Factors affecting power in stepped wedge trials when the treatment effect varies with time

Abstract: Stepped wedge cluster randomized trials (SW-CRTs) have historically been analyzed using immediate treatment (IT) models, which assume the effect of the treatment is immediate after treatment initiation and subsequently remains constant over time. However, recent research has shown that this assumption can lead to severely misleading results if treatment effects vary with exposure time, i.e. time since the intervention started. Models that account for time-varying treatment effects, such as the exposure time indicator (ETI) model, allow researchers to target estimands such as the time-averaged treatment effect (TATE) over an interval of exposure time, or the point treatment effect (PTE) representing a treatment contrast at one time point. However, this increased flexibility results in reduced power. In this paper, we use public power calculation software and simulation to characterize factors affecting SW-CRT power. Key elements include choice of estimand, study design considerations, and analysis model selection. For common SW-CRT designs, the sample size (individuals per cluster-period) must be increased by a factor of roughly 2.5 to 3 to maintain 90\% power when switching from an IT model to an ETI model (targeting the TATE over the entire study). However, the inflation factor is lower when considering TATE estimands over shorter periods that exclude longer exposure times for which there is limited information. In general, SW-CRT designs (including the staircase'' variant) have much greater power for estimatingshort-term effects'' relative to ``long-term effects''. For an ETI model targeting a TATE estimand, substantial power can be gained by adding time points to the start of the study or increasing baseline sample size, but surprisingly little power is gained from adding time points to the end of the study. More restrictive choices for modeling the exposure time... [truncated]