Clinical Trialists Should Use Economies of Scale to Maximize Profits of Large RCTs

The lever is a powerful tool

I am writing (very slowly) a review article about ionized calcium in the ICU - should it be measured, and should it be treated?  There are several recent large observational studies that look at the association between calcium and outcomes of  critical illness, but being observational, they do not offer guidance as to whether chasing calcium levels with calcium gluconate or chloride will improve outcomes or whether hypo- or hyper-calcemia is simply a marker of severity of illness (the latter is of course my bet.)

Thinking about calcium levels and causation and repletion, one cannot help but think about all sorts of other levels we check in the ICU - potassium, magnesium, phosphate - and may other things we routinely do but about which we have no real inkling of an idea as to whether we're doing any patients any good.  (Arterial lines are another example.)  Are we just wasting our time with many of the things we do?  This question becomes more urgent as evidence mounts that much of what we do (in the ICU and elsewhere) is useless, wasteful, or downright harmful.  But who or what agency is going to fund a trial of potassium or calcium replacement in the ICU?  It certainly seems unglamorous.   Don't we have other disease-specific priorities that are paramount in importance to such a trial?

I then realized that a good businessman, wanting to maximize the "profit" from a large, randomized controlled trial (and the dollars "invested" in it), would take advantage of economies of scale.  For those who are not business savvy (I do not imply that I am), business costs can be roughly divided into fixed costs and variable costs.  If you have a factory making widgets you have certain  costs such as the rent, advertising, widget making machines.  These costs are "fixed" meaning that they are invariable whether you make 100 widgets or 10,000 widgets.  Variable costs are the costs of materials, electricity, and human resources which must be scaled up as you make more widgets.  In general, the cost of making each widget goes down as the fixed costs are spread out over more widget units.  Additionally, if you can leverage your infrastructure to make wadgets, a product similar to a widget, you likewise increase profits by lowering costs per unit.