On the mixed-model analysis of covariance in cluster-randomized trials

In the analyses of cluster-randomized trials, mixed-model analysis of covariance (ANCOVA) is a standard approach for covariate adjustment and handling within-cluster correlations. However, when the normality, linearity, or the random-intercept assumption is violated, the validity and efficiency of the mixed-model ANCOVA estimators for estimating the average treatment effect remain unclear. Under the potential outcomes framework, we prove that the mixed-model ANCOVA estimators for the average treatment effect are consistent and asymptotically normal under arbitrary misspecification of its working model. If the probability of receiving treatment is 0.5 for each cluster, we further show that the model-based variance estimator under mixed-model ANCOVA1 (ANCOVA without treatment-covariate interactions) remains consistent, clarifying that the confidence interval given by standard software is asymptotically valid even under model misspecification. Beyond robustness, we discuss several insights on precision among classical methods for analyzing cluster-randomized trials, including the mixed-model ANCOVA, individual-level ANCOVA, and cluster-level ANCOVA estimators. These insights may inform the choice of methods in practice. Our analytical results and insights are illustrated via simulation studies and analyses of three cluster-randomized trials.