Year of SMART

September 7, 2016:

The Methodology Center is declaring this the “Year of SMART” to raise awareness among researchers, reviewers, and program officersbilliedanny at various agencies about the potential value of the sequential, multiple-assignment, randomized trial (SMART). SMART is a type of multi-stage factorial experimental design that allows researchers to build or optimize high-quality adaptive interventions. An adaptive intervention is a sequence of individually tailored intervention decision rules that help guide how best to adapt and re-adapt an intervention over time based on the evolving condition of the individual.

Scientists often have many questions about how best to develop the most effective adaptive intervention. This includes questions about how to initiate treatment (e.g., with more intensive treatment or with less intensive treatment), how best to monitor individuals’ progress in treatment (e.g., monitoring frequently), and what next treatment is best for individuals based on their response to the initial treatment. SMART has become a go-to approach to answer such critical questions. SMART extends a factorial experimental design to settings where there are multiple stages of treatment.

In recent years many funded research projects have been using SMART to build adaptive interventions for a broad range of health problems. For example, a recent special issue of the Journal of Clinical Child and Adolescent Psychology was devoted explicitly to the topic of adaptive interventions to improve the lives of children and adolescents with emotional or mental health disorders; various studies in this special issue use SMART.

Recent work on SMART by Center researchers focuses on developing new methods for multi-level adaptive interventions. Here, the goal is to understand whether or how best to intervene adaptively in classrooms, schools, clinics, or even organizations, with the goal to improve the health outcomes of the individuals within the clusters. For example, a current project is using SMART to understand how best to implement an evidence-based intervention for mood disorders in community-based mental health clinics. This implementation science study is a first-of-its-kind, NIMH-funded, cluster-randomized SMART. It randomizes clinics across Michigan and Colorado to different implementation interventions, with the goal of improving mental health outcomes for the individual patients within these clinics. A second IES-funded cluster-randomized SMART focuses on improving academic engagement outcomes of children with autism. In this SMART children are randomized to receive or not receive a classroom-level intervention, and then children not sufficiently responding are re-randomized to a peer-mediated or parent-mediated intervention.

Center researchers are also using SMART to develop adaptive mobile health (mHealth) interventions. mHealth tools offer many opportunities to improve the accessibility and scalability of care. The relatively low cost and widespread use of many mHealth tools make them ideal for use as minimal support in stepped-care interventions. A stepped-care intervention is a form of an adaptive intervention in which minimal (low cost, low burden) support is offered first, and then the extent of support (e.g., in terms of cost and burden) can be stepped up and down depending on response to initial support. However, many interesting questions arise concerning the most effective way to integrate mHealth tools in such stepped-care interventions. These include how best to initiate mHealth support (e.g., with or without additional human support); how to best assess non-response to mHealth support (e.g., how to identify early non-responders); and the best way to step care up and down based on response to mHealth support. An NIH-funded study is using SMART to investigate how to best initiate and augment mHealth tools for weight loss with more traditional intervention components (e.g., coaching, meal replacement) to treat obese adults.

We initiated this one-year effort to encourage each of you to consider novel methods for your research on adaptive interventions, including whether and how SMART could be used in your research. Stay tuned all year for the latest on SMART!

Read more about SMART and adaptive interventions.

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