Integrating Prioritized and Non-Prioritized Structures in Win Statistics

Composite endpoints are frequently used as primary or secondary analyses in cardiovascular clinical trials to increase clinical relevance and statistical efficiency. Alternatively, the Win Ratio (WR) and other Win Statistics (WS) analyses rely on a strict hierarchical ordering of endpoints, assigning higher priority to clinically important endpoints. However, determining a definitive endpoint hierarchy can be challenging and may not adequately reflect situations where endpoints have comparable importance. In this study, we discuss the challenges of endpoint prioritization, underscore its critical role in WS analyses, and propose Rotation WR (RWR), a hybrid prioritization framework that integrates both prioritized and non-prioritized structures. By permitting blocks of equally-prioritized endpoints, RWR accommodates endpoints of equal or near equal clinical importance, recurrent events, and contexts requiring individualized shared decision making. Statistical inference for RWR is developed using U-statistics theory, including the hypothesis testing procedure and confidence interval construction. Extensions to two additional WS measures, Rotation Net Benefit and Rotation Win Odds, are also provided. Through extensive simulation studies involving multiple time-to-event endpoints, including recurrent events, we demonstrate that RWR achieves valid type I error control, desirable statistical power, and accurate confidence interval coverage. We illustrate both the methodological and practical insights of our work in a case study on endpoint prioritization with the SPRINT clinical trial, highlighting its implications for real-world clinical trial studies.