Interpreting the Results of Intention-to-Treat, Per-Protocol, and As-Treated Analyses of Clinical Trials

Nonadherence in a randomized clinical trial (RCT) occurs when study participants do not follow the randomly assigned treatment protocol. Reasons for nonadherence may include the study participant not taking trial medications, crossing over to the other intervention being studied, or accessing treatment outside of the trial. Nonadherence also may occur when the clinician is unable to complete the assigned therapy (eg, a surgical procedure) as intended. The CABANA clinical trial published in JAMA by Packer et al was difficult to interpret because of nonadherence with the treatment protocol that resulted from substantial crossover between groups. In this trial, patients with atrial fibrillation were randomized to either undergo catheter ablation or receive conventional medical therapy. Of the 1108 participants randomized to ablation, 102 (9%) did not receive the procedure. Of the 1096 patients randomized to drug therapy, 301 (27%) underwent ablation during the follow-up period, resulting in nonadherence to assigned treatment in both groups of the study.