arXiv subjects

Kara E. Rudolph

Publications and source records attributed to Kara E. Rudolph.

At least 19 recordsLinked to original sources

arXiv2026

Causal Effects of Modified Treatment Policies under Positivity Violations: A Partial Identification Approach

Modified treatment policies (MTPs) are interventions based on each individual's natural treatment value. We study mean outcomes under MTPs for continuous treatments, including exposure mixtures. Positivity is the standard sufficient condition for identifying these mean outcomes without extrapolation: policy-generated values remain supported given covariates. With multivariate treatments or continuous covariates, treatment--covariate combinations can be sparse or unsupported. Retaining the policy, our partial-identification framework decomposes its mean outcome into a point-identified contribution inside a positivity region and one outside. We bound the latter by imposing Lipschitz continuity on conditional mean potential outcomes rather than a parametric extrapolation model. The restriction compares each outside mean with the mean at an anchor inside the region. Metric projection minimizes width among one-anchor intervals but concentrates anchors on a lower-dimensional boundary, making the endpoints not pathwise differentiable. Our novel interior-displaced projection moves anchors inward, restoring pathwise differentiability. With a known region, we derive influence functions, characterize when they are efficient, and obtain asymptotically normal estimators and confidence intervals. In simulations, our intervals attain at least nominal coverage where those assuming positivity undercover. In a pesticide-mixture application, protective associations suggested by methods assuming positivity are not robust to modest outcome variation beyond the estimated region.

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arXiv2026

A novel decomposition to explain heterogeneity in observational and randomized studies of causality

This paper introduces a novel decomposition framework to explain heterogeneity in causal effects observed across different studies, considering both observational and randomized settings. We present a formal decomposition of between-study heterogeneity, identifying sources of variability in treatment effects across studies. The proposed methodology allows for robust estimation of causal parameters under various assumptions, addressing differences in pre-treatment covariate distributions, mediating variables, and the outcome mechanism. Our approach is validated through a simulation study and applied to data from the Moving to Opportunity (MTO) study, demonstrating its practical relevance. This work contributes to the broader understanding of causal inference in multi-study environments, with potential applications in evidence synthesis and policy-making.

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arXiv2026

Modified treatment policies that depend on the natural history of treatment

Longitudinal modified treatment policies (LMTP) are a class of interventions that allow the definition, identification, and estimation of causal effects in general settings, such as with continuous or multivariate exposures, treatment regimens that require grace periods. Targeted machine learning estimators (i.e., double/debiased) have been formulated for LMTPs that assign the exposure at time $t$ as a function of the natural value of treatment at time $t$. However, important applications such as estimating the effect of a delay in the start of a treatment require formulating LMTPs that depend not only on the natural value of treatment at time $t$ but also on the \textit{history} of the natural value of treatment prior to time $t$. This paper develops targeted learning estimators for this general case. We discuss the definition of the effects, and propose estimators that use an augmented-data version of the sequential regression form of the longitudinal g-computation formula. Our estimators are based on the efficient influence function and provide $\sqrt{n}$ inference under standard doubly robust rate assumptions on the convergence of the outcome and treatment regressions. We apply the new estimators to assess the effect of delaying a risky pain treatment by one month on 12-month incidence of opioid use disorder.

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arXiv2026

Everything all at once: On choosing an estimand for multi-component environmental exposures

Many research questions -- particularly those in environmental health -- do not involve binary exposures. In environmental epidemiology, this includes multivariate exposure mixtures with nondiscrete components. Causal inference estimands and estimators to quantify the relationship between an exposure mixture and an outcome are relatively few. We propose an approach to quantify a relationship between a shift in the exposure mixture and the outcome -- either in the single timepoint or longitudinal setting. The shift in the exposure mixture can be defined flexibly in terms of shifting one or more components, including examining interaction between mixture components, and in terms of shifting the same or different amounts across components. The estimand we discuss has a similar interpretation as a main effect regression coefficient. First, we focus on choosing a shift in the exposure mixture supported by observed data. We demonstrate how to assess extrapolation and modify the shift to minimize reliance on extrapolation. Second, we propose estimating the relationship between the exposure mixture shift and outcome completely nonparametrically, using machine learning in model-fitting. This is in contrast to other current approaches, which employ parametric modeling for at least some relationships, which we would like to avoid because parametric modeling assumptions in complex, nonrandomized settings are tenuous at best. We are motivated by longitudinal data on pesticide exposures among participants in the CHAMACOS Maternal Cognition cohort. We examine the relationship between longitudinal exposure to agricultural pesticides and risk of hypertension. We provide step-by-step code to facilitate the easy replication and adaptation of the approaches we use.

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arXiv2026

crumble: A comprehensive framework for modern causal mediation analysis with intermediate confounding

Causal mediation analysis is widely used to investigate how causal effects operate through specific pathways linking treatments or exposures to outcomes. Recently, \texttt{crumble} was developed to enable nonparametric estimation of several mediation parameters, even when mediators are continuous and/or multi-dimensional or when treatments are non-binary. But a practical and accessible guide to using \texttt{crumble} -- one that does not require deep familiarity with mediation analysis or semiparametric theory -- is currently lacking. This tutorial aims to an accessible introduction to \texttt{crumble} while minimizing technical complexity. We first review the mediation parameters implemented in \texttt{crumble} -- natural direct and indirect effects, randomized interventional effects, and recanting-twin effects. For each, we give the definition, interpretation, identification assumptions, and suitability in the presence or absence of intermediate confounding. Then, we demonstrate the usage of \texttt{crumble} by examining an example configuration. Next, we describe how \texttt{crumble} accommodates non-binary treatments through modified treatment policies. Finally, we illustrate the practical use of \texttt{crumble} through two case studies -- one with a binary treatment and one with a non-binary treatment -- based on the Job Search Intervention Study data.

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arXiv2026

Riesz representers for the rest of us

The application of semiparametric efficient estimators, particularly those that leverage machine learning, is rapidly expanding within epidemiology and causal inference. This literature is increasingly invoking the Riesz representation theorem and Riesz regression. This paper aims to introduce the Riesz representation theorem to an epidemiologic audience, explaining what it is and why it's useful, using step-by-step worked examples.

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arXiv2025

Identification and estimation of mediational effects of longitudinal modified treatment policies

We demonstrate a comprehensive semiparametric approach to causal mediation analysis, addressing the complexities inherent in settings with longitudinal and continuous treatments, confounders, and mediators. Our methodology utilizes a nonparametric structural equation model and a cross-fitted sequential regression technique based on doubly robust pseudo-outcomes, yielding an efficient, asymptotically normal estimator without relying on restrictive parametric modeling assumptions. We are motivated by a recent scientific controversy regarding the effects of invasive mechanical ventilation (IMV) on the survival of COVID-19 patients, considering acute kidney injury (AKI) as a mediating factor. We highlight the possibility of "inconsistent mediation," in which the direct and indirect effects of the exposure operate in opposite directions. We discuss the significance of mediation analysis for scientific understanding and its potential utility in treatment decisions.

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arXiv2025

General targeted machine learning for modern causal mediation analysis

Causal mediation analyses investigate the mechanisms through which causes exert their effects, and are therefore central to scientific progress. The literature on the non-parametric definition and identification of mediational effects in rigourous causal models has grown significantly in recent years, and there has been important progress to address challenges in the interpretation and identification of such effects. Despite great progress in the causal inference front, statistical methodology for non-parametric estimation has lagged behind, with few or no methods available for tackling non-parametric estimation in the presence of multiple, continuous, or high-dimensional mediators. In this paper we show that the identification formulas for six popular non-parametric approaches to mediation analysis proposed in recent years can be recovered from just two statistical estimands. We leverage this finding to propose an all-purpose one-step estimation algorithm that can be coupled with machine learning in any mediation study that uses any of these six definitions of mediation. The estimators have desirable properties, such as $\sqrt{n}$-convergence and asymptotic normality. Estimating the first-order correction for the one-step estimator requires estimation of complex density ratios on the potentially high-dimensional mediators, a challenge that is solved using recent advancements in so-called Riesz learning. We illustrate the properties of our methods in a simulation study and illustrate its use on real data to estimate the extent to which pain management practices mediate the total effect of having a chronic pain disorder on opioid use disorder.

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arXiv2025

Transporting results from a trial to an external target population when trial participation impacts adherence

Randomized clinical trials are considered the gold standard for informing treatment guidelines, but results may not generalize to real-world populations. Generalizability is hindered by distributional differences in baseline covariates and treatment-outcome mediators. Approaches to address differences in covariates are well established, but approaches to address differences in mediators are more limited. Here we consider the setting where trial activities that differ from usual care settings (e.g., monetary compensation, follow-up visits frequency) affect treatment adherence. When treatment and adherence data are unavailable for the real-world target population, we cannot identify the mean outcome under a specific treatment assignment (i.e., mean potential outcome) in the target. Therefore, we propose a sensitivity analysis in which a parameter for the relative difference in adherence to a specific treatment between the trial and the target, possibly conditional on covariates, must be specified. We discuss options for specification of the sensitivity analysis parameter based on external knowledge including setting a range to estimate bounds or specifying a probability distribution from which to repeatedly draw parameter values (i.e., use Monte Carlo sampling). We introduce two estimators for the mean counterfactual outcome in the target that incorporates this sensitivity parameter, a plug-in estimator and a one-step estimator that is double robust and supports the use of machine learning for estimating nuisance models. Finally, we apply the proposed approach to the motivating application where we transport the risk of relapse under two different medications for the treatment of opioid use disorder from a trial to a real-world population.

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arXiv2025

A Cautionary Tale on Integrating Studies with Disparate Outcome Measures for Causal Inference

Data integration approaches are increasingly used to enhance the efficiency and generalizability of studies. However, a key limitation of these methods is the assumption that outcome measures are identical across datasets -- an assumption that often does not hold in practice. Consider the following opioid use disorder (OUD) studies: the XBOT trial and the POAT study, both evaluating the effect of medications for OUD on withdrawal symptom severity (not the primary outcome of either trial). While XBOT measures withdrawal severity using the subjective opiate withdrawal scale, POAT uses the clinical opiate withdrawal scale. We analyze this realistic yet challenging setting where outcome measures differ across studies and where neither study records both types of outcomes. Our paper studies whether and when integrating studies with disparate outcome measures leads to efficiency gains. We introduce three sets of assumptions -- with varying degrees of strength -- linking both outcome measures. Our theoretical and empirical results highlight a cautionary tale: integration can improve asymptotic efficiency only under the strongest assumption linking the outcomes. However, misspecification of this assumption leads to bias. In contrast, a milder assumption may yield finite-sample efficiency gains, yet these benefits diminish as sample size increases. We illustrate these trade-offs via a case study integrating the XBOT and POAT datasets to estimate the comparative effect of two medications for opioid use disorder on withdrawal symptoms. By systematically varying the assumptions linking the SOW and COW scales, we show potential efficiency gains and the risks of bias. Our findings emphasize the need for careful assumption selection when fusing datasets with differing outcome measures, offering guidance for researchers navigating this common challenge in modern data integration.

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arXiv2024

Longitudinal Generalizations of the Average Treatment Effect on the Treated for Multi-valued and Continuous Treatments

The Average Treatment Effect on the Treated (ATT) is a common causal parameter defined as the average effect of a binary treatment among the subset of the population receiving treatment. We propose a novel family of parameters, Generalized ATTs (GATTs), that generalize the concept of the ATT to longitudinal data structures, multi-valued or continuous treatments, and conditioning on arbitrary treatment subsets. We provide a formal causal identification result that expresses the GATT in terms of sequential regressions, and derive the efficient influence function of the parameter, which defines its semi-parametric efficiency bound. Efficient semi-parametric inference of the GATT requires estimating the ratios of functions of conditional probabilities (or densities); we propose directly estimating these ratios via empirical loss minimization, drawing on the theory of Riesz representers. Simulations suggest that estimation of the density ratios using Riesz representation have better stability in finite samples. Lastly, we illustrate the use of our methods to evaluate the effect of chronic pain management strategies on the development of opioid use disorder among Medicare patients with chronic pain.

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arXiv2024

Transporting treatment effects from difference-in-differences studies

Difference-in-differences (DID) is a popular approach to identify the causal effects of treatments and policies in the presence of unmeasured confounding. DID identifies the sample average treatment effect in the treated (SATT). However, a goal of such research is often to inform decision-making in target populations outside the treated sample. Transportability methods have been developed to extend inferences from study samples to external target populations; these methods have primarily been developed and applied in settings where identification is based on conditional independence between the treatment and potential outcomes, such as in a randomized trial. We present a novel approach to identifying and estimating effects in a target population, based on DID conducted in a study sample that differs from the target population. We present a range of assumptions under which one may identify causal effects in the target population and employ causal diagrams to illustrate these assumptions. In most realistic settings, results depend critically on the assumption that any unmeasured confounders are not effect measure modifiers on the scale of the effect of interest (e.g., risk difference, odds ratio). We develop several estimators of transported effects, including g-computation, inverse odds weighting, and a doubly robust estimator based on the efficient influence function. Simulation results support theoretical properties of the proposed estimators. As an example, we apply our approach to study the effects of a 2018 US federal smoke-free public housing law on air quality in public housing across the US, using data from a DID study conducted in New York City alone.

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arXiv2024

Improving efficiency in transporting average treatment effects

We develop flexible, semiparametric estimators of the average treatment effect (ATE) transported to a new population ("target population") that offer potential efficiency gains. Transport may be of value when the ATE may differ across populations. We consider the setting where differences in the ATE are due to differences in the distribution of baseline covariates that modify the treatment effect ("effect modifiers"). First, we propose a collaborative one-step semiparametric estimator that can improve efficiency. This approach does not require researchers to have knowledge about which covariates are effect modifiers and which differ in distribution between the populations, but does require all covariates to be measured in the target population. Second, we propose two one-step semiparametric estimators that assume knowledge of which covariates are effect modifiers and which are both effect modifiers and differentially distributed between the populations. These estimators can be used even when not all covariates are observed in the target population; one requires that only effect modifiers are observed, and the other requires that only those modifiers that are also differentially distributed are observed. We use simulation to compare finite sample performance across our proposed estimators and an existing semiparametric estimator of the transported ATE, including in the presence of practical violations of the positivity assumption. Lastly, we apply our proposed estimators to a large-scale housing trial.

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arXiv2024

Studying continuous, time-varying, and/or complex exposures using longitudinal modified treatment policies

This tutorial discusses methodology for causal inference using longitudinal modified treatment policies. This method facilitates the mathematical formalization, identification, and estimation of many novel parameters, and mathematically generalizes many commonly used parameters, such as the average treatment effect. Longitudinal modified treatment policies apply to a wide variety of exposures, including binary, multivariate, and continuous, and can accommodate time-varying treatments and confounders, competing risks, loss-to-follow-up, as well as survival, binary, or continuous outcomes. Longitudinal modified treatment policies can be seen as an extension of static and dynamic interventions to involve the natural value of treatment, and, like dynamic interventions, can be used to define alternative estimands with a positivity assumption that is more likely to be satisfied than estimands corresponding to static interventions. This tutorial aims to illustrate several practical uses of the longitudinal modified treatment policy methodology, including describing different estimation strategies and their corresponding advantages and disadvantages. We provide numerous examples of types of research questions which can be answered using longitudinal modified treatment policies. We go into more depth with one of these examples--specifically, estimating the effect of delaying intubation on critically ill COVID-19 patients' mortality. We demonstrate the use of the open-source R package lmtp to estimate the effects, and we provide code on https://github.com/kathoffman/lmtp-tutorial.

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arXiv2024

Two-Step Targeted Minimum-Loss Based Estimation for Non-Negative Two-Part Outcomes

Non-negative two-part outcomes are defined as outcomes with a density function that have a zero point mass but are otherwise positive. Examples, such as healthcare expenditure and hospital length of stay, are common in healthcare utilization research. Despite the practical relevance of non-negative two-part outcomes, very few methods exist to leverage knowledge of their semicontinuity to achieve improved performance in estimating causal effects. In this paper, we develop a nonparametric two-step targeted minimum-loss based estimator (denoted as hTMLE) for non-negative two-part outcomes. We present methods for a general class of interventions referred to as modified treatment policies, which can accommodate continuous, categorical, and binary exposures. The two-step TMLE uses a targeted estimate of the intensity component of the outcome to produce a targeted estimate of the binary component of the outcome that may improve finite sample efficiency. We demonstrate the efficiency gains achieved by the two-step TMLE with simulated examples and then apply it to a cohort of Medicaid beneficiaries to estimate the effect of chronic pain and physical disability on days' supply of opioids.

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arXiv2024

Associations between pain-management treatments and opioid use disorder risk among Medicaid patients

Introduction: Chronic pain patients are at increased risk of opioid-misuse. Less is known about the unique risk conferred by each pain-management treatment, as treatments are typically implemented together, confounding their independent effects. We estimated the extent to which pain-management strategies were associated with risk of incident opioid use disorder (OUD) for those with chronic pain, controlling for baseline demographic and clinical confounding variables and holding other pain-management treatments at their observed levels. Methods: We used data from two chronic pain subgroups within a cohort of non-pregnant Medicaid patients aged 35-64 years, 2016-2019, from 25 states: 1) those with a chronic pain condition co-morbid with physical disability (N=6,133) or 2) those with chronic pain without disability (N=67,438). We considered 9 pain-management treatments: prescription opioid i) dose and ii) duration; iii) number of opioid prescribers; opioid co-prescription with iv) benzodiazepines, v) muscle relaxants, and vi) gabapentinoids; vii) non-opioid pain prescription, viii) physical therapy, and ix) other pain treatment modality. Our outcome was incident OUD. Results: Having an opioid and gabapentin co-prescription or an opioid and benzodiazepine co-prescription was statistically significantly associated with a 16-46% increased risk of OUD. Opioid dose and duration also were significantly associated with increased risk of OUD. Physical therapy was significantly associated with an 11% decreased risk of OUD in the subgroup with chronic pain but no disability. Conclusions: Co-prescription of opioids with either gabapentin or benzodiazepines may substantially increase risk of OUD. More positively, physical therapy may be a relatively accessible and safe pain-management strategy.

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arXiv2024

A drug classification pipeline for Medicaid claims using RxNorm

Objective: Freely preprocess drug codes recorded in electronic health records and insurance claims to drug classes that may then be used in biomedical research. Materials and Methods: We developed a drug classification pipeline for linking National Drug Codes to the World Health Organization Anatomical Therapeutic Chemical classification. To implement our solution, we created an R package interface to the National Library of Medicine's RxNorm API. Results: Using the classification pipeline, 59.4% of all unique NDC were linked to an ATC, resulting in 95.5% of all claims being successfully linked to a drug classification. We identified 12,004 unique NDC codes that were classified as being an opioid or non-opioid prescription for treating pain. Discussion: Our proposed pipeline performed similarly well to other NDC classification routines using commercial databases. A check of a small, random sample of non-active NDC found the pipeline to be accurate for classifying these codes. Conclusion: The RxNorm NDC classification pipeline is a practical and reliable tool for categorizing drugs in large-scale administrative claims data.

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arXiv2024

Learning Optimal Dynamic Treatment Regimes from Longitudinal Data

Studies often report estimates of the average treatment effect. While the ATE summarizes the effect of a treatment on average, it does not provide any information about the effect of treatment within any individual. A treatment strategy that uses an individual's information to tailor treatment to maximize benefit is known as an optimal dynamic treatment rule. Treatment, however, is typically not limited to a single point in time; consequently, learning an optimal rule for a time-varying treatment may involve not just learning the extent to which the comparative treatments' benefits vary across the characteristics of individuals, but also learning the extent to which the comparative treatments' benefits vary as relevant circumstances evolve within an individual. The goal of this paper is to provide a tutorial for estimating ODTR from longitudinal observational and clinical trial data for applied researchers. We describe an approach that uses a doubly-robust unbiased transformation of the conditional average treatment effect. We then learn a time-varying ODTR for when to increase buprenorphine-naloxone dose to minimize return-to-regular-opioid-use among patients with opioid use disorder. Our analysis highlights the utility of ODTRs in the context of sequential decision making: the learned ODTR outperforms a clinically defined strategy.

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