Box 2 - Randomisation and minimisation

Simple randomisation

Pure randomisation based on a single allocation ratio is known as simple randomisation. Simple randomisation with a 1:1 allocation ratio is analogous to a coin toss, although we do not advocate coin tossing for randomisation in an RCT. “Simple” is somewhat of a misnomer. While other randomisation schemes sound complex and more sophisticated, in reality, simple randomisation is elegantly sophisticated in that it is more unpredictable and surpasses the bias prevention levels of all other alternatives.

Restricted randomisation

Any randomised approach that is not simple randomisation. Blocked randomisation is the most common form. Other means of restricted randomisation include replacement, biased coin, and urn randomisation, although these are used much less frequently.(141)

Blocked randomisation

Blocking is used to ensure that comparison groups will be generated according to a predetermined ratio, usually 1:1 or groups of approximately the same size. Blocking can be used to ensure close balance of the numbers in each group at any time during the trial. For every block of eight participants, for example, four would be allocated to each arm of the trial.(142) Improved balance comes at the cost of reducing the unpredictability of the sequence. Although the order of interventions varies randomly within each block, a person running the trial could deduce some of the next treatment allocations if he or she knew the block size.(143) Blinding the interventions, using larger block sizes, and randomly varying the block size can ameliorate this problem.

Stratified randomisation

Stratification is used to ensure good balance of participant characteristics in each group. By chance, particularly in small trials, study groups may not be well matched for baseline characteristics, such as age and stage of disease. This weakens the trial’s credibility.(144) Such imbalances can be avoided without sacrificing the advantages of randomisation. Stratification ensures that the numbers of participants receiving each intervention are closely balanced within each stratum. Stratified randomisation is achieved by performing a separate randomisation procedure within each of two or more subsets of participants (for example, those defining each study centre, age, or disease severity). Stratification by centre is common in multicentre trials. Stratification requires some form of restriction (such as blocking within strata). Stratification without blocking is ineffective.

Minimisation

Minimisation ensures balance between intervention groups for several selected patient factors (such as age).(22) (60) The first patient is truly randomly allocated; for each subsequent participant, the treatment allocation that minimises the imbalance on the selected factors between groups at that time is identified. That allocation may then be used, or a choice may be made at random with a heavy weighting in favour of the intervention that would minimise imbalance (for example, with a probability of 0.8). The use of a random component is generally preferable. Minimisation has the advantage of making small groups closely similar in terms of participant characteristics at all stages of the trial.  Minimisation offers the only acceptable alternative to randomisation, and some have argued that it is superior.(145) On the other hand, minimisation lacks the theoretical basis for eliminating bias on all known and unknown factors. Nevertheless, in general, trials that use minimisation are considered methodologically equivalent to randomised trials, even when a random element is not incorporated.

Page last edited: 24 March 2010