Optimization of behavioral dynamic treatment regimens based on the sequential, multiple assignment, randomized trial (SMART)

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Abstract
Background and purpose: A behavioral intervention is a program aimed at modifying behavior for the purpose of treating or preventing disease, promoting health, and/or enhancing well-being. Many behavioral interventions are dynamic treatment regimens, that is, sequential, individualized multicomponent interventions in which the intensity and/or type of treatment is varied in response to the needs and progress of the individual participant. The multiphase optimization strategy (MOST) is a comprehensive framework for development, optimization, and evaluation of behavioral interventions, including dynamic treatment regimens. The objective of optimization is to make dynamic treatment regimens more effective, efficient, scalable, and sustainable. An important tool for optimization of dynamic treatment regimens is the sequential, multiple assignment, randomized trial (SMART). The purpose of this article is to discuss how to develop optimized dynamic treatment regimens within the MOST framework. Methods and results: The article discusses the preparation, optimization, and evaluation phases of MOST. It is shown how MOST can be used to develop a dynamic treatment regimen to meet a prespecified optimization criterion. The SMART is an efficient experimental design for gathering the information needed to optimize a dynamic treatment regimen within MOST. One signature feature of the SMART is that randomization takes place at more than one point in time. Conclusion: MOST and SMART can be used to develop optimized dynamic treatment regimens that will have a greater public health impact.

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