arXiv subjects

Maya Petersen

Publications and source records attributed to Maya Petersen.

18 recordsLinked to original sources

arXiv2026

Towards Best Practices for Covariate Adjustment in Regulatory Trials: From Fixed to Data-Adaptive Approaches

While randomization justifies the use of unadjusted effect estimators in randomized trials, there is growing interest in covariate adjustment to improve precision. Adjusting for baseline variables that are prognostic of the outcome can reduce estimator variance, resulting in narrower confidence intervals and increased statistical power. Recent guidance by the U.S. Food and Drug Administration supports fixed adjustment for prognostic covariates using parametric regression models. However, this guidance does not address more flexible approaches using data-adaptive or machine learning methods. We offer our perspectives on covariate adjustment to improve analytic precision. We focus on estimating the average effect for the target population in trials with minimal outcome missingness. We provide a non-technical overview of effect estimators that are unadjusted and effect estimators using fixed versus data-adaptive adjustment. We offer practical suggestions for conducting adjusted analyses that are data-adaptive, fully pre-specified, transparently and reproducibly implemented, robust to model misspecification, and guaranteed to improve precision relative to unadjusted analyses --- all while preserving statistical validity and the causal effect of interest. We hope that sharing our perspectives will foster broader discussion and eventual acceptance of principled, pre-specified, data-adaptive covariate adjustment in randomized trials.

stat.ME↗

arXiv2026

Improving the Efficiency of Subgroup Analysis in Randomized Controlled Trials with TMLE

Subgroup analyses within randomized controlled trials are often underpowered due to limited sample sizes. We address this challenge by leveraging trial participants outside the subgroup of interest to augment estimation within the subgroup. Specifically, we study two Targeted Maximum Likelihood Estimators (TMLEs) that borrow information from non-subgroup participants within the same trial: a TMLE with pooled regression (TMLE-PR) and an Adaptive Targeted Maximum Likelihood Estimator (A-TMLE). Both estimators enable information sharing without relying on any external real-world data, thereby capitalizing on key strengths of the trial: most importantly, the protection against bias afforded by the randomized treatment, but also harmonized data collection, and consistent treatment and outcome definitions. The general strategy proposed here directly advances the priorities of key regulatory agencies, including the FDA, by improving the precision of subgroup-specific treatment effect estimates without introducing external sources of bias, thereby facilitating rigorous inference to support equitable labeling, access, and post-market evaluation. In a case study based on analysis of data from a cardiovascular outcome trial (LEADER, NCT01179048), we estimate the risk reduction of major adverse cardiac events (MACE) under liraglutide treatment among Black and Asian subgroups -- each comprising less than 10\% of the trial population -- using the proposed estimators that borrow information from the remainder of the trial. Using A-TMLE, in particular, we find estimated absolute MACE risk reductions of 1.6, 1.5, and 1.5 percentage points among Asian participants and 2.1, 2.0, and 2.1 percentage points among Black participants at 365, 540, and 730 days, respectively, with 95\% confidence intervals excluding the null at each time point.

stat.ME↗

arXiv2026

Considerations for the Integration of Randomized Controlled Trials and Real-World Data

As clinical decision-making increasingly moves toward individualized and context-specific treatment recommendations, reliance on any single evidence source, randomized or observational, may be insufficient. Principled integration of randomized controlled trials and real-world data, grounded in explicit causal frameworks, offers a path toward evidence that is both internally credible and externally relevant. In this article, we describe distinct objectives for the integration of randomized controlled trials and real-world data and discuss how these objectives shape key design and analytic considerations, illustrating the resulting choices through example estimands. We highlight practical issues that commonly arise in applied settings, including data relevance and curation, cross-source comparability, estimand specification, and sensitivity analysis. We aim for this article to help readers evaluate and implement principled approaches to integrating randomized controlled trials and real-world data in ways that can support more reliable treatment recommendations while maintaining regulatory-grade evidentiary standards.

stat.ME↗

arXiv2025

Deep Causal Behavioral Policy Learning: Applications to Healthcare

We present a deep learning-based approach to studying dynamic clinical behavioral regimes in diverse non-randomized healthcare settings. Our proposed methodology - deep causal behavioral policy learning (DC-BPL) - uses deep learning algorithms to learn the distribution of high-dimensional clinical action paths, and identifies the causal link between these action paths and patient outcomes. Specifically, our approach: (1) identifies the causal effects of provider assignment on clinical outcomes; (2) learns the distribution of clinical actions a given provider would take given evolving patient information; (3) and combines these steps to identify the optimal provider for a given patient type and emulate that provider's care decisions. Underlying this strategy, we train a large clinical behavioral model (LCBM) on electronic health records data using a transformer architecture, and demonstrate its ability to estimate clinical behavioral policies. We propose a novel interpretation of a behavioral policy learned using the LCBM: that it is an efficient encoding of complex, often implicit, knowledge used to treat a patient. This allows us to learn a space of policies that are critical to a wide range of healthcare applications, in which the vast majority of clinical knowledge is acquired tacitly through years of practice and only a tiny fraction of information relevant to patient care is written down (e.g. in textbooks, studies or standardized guidelines).

stat.ML↗

arXiv2024

An Online Meta-Level Adaptive Design Framework with Targeted Learning Inference: Applications to Evaluating and Utilizing Surrogate Outcomes in Adaptive Designs

Adaptive designs are increasingly used in clinical trials and online experiments to improve participant outcomes by dynamically updating treatment allocation as data accumulate. In practice, experimenters often consider multiple candidate designs, each with distinct trade-offs. However, typically only one design is implemented at a time, leaving benefits and costs of alternative designs unobserved and unquantified. To address this, we propose a novel meta-level adaptive design framework that enables real-time, data-driven evaluation and selection among candidate adaptive designs. Specifically, we define a new class of causal estimands to evaluate adaptive designs and propose Targeted Maximum Likelihood Estimators for these estimands. These estimators are asymptotically normal while accommodating dependence in adaptive-design data without parametric assumptions, enabling online selection among candidate designs. We further apply this framework to a motivating example where multiple surrogates of a long-term outcome are considered for updating randomization probabilities in adaptive experiments. Unlike existing surrogate evaluation methods, our approach comprehensively quantifies surrogates' utility to accelerate detection of heterogeneous treatment effects, expedite updates to treatment randomization, and improve participant outcomes, facilitating dynamic selection among surrogate-guided designs. Overall, our framework provides a unified approach for evaluating opportunities and costs of various adaptive designs and guiding real-time decision-making in adaptive experiments.

stat.ME↗

arXiv2024

Large Language Models as Co-Pilots for Causal Inference in Medical Studies

The validity of medical studies based on real-world clinical data, such as observational studies, depends on critical assumptions necessary for drawing causal conclusions about medical interventions. Many published studies are flawed because they violate these assumptions and entail biases such as residual confounding, selection bias, and misalignment between treatment and measurement times. Although researchers are aware of these pitfalls, they continue to occur because anticipating and addressing them in the context of a specific study can be challenging without a large, often unwieldy, interdisciplinary team with extensive expertise. To address this expertise gap, we explore the use of large language models (LLMs) as co-pilot tools to assist researchers in identifying study design flaws that undermine the validity of causal inferences. We propose a conceptual framework for LLMs as causal co-pilots that encode domain knowledge across various fields, engaging with researchers in natural language interactions to provide contextualized assistance in study design. We provide illustrative examples of how LLMs can function as causal co-pilots, propose a structured framework for their grounding in existing causal inference frameworks, and highlight the unique challenges and opportunities in adapting LLMs for reliable use in epidemiological research.

cs.AI↗

arXiv2023

Applying the causal roadmap to longitudinal national Danish registry data: a case study of second-line diabetes medication and dementia

The causal roadmap is a formal framework for causal and statistical inference that supports clear specification of the causal question, interpretable and transparent statement of required causal assumptions, robust inference, and optimal precision. The roadmap is thus particularly well-suited to evaluating longitudinal causal effects using large scale registries; however, application of the roadmap to registry data also introduces particular challenges. In this paper we provide a detailed case study of the longitudinal causal roadmap applied to the Danish National Registry to evaluate the comparative effectiveness of second-line diabetes drugs on dementia risk. Specifically, we evaluate the difference in counterfactual five-year cumulative risk of dementia if a target population of adults with type 2 diabetes had initiated and remained on GLP-1 receptor agonists (a second-line diabetes drug) compared to a range of active comparator protocols. Time-dependent confounding is accounted for through use of the iterated conditional expectation representation of the longitudinal g-formula as a statistical estimand. Statistical estimation uses longitudinal targeted maximum likelihood, incorporating machine learning. We provide practical guidance on the implementation of the roadmap using registry data, and highlight how rare exposures and outcomes over long-term follow up can raise challenges for flexible and robust estimators, even in the context of the large sample sizes provided by the registry. We demonstrate how simulations can be used to help address these challenges by supporting careful estimator pre-specification. We find a protective effect of GLP-1RAs compared to some but not all other second-line treatments.

stat.AP↗

arXiv2023

A Causal Roadmap for Hybrid Randomized and Real-World Data Designs: Case Study of Semaglutide and Cardiovascular Outcomes

Introduction: Increasing interest in real-world evidence has fueled the development of study designs incorporating real-world data (RWD). Using the Causal Roadmap, we specify three designs to evaluate the difference in risk of major adverse cardiovascular events (MACE) with oral semaglutide versus standard-of-care: 1) the actual sequence of non-inferiority and superiority randomized controlled trials (RCTs), 2) a single RCT, and 3) a hybrid randomized-external data study. Methods: The hybrid design considers integration of the PIONEER 6 RCT with RWD controls using the experiment-selector cross-validated targeted maximum likelihood estimator. We evaluate 95% confidence interval coverage, power, and average patient-time during which participants would be precluded from receiving a glucagon-like peptide-1 receptor agonist (GLP1-RA) for each design using simulations. Finally, we estimate the effect of oral semaglutide on MACE for the hybrid PIONEER 6-RWD analysis. Results: In simulations, Designs 1 and 2 performed similarly. The tradeoff between decreased coverage and patient-time without the possibility of a GLP1-RA for Designs 1 and 3 depended on the simulated bias. In real data analysis using Design 3, external controls were integrated in 84% of cross-validation folds, resulting in an estimated risk difference of -1.53%-points (95% CI -2.75%-points to -0.30%-points). Conclusions: The Causal Roadmap helps investigators to minimize potential bias in studies using RWD and to quantify tradeoffs between study designs. The simulation results help to interpret the level of evidence provided by the real data analysis in support of the superiority of oral semaglutide versus standard-of-care for cardiovascular risk reduction.

stat.AP↗

arXiv2023

A Causal Roadmap for Generating High-Quality Real-World Evidence

Increasing emphasis on the use of real-world evidence (RWE) to support clinical policy and regulatory decision-making has led to a proliferation of guidance, advice, and frameworks from regulatory agencies, academia, professional societies, and industry. A broad spectrum of studies use real-world data (RWD) to produce RWE, ranging from randomized controlled trials with outcomes assessed using RWD to fully observational studies. Yet many RWE study proposals lack sufficient detail to evaluate adequacy, and many analyses of RWD suffer from implausible assumptions, other methodological flaws, or inappropriate interpretations. The Causal Roadmap is an explicit, itemized, iterative process that guides investigators to pre-specify analytic study designs; it addresses a wide range of guidance within a single framework. By requiring transparent evaluation of causal assumptions and facilitating objective comparisons of design and analysis choices based on pre-specified criteria, the Roadmap can help investigators to evaluate the quality of evidence that a given study is likely to produce, specify a study to generate high-quality RWE, and communicate effectively with regulatory agencies and other stakeholders. This paper aims to disseminate and extend the Causal Roadmap framework for use by clinical and translational researchers, with companion papers demonstrating application of the Causal Roadmap for specific use cases.

stat.ME↗

arXiv2023

Targeted Maximum Likelihood Based Estimation for Longitudinal Mediation Analysis

Causal mediation analysis with random interventions has become an area of significant interest for understanding time-varying effects with longitudinal and survival outcomes. To tackle causal and statistical challenges due to the complex longitudinal data structure with time-varying confounders, competing risks, and informative censoring, there exists a general desire to combine machine learning techniques and semiparametric theory. In this manuscript, we focus on targeted maximum likelihood estimation (TMLE) of longitudinal natural direct and indirect effects defined with random interventions. The proposed estimators are multiply robust, locally efficient, and directly estimate and update the conditional densities that factorize data likelihoods. We utilize the highly adaptive lasso (HAL) and projection representations to derive new estimators (HAL-EIC) of the efficient influence curves of longitudinal mediation problems and propose a fast one-step TMLE algorithm using HAL-EIC while preserving the asymptotic properties. The proposed method can be generalized for other longitudinal causal parameters that are smooth functions of data likelihoods, and thereby provides a novel and flexible statistical toolbox.

stat.ME↗

arXiv2022

Efficient Targeted Learning of Heterogeneous Treatment Effects for Multiple Subgroups

In biomedical science, analyzing treatment effect heterogeneity plays an essential role in assisting personalized medicine. The main goals of analyzing treatment effect heterogeneity include estimating treatment effects in clinically relevant subgroups and predicting whether a patient subpopulation might benefit from a particular treatment. Conventional approaches often evaluate the subgroup treatment effects via parametric modeling and can thus be susceptible to model mis-specifications. In this manuscript, we take a model-free semiparametric perspective and aim to efficiently evaluate the heterogeneous treatment effects of multiple subgroups simultaneously under the one-step targeted maximum-likelihood estimation (TMLE) framework. When the number of subgroups is large, we further expand this path of research by looking at a variation of the one-step TMLE that is robust to the presence of small estimated propensity scores in finite samples. From our simulations, our method demonstrates substantial finite sample improvements compared to conventional methods. In a case study, our method unveils the potential treatment effect heterogeneity of rs12916-T allele (a proxy for statin usage) in decreasing Alzheimer's disease risk.

stat.ME↗

arXiv2022

Experiment-selector cross-validated targeted maximum likelihood estimator for hybrid RCT-external data studies

Augmenting a randomized controlled trial (RCT) with external data may increase power at the risk of introducing bias. To select and analyze the experiment (RCT alone or combined with external data) with the optimal bias-variance tradeoff, we develop a novel experiment-selector cross-validated targeted maximum likelihood estimator for randomized-external data studies (ES-CVTMLE). This estimator utilizes two estimates of bias to determine whether to integrate external data based on 1) a function of the difference in conditional mean outcome under control between the RCT and combined experiments and 2) an estimate of the average treatment effect on a negative control outcome (NCO). We define the asymptotic distribution of the ES-CVTMLE under varying magnitudes of bias and construct confidence intervals by Monte Carlo simulation. We evaluate ES-CVTMLE compared to three other data fusion estimators in simulations and demonstrate the ability of ES-CVTMLE to distinguish biased from unbiased external controls in a real data analysis of the effect of liraglutide on glycemic control from the LEADER trial. The ES-CVTMLE has the potential to improve power while providing relatively robust inference for future hybrid RCT-external data studies.

stat.ME↗

arXiv2021

The Optimal Dynamic Treatment Rule SuperLearner: Considerations, Performance, and Application

The optimal dynamic treatment rule (ODTR) framework offers an approach for understanding which kinds of patients respond best to specific treatments -- in other words, treatment effect heterogeneity. Recently, there has been a proliferation of methods for estimating the ODTR. One such method is an extension of the SuperLearner algorithm -- an ensemble method to optimally combine candidate algorithms extensively used in prediction problems -- to ODTRs. Following the "causal roadmap," we causally and statistically define the ODTR and provide an introduction to estimating it using the ODTR SuperLearner. Additionally, we highlight practical choices when implementing the algorithm, including choice of candidate algorithms, metalearners to combine the candidates, and risk functions to select the best combination of algorithms. Using simulations, we illustrate how estimating the ODTR using this SuperLearner approach can uncover treatment effect heterogeneity more effectively than traditional approaches based on fitting a parametric regression of the outcome on the treatment, covariates and treatment-covariate interactions. We investigate the implications of choices in implementing an ODTR SuperLearner at various sample sizes. Our results show the advantages of: (1) including a combination of both flexible machine learning algorithms and simple parametric estimators in the library of candidate algorithms; (2) using an ensemble metalearner to combine candidates rather than selecting only the best-performing candidate; (3) using the mean outcome under the rule as a risk function. Finally, we apply the ODTR SuperLearner to the "Interventions" study, an ongoing randomized controlled trial, to identify which justice-involved adults with mental illness benefit most from cognitive behavioral therapy (CBT) to reduce criminal re-offending.

stat.AP↗

arXiv2021

Performance and Application of Estimators for the Value of an Optimal Dynamic Treatment Rule

Given an (optimal) dynamic treatment rule, it may be of interest to evaluate that rule -- that is, to ask the causal question: what is the expected outcome had every subject received treatment according to that rule? In this paper, we study the performance of estimators that approximate the true value of: 1) an $a$ $priori$ known dynamic treatment rule 2) the true, unknown optimal dynamic treatment rule (ODTR); 3) an estimated ODTR, a so-called "data-adaptive parameter," whose true value depends on the sample. Using simulations of point-treatment data, we specifically investigate: 1) the impact of increasingly data-adaptive estimation of nuisance parameters and/or of the ODTR on performance; 2) the potential for improved efficiency and bias reduction through the use of semiparametric efficient estimators; and, 3) the importance of sample splitting based on CV-TMLE for accurate inference. In the simulations considered, there was very little cost and many benefits to using the cross-validated targeted maximum likelihood estimator (CV-TMLE) to estimate the value of the true and estimated ODTR; importantly, and in contrast to non cross-validated estimators, the performance of CV-TMLE was maintained even when highly data-adaptive algorithms were used to estimate both nuisance parameters and the ODTR. In addition, we apply these estimators for the value of the rule to the "Interventions" Study, an ongoing randomized controlled trial, to identify whether assigning cognitive behavioral therapy (CBT) to criminal justice-involved adults with mental illness using an ODTR significantly reduces the probability of recidivism, compared to assigning CBT in a non-individualized way.

stat.ME↗

arXiv2021

Sequential causal inference in a single world of connected units

We consider adaptive designs for a trial involving N individuals that we follow along T time steps. We allow for the variables of one individual to depend on its past and on the past of other individuals. Our goal is to learn a mean outcome, averaged across the N individuals, that we would observe, if we started from some given initial state, and we carried out a given sequence of counterfactual interventions for $τ$ time steps. We show how to identify a statistical parameter that equals this mean counterfactual outcome, and how to perform inference for this parameter, while adaptively learning an oracle design defined as a parameter of the true data generating distribution. Oracle designs of interest include the design that maximizes the efficiency for a statistical parameter of interest, or designs that mix the optimal treatment rule with a certain exploration distribution. We also show how to design adaptive stopping rules for sequential hypothesis testing. This setting presents unique technical challenges. Unlike in usual statistical settings where the data consists of several independent observations, here, due to network and temporal dependence, the data reduces to one single observation with dependent components. In particular, this precludes the use of sample splitting techniques. We therefore had to develop a new equicontinuity result and guarantees for estimators fitted on dependent data. We were motivated to work on this problem by the following two questions. (1) In the context of a sequential adaptive trial with K treatment arms, how to design a procedure to identify in as few rounds as possible the treatment arm with best final outcome? (2) In the context of sequential randomized disease testing at the scale of a city, how to estimate and infer the value of an optimal testing and isolation strategy?

math.ST↗

arXiv2019

Semi-Supervised Record Linkage for Construction of Large-Scale Sociocentric Networks in Resource-limited Settings: An application to the SEARCH Study in Rural Uganda and Kenya

This paper presents a novel semi-supervised algorithmic approach to creating large scale sociocentric networks in rural East Africa. We describe the construction of 32 large-scale sociocentric social networks in rural Sub-Saharan Africa. Networks were constructed by applying a semi-supervised record-linkage algorithm to data from census-enumerated residents of the 32 communities included in the SEARCH study (NCT01864603), a community-cluster randomized HIV prevention trial in Uganda and Kenya. Contacts were solicited using a five question name generator in the domains of emotional support, food sharing, free time, health issues and money issues. The fully constructed networks include 170; 028 nodes and 362; 965 edges aggregated across communities (ranging from 4449 to 6829 nodes and from 2349 to 31,779 edges per community). Our algorithm matched on average 30% of named contacts in Kenyan communities and 50% of named contacts in Ugandan communities to residents named in census enumeration. Assortative mixing measures for eight different covariates reveal that residents in the network have a very strong tendency to associate with others who are similar to them in age, sex, and especially village. The networks in the SEARCH Study will provide a platform for improved understanding of health outcomes in rural East Africa. The network construction algorithm we present may facilitate future social network research in resource-limited settings.

stat.AP↗

arXiv2018

Causal Inference When Counterfactuals Depend on the Proportion of All Subjects Exposed

The assumption that no subject's exposure affects another subject's outcome, known as the no-interference assumption, has long held a foundational position in the study of causal inference. However, this assumption may be violated in many settings, and in recent years has been relaxed considerably. Often this has been achieved with either the aid of a known underlying network, or the assumption that the population can be partitioned into separate groups, between which there is no interference, and within which each subject's outcome may be affected by all the other subjects in the group via the proportion exposed (the stratified interference assumption). In this paper, we instead consider a complete interference setting, in which each subject affects every other subject's outcome. In particular, we make the stratified interference assumption for a single group consisting of the entire sample. This can occur when the exposure is a shared resource whose efficacy is modified by the number of subjects among whom it is shared. We show that a targeted maximum likelihood estimator for the i.i.d.~setting can be used to estimate a class of causal parameters that includes direct effects and overall effects under certain interventions. This estimator remains doubly-robust, semiparametric efficient, and continues to allow for incorporation of machine learning under our model. We conduct a simulation study, and present results from a data application where we study the effect of a nurse-based triage system on the outcomes of patients receiving HIV care in Kenyan health clinics.

stat.ME↗

arXiv2018

Robust variance estimation and inference for causal effect estimation

We consider a longitudinal data structure consisting of baseline covariates, time-varying treatment variables, intermediate time-dependent covariates, and a possibly time dependent outcome. Previous studies have shown that estimating the variance of asymptotically linear estimators using empirical influence functions in this setting result in anti-conservative estimates with increasing magnitudes of positivity violations, leading to poor coverage and uncontrolled Type I errors. In this paper, we present two alternative approaches of estimating the variance of these estimators: (i) a robust approach which directly targets the variance of the influence function as a counterfactual mean outcome, and (ii) a non-parametric bootstrap based approach that is theoretically valid and lowers the computational cost, thereby increasing the feasibility in non-parametric settings using complex machine learning algorithms. The performance of these approaches are compared to that of the empirical influence function in simulations across different levels of positivity violations and treatment effect sizes.

math.ST↗