Covariate-adjusted win statistics in randomized clinical trials with ordinal outcomes

Ordinal outcomes are common in clinical settings where they often represent increasing levels of disease progression or different levels of functional impairment. In this article, we focus on representing the average treatment effect for ordinal outcomes via intrinsic pairwise outcome comparisons captured through win estimands, such as the win ratio and win difference. Recognizing the value of baseline covariate adjustment toward enhanced precision, we first develop propensity score weighting estimators, including both inverse probability weighting (IPW) and overlap weighting (OW), tailored to estimating win estimands. Furthermore, we develop augmented weighting estimators that leverage an additional ordinal outcome regression to potentially improve efficiency over weighting alone. Leveraging the theory of U-statistics, we establish the asymptotic theory for all estimators, and derive closed-form variance estimators to support statistical inference. We also prove that all of the covariate-adjusted estimators do not compromise consistency for the target estimand even when the associated working models are incorrectly specified; hence these covariate-adjusted estimators are model-robust. Through simulations we demonstrate the enhanced efficiency of the weighted estimators over the unadjusted estimator, with the augmented weighting estimators showing a further improvement in efficiency except for extreme cases. Finally, we illustrate our proposed methods with the ORCHID trial, and implement our covariate adjustment methods in an R package winPSW.