Analysis of clustered binary outcomes using within-cluster paired resampling

Conditional logistic regression (CLR) is useful for analyzing clustered binary outcome data when interest lies in estimating a cluster-specific exposure parameter while treating the dependency arising from random cluster effects as a nuisance. CLR aggregates unmeasured cluster-specific factors into a cluster-specific baseline risk and is invalid in the presence of unmodeled heterogeneous covariate effects or within-cluster dependency. We propose an alternative, resampling-based method for analyzing clustered binary outcome data, within-cluster paired resampling (WCPR), which allows for within-cluster dependency not solely due to baseline heterogeneity. For example, dependency may be in part caused by heterogeneity in response to an exposure across clusters due to unmeasured cofactors. When both CLR and WCPR are valid, our simulations suggest that the two methods perform comparably. When CLR is invalid, WCPR continues to have good operating characteristics. For illustration, we apply both WCPR and CLR to a periodontal data set where there is heterogeneity in response to exposure across clusters.