clinical trial of how potential interactions between the assessed interventions might affect conclusions. Protocolising this simulation study is important to ensure valid and unbiased results.

Original languageEnglish
Article number889
Number of pages7
Publication statusPublished - Dec 2022

Bibliographical note

Publisher Copyright:
© 2022, The Author(s).


  • Factorial design
  • Interactions
  • Protocol
  • Randomised clinical trial
  • Simulation study
  • Statistical analysis plan
  • Sample Size
  • Humans
  • Computer Simulation
  • Out-of-Hospital Cardiac Arrest/diagnosis
  • Research Design
  • Randomized Controlled Trials as Topic


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