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where $k$ is the number of endpoints required for equivalence, and $m$ is the total number of endpoints evaluated.
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## Hierarchical testing of multiple endpoints
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Hierarchical testing is an approach to multiple endpoint testing where endpoints are tested in a predefined order, typically based on their clinical or regulatory importance. A fallback testing strategy is applied, allowing sequential hypothesis testing. If a hypothesis earlier in the sequence fails to be rejected, testing stops, and subsequent hypotheses are not evaluated.
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Hierarchical testing is an approach to multiple endpoint testing where endpoints are tested in a predefined order, typically based on their clinical or regulatory importance. A fallback testing strategy is applied, allowing sequential hypothesis testing. If a hypothesis earlier in the sequence fails to be rejected, testing stops, and subsequent hypotheses are not evaluated.[@chowdhry_finding_2024]
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To implement hierarchical testing in SimTOST, the user defines primary and secondary endpoints using the `type_y` vector argument. The significance level ($\alpha$) is adjusted separately for each endpoint group:
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To implement hierarchical testing in SimTOST, the user specifies `adjust = "seq"` in the [sampleSize()](../reference/sampleSize.html) function and defines primary and secondary endpoints using the `type_y` vector argument. The significance level ($\alpha$) is adjusted separately for each group of endpoints, ensuring strong control of the Family-Wise Error Rate (FWER) while maintaining interpretability.
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1.**Evaluate primary endpoints**
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- Testing begins with the pre-specified primary endpoints.
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- The adjusted significance level for a primary endpoint $p$ is: $$\alpha_H= \frac{\alpha}{\text{Number of primary endpoints}}$$
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- If any primary hypothesis fails to be rejected, testing stops, and secondary endpoints are not tested.
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- The adjusted significance level for a primary endpoint $p$ is: $$\alpha_p= \frac{\alpha}{\text{Number of primary endpoints}}$$
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- If any primary endpoint fails to meet the equivalence criteria, testing stops, and secondary endpoints are not tested.
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2.**Proceed to secondary endpoints (if applicable)**
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- If all primary endpoints demonstrate equivalence, testing continues to the secondary endpoints.
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- A Bonferroni adjustment is applied again, based on the number of secondary endpoints.
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The adjusted significance level is determined using a weighting approach, ensuring that primary and secondary endpoints are tested sequentially while maintaining strong control over the Family-Wise Error Rate (FWER). The sequential adjustment correction can be implemented by specifying `adjust = "seq"` in the [sampleSize()](../reference/sampleSize.html) function.
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- If all primary endpoints meet the equivalence criteria, testing proceeds to the secondary endpoints.
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- The significance level for a secondary endpoint $s$ is adjusted as: $$\alpha_s= \frac{\alpha}{\text{Number of secondary endpoints}}$$
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3.**Final Decision**
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- The test is considered successful if at least `k` endpoints meet equivalence and all primary endpoints pass.
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An example of hierarchical testing can be found in [this vignette](sampleSize_parallel_2A3E.html#hierarchical-testing).
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