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This intermediate outcome was used in the analysis because patients in our study population have not been followed over a long-enough time period to allow for a more appropriate outcome to be measured.
Another intermediate outcome was the general perception of an increase in competence in cognitive behavioural therapy at the clinical level.
However, if there was final outcome information at the interim analysis, or a correlated intermediate outcome was available, then this, rather than the concordance of the biomarkers, could be used to pick the higher quality biomarker.
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Although smear microscopy may be more rapid and less expensive than culture, its use as an intermediate outcome is severely limited, especially in patients with HIV co-infection, who are more likely to have paucibacillary disease [11].
If a suitable intermediate outcome is unavailable then the MAMS design may still be used, for example, as a standalone phase II or III trial.
The improvement in prognostic accuracy is illustrated in Figure 1: with array-based grading histologic G2 tumours (associated with intermediate outcome) are reclassified as either genomic G1 or G3 (associated with favourable or worse outcome, respectively).
Another candidate for the intermediate outcome is time to culture conversion, which is increasingly being used in phase II trials and is arguably a more reliable surrogate endpoint than culture status at a single time point [ 24].
At the ith interim analysis recruitment continues to experimental arms whose treatment effect estimate on the intermediate outcome is significant at the 100 α i % level, otherwise consideration is given for ceasing further randomisations to it.
For example, the MAMS design may be used for a seamless phase II/III trial where the intermediate outcome is that used in a phase II trial while a phase III outcome is of primary interest in the final stage.
Although this reduces the correlation between stages compared to the calculation given in the appendix where all patients with a missing intermediate outcome are also assumed to have a missing definitive outcome, these different assumptions will indicate the robustness of the calculation of the overall type I error rate and power.
To the extent that reliable information is available, it can be stated that a reasonable level of intermediate outcomes was achieved, e.g. in terms of new strategies on ECCD and child protection.
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Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com