Analysis of

2 x 2 Crossover Designs
with Continuous Data

Orawan sAETAN
Biostatistician
Overview
 Crossover designs
 Common Crossover design
 Possible effects
 Dealing with aliasing
- Methodology
- Statistical Analysis
 Example

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Crossover Designs
“Each treatment is administered to each
patient at different times in the study”

subjects may undergo an active drug

for 6 weeks and then “cross over” to the
placebo for 6 weeks
Chronic & stable disease
(asthma, arthritis, diabetes,
hypertension, migraine …)
migraine…)
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Common Crossover Design
Se
qu
e nc

Treatment
Treatment Treatment
Treatment
e1

A
A B
B
Run-in
Run-in Washout
Washout
(Baseline)
(Baseline) (Baseline)
(Baseline)

Treatment
Treatment Treatment
Treatment
2
nce B
B A
A
e
e qu Period 1 Period 2
S

Figure 1: 2 x 2 crossover design

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 Example Study (My Research)
A comparative study of heat effect between hot pack
and Thai herbal ball on pain and physiological changes

Hot
Hot pack
pack Thai
Thai
herbal
herbal ball
ball
Run-in
Run-in Washout
Washout
(Baseline)
(Baseline) (1
(1 wk)
wk)

Thai
Thai Hot
Hot pack
pack
herbal
herbal ball
ball

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Crossover Designs
Advantages:
 Own control
 Within-subject comparison
 Removal of intersubject variability
 Reducing of the costs
 Increasing of Precision & power
 Small sample size

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Crossover Designs
Disadvantages:
 Carryover effects

 Drop out

 The analysis is more complex than

in a parallel groups design

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Possible Effects

 Direct treatment effect ( )

 Period effect ()
 Carryover effect ( )
 Treatment-by-period interaction ( )
 Sequence (Group) effect ()

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 Direct treatment effect  Period effect

2,5
2.5
2 1A 2A
2 2A
1,5 1A
mean

1.5 1B

mean
1 2B 1B
1
0,5 2B
0.5
0
1 2 0
period 1 period 2

(a) (b)
Treatment A
better
Treatment B
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  Carryover effect
 Treatment-by-period interaction
3
3

Treatment A
2 .5
2A
2.5 2A
2

better
2
mean

1A

mean
1 .5 1B
1.5
1B 1A

Treatment B
1
2B 1
0 .5
0.5
2B
0
0
1 2
p e r io d 1 p e r io d 2

(c) (d)
3

2.5 1B

Sequence
1A
mean

(e) 1.5
2A 
1

0.5 2B
effect
0
1 p e r io d 2

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Dealing with aliasing
 Methodology  Statistical
Analysis
 Latin square for
 Preliminary
crossover
test
designs
 Washout period

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Latin square for crossover designs
Examples Uniform within Uniform within Balanced Strongly
Sequences Periods Balanced

AAB/ABB × × × ×
ABB/BAB √ × × ×
ABAA/BAAB × × √ ×
AABBA/BAABB × × √ √
AABA/ABAA √ × √ ×
ABA/BAB × √ √ ×
AABBA/ABBAA √ × √ √
ABB/BAA, AB/BA/AA/BB × √ √ √
AB/BA √ √ √ ×
ABBA/BAAB/AABB/BBAA √ √ √ √
Table 1: comparison of two-treatment crossover designs (Piantadosi,
Piantadosi 2003)

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Model: Continuous data
Yijk    bij   k  m  m   ijk
where,
 overall mean
bij effect of jth patient with ith sequence &
is ~N (0,  b )
2

 k effect of kth period

 m treatment effect of mth treatment
m carryover effect of mth treatment
 ijk random error and is ~N (0, b )
2

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Statistical Analysis 2,5

2 1A 2A

1. Graph 1,5

mean
1 2B 1B

 Subject profiles plot 0,5

 Group by period plot

1 2

period

2. Preliminary test
 Equal of carryover effect
3. Estimation of treatment effect
 2 periods
 1stperiod
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 Two-stage procedure
1 Preliminary test for
carryover effect 10%
10% 2-side
2-side level
level
( A   B )
two-sample
two-sample
t-test
t-test or
or Sig Si
n - g
ANOVA
ANOVA No

2 Estimate the Estimate the

5%
5% 2-side
2-side
treatment effect treatment effect
level
level
of 2 periods of the 1stperiod
( A   B ) ( A   B )

By…Grizzle’s procedure (1965) 15

 Preliminary test for
carryover effect
Group Period 1 Period 2

1 (Sequence AB)   1   A    2  B  A

2 (Sequence BA)   1  B    2   A  B

sequence AB = sequence BA
A+B=B+A
  1   A     2   B   A =   1   B     2   A  B
H0:  A  B
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 Estimation of treatment effect
1: Estimate the treatment effect of 2 periods
½ (A – B) = ½ (B – A)
½(   1   A     2   A  B ) = ½(   1   B     2   B   A )
 A- ½  A =  B - ½  B
 A  B H0: A B
2: Estimate the treatment effect of the1stperiod
A=B
  1   A =   1  B
H0:  A B
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Statistical Analysis
 Assumptions Residual Analysis

The repeated measurements

on each subject are
independent

Normally distributed random

variables with equal variances

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Cause of  A  B
 Physical Carryover Effects

 Psychological Carryover Effects

 Treatment-by-Period Interaction

 Group Difference

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 Example
2 x 2 crossover design
Group 1 (AB) Group 2 (BA)
Subject Period 1 Period 2 Subject Period 1 Period 2
1 0.2 1.0 1 1.3 0.9
2 0.0 -0.7 2 -2.3 1.0
3 -0.8 0.2 3 0.0 0.6
4 0.6 1.1 4 -0.8 -0.3
5 0.3 0.4 5 -0.4 -1.0
6 1.5 1.2 6 -2.9 1.7
7 -1.9 -0.3
8 -2.9 0.9

Table 2: Grizzle’s data (Grizzle, J.E. The two-period changeover

design and its use in clinical trials. Biometrics, 1965; 21: 467-80.)
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Example
0,8
0,6 1B
1A
0,4
0,2
2A
• Strongly
• Strongly carryover
carryover
mean responds

0
-0,2
effect
effect
•Treatment-by period
•Treatment-by
-0,4
-0,6
period
-0,8
interaction
interaction
-1
-1,2 2B •Sequence effect
•Sequence effect
1 2
-1,4
period

Figure 2: Group-by-period plot for Grizzle’s data

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Example
variable diff SE 95% CI p-value

*Carryover 1.63 0.76 -0.03 to 3.3 0.05

**Direct treatment
(first period )
1.54 0.68 0.06 to 3.01 0.04 
**Direct treatment 0.72 0.38 -0.13 to 1.57 0.09 
(two period )
*  0.1, **   0.05

Table 3: Two-sample t-test for 2 x 2 crossover design from

Grizzle’s data
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Example (My Research)

A comparative study of heat effect

between hot pack and
Thai herbal ball
on pain and
physiological changes

Data Analysis Report

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