# 7 The TMLE Framework

*Jeremy Coyle*

Based on the `tmle3`

`R`

package.

## 7.1 Learning Objectives

By the end of this chapter, you will be able to

- Understand why we use TMLE for effect estimation.
- Use
`tmle3`

to estimate an Average Treatment Effect (ATE). - Understand how to use
`tmle3`

“Specs” objects. - Fit
`tmle3`

for a custom set of target parameters. - Use the delta method to estimate transformations of target parameters.

## 7.2 Introduction

In the previous chapter on `sl3`

we learned how to estimate a regression
function like \(\mathbb{E}[Y \mid X]\) from data. That’s an important first step
in learning from data, but how can we use this predictive model to estimate
statistical and causal effects?

Going back to the roadmap for targeted learning, suppose we’d like to estimate the effect of a treatment variable \(A\) on an outcome \(Y\). As discussed, one potential parameter that characterizes that effect is the Average Treatment Effect (ATE), defined as \(\psi_0 = \mathbb{E}_W[\mathbb{E}[Y \mid A=1,W] - \mathbb{E}[Y \mid A=0,W]]\) and interpreted as the difference in mean outcome under when treatment \(A=1\) and \(A=0\), averaging over the distribution of covariates \(W\). We’ll illustrate several potential estimators for this parameter, and motivate the use of the TMLE (targeted maximum likelihood estimation; targeted minimum loss-based estimation) framework, using the following example data:

The small ticks on the right indicate the mean outcomes (averaging over \(W\)) under \(A=1\) and \(A=0\) respectively, so their difference is the quantity we’d like to estimate.

While we hope to motivate the application of TMLE in this chapter, we refer the interested reader to the two Targeted Learning books and associated works for full technical details.

## 7.3 Substitution Estimators

We can use `sl3`

to fit a Super Learner or other regression model to estimate
the outcome regression function \(\mathbb{E}_0[Y \mid A,W]\), which we often refer
to as \(\overline{Q}_0(A,W)\) and whose estimate we denote \(\overline{Q}_n(A,W)\).
To construct an estimate of the ATE \(\psi_n\), we need only “plug-in” the
estimates of \(\overline{Q}_n(A,W)\), evaluated at the two intervention contrasts,
to the corresponding ATE “plug-in” formula:
\(\psi_n = \frac{1}{n}\sum(\overline{Q}_n(1,W)-\overline{Q}_n(0,W))\). This kind
of estimator is called a *plug-in* or *substitution* estimator, since accurate
estimates \(\psi_n\) of the parameter \(\psi_0\) may be obtained by substituting
estimates \(\overline{Q}_n(A,W)\) for the relevant regression functions
\(\overline{Q}_0(A,W)\) themselves.

Applying `sl3`

to estimate the outcome regression in our example, we can see
that the ensemble machine learning predictions fit the data quite well:

The solid lines indicate the `sl3`

estimate of the regression function, with the
dotted lines indicating the `tmle3`

updates (described below).

While substitution estimators are intuitive, naively using this approach with a
Super Learner estimate of \(\overline{Q}_0(A,W)\) has several limitations. First,
Super Learner is selecting learner weights to minimize risk across the entire
regression function, instead of “targeting” the ATE parameter we hope to
estimate, leading to biased estimation. That is, `sl3`

is trying to do well on
the full regression curve on the left, instead of focusing on the small ticks on
the right. What’s more, the sampling distribution of this approach is not
asymptotically linear, and therefore inference is not possible.

We can see these limitations illustrated in the estimates generated for the example data:

We see that Super Learner, estimates the true parameter value (indicated by the dashed vertical line) more accurately than GLM. However, it is still less accurate than TMLE, and valid inference is not possible. In contrast, TMLE achieves a less biased estimator and valid inference.

## 7.4 Targeted Maximum Likelihood Estimation

TMLE takes an initial estimate \(\overline{Q}_n(A,W)\) as well as an estimate of
the propensity score \(g_n(A \mid W) = \mathbb{P}(A = 1 \mid W)\) and produces an
updated estimate \(\overline{Q}^{\star}_n(A,W)\) that is “targeted” to the
parameter of interest. TMLE keeps the benefits of substitution estimators (it is
one), but augments the original, potentially erratic estimates to *correct for
bias* while also resulting in an *asymptotically linear* (and thus normally
distributed) estimator that accommodates inference via asymptotically consistent
Wald-style confidence intervals.

### 7.4.1 TMLE Updates

There are different types of TMLEs (and, sometimes, multiple for the same set of
target parameters) – below, we give an example of the algorithm for TML
estimation of the ATE. \(\overline{Q}^{\star}_n(A,W)\) is the TMLE-augmented
estimate \(f(\overline{Q}^{\star}_n(A,W)) = f(\overline{Q}_n(A,W)) + \epsilon \cdot H_n(A,W)\), where \(f(\cdot)\) is the appropriate link function (e.g.,
\(\text{logit}(x) = \log(x / (1 - x))\)), and an estimate \(\epsilon_n\) of the
coefficient \(\epsilon\) of the “clever covariate” \(H_n(A,W)\) is computed. The
form of the covariate \(H_n(A,W)\) differs across target parameters; in this case
of the ATE, it is \(H_n(A,W) = \frac{A}{g_n(A \mid W)} - \frac{1-A}{1-g_n(A, W)}\), with \(g_n(A,W) = \mathbb{P}(A=1 \mid W)\) being the estimated propensity
score, so the estimator depends both on the initial fit (by `sl3`

) of the
outcome regression (\(\overline{Q}_n\)) and of the propensity score (\(g_n\)).

There are several robust augmentations that are used across the `tlverse`

,
including the use of an additional layer of cross-validation to avoid
over-fitting bias (i.e., CV-TMLE) as well as approaches for more consistently
estimating several parameters simultaneously (e.g., the points on a survival
curve).

### 7.4.2 Statistical Inference

Since TMLE yields an **asymptotically linear** estimator, obtaining statistical
inference is very convenient. Each TML estimator has a corresponding
**(efficient) influence function** (often, “EIF”, for short) that describes the
asymptotic distribution of the estimator. By using the estimated EIF, Wald-style
inference (asymptotically correct confidence intervals) can be constructed
simply by plugging into the form of the EIF our initial estimates
\(\overline{Q}_n\) and \(g_n\), then computing the sample standard error.

The following sections describe both a simple and more detailed way of
specifying and estimating a TMLE in the `tlverse`

. In designing `tmle3`

, we
sought to replicate as closely as possible the very general estimation framework
of TMLE, and so each theoretical object relevant to TMLE is encoded in a
corresponding software object/method. First, we will present the simple
application of `tmle3`

to the WASH Benefits example, and then go on to describe
the underlying objects in greater detail.

##
7.5 Easy-Bake Example: `tmle3`

for ATE

We’ll illustrate the most basic use of TMLE using the WASH Benefits data introduced earlier and estimating an average treatment effect.

### 7.5.2 Define the variable roles

We’ll use the common \(W\) (covariates), \(A\) (treatment/intervention), \(Y\)
(outcome) data structure. `tmle3`

needs to know what variables in the dataset
correspond to each of these roles. We use a list of character vectors to tell
it. We call this a “Node List” as it corresponds to the nodes in a Directed
Acyclic Graph (DAG), a way of displaying causal relationships between variables.

```
node_list <- list(
W = c(
"month", "aged", "sex", "momage", "momedu",
"momheight", "hfiacat", "Nlt18", "Ncomp", "watmin",
"elec", "floor", "walls", "roof", "asset_wardrobe",
"asset_table", "asset_chair", "asset_khat",
"asset_chouki", "asset_tv", "asset_refrig",
"asset_bike", "asset_moto", "asset_sewmach",
"asset_mobile"
),
A = "tr",
Y = "whz"
)
```

### 7.5.3 Handle Missingness

Currently, missingness in `tmle3`

is handled in a fairly simple way:

- Missing covariates are median- (for continuous) or mode- (for discrete)
imputed, and additional covariates indicating imputation are generated, just
as described in the
`sl3`

chapter. - Missing treatment variables are excluded – such observations are dropped.
- Missing outcomes are efficiently handled by the automatic calculation (and
incorporation into estimators) of
*inverse probability of censoring weights*(IPCW); this is also known as IPCW-TMLE and may be thought of as a joint intervention to remove missingness and is analogous to the procedure used with classical inverse probability weighted estimators.

These steps are implemented in the `process_missing`

function in `tmle3`

:

```
processed <- process_missing(washb_data, node_list)
washb_data <- processed$data
node_list <- processed$node_list
```

### 7.5.4 Create a “Spec” Object

`tmle3`

is general, and allows most components of the TMLE procedure to be
specified in a modular way. However, most users will not be interested in
manually specifying all of these components. Therefore, `tmle3`

implements a
`tmle3_Spec`

object that bundles a set of components into a *specification*
(“Spec”) that, with minimal additional detail, can be run to fit a TMLE.

We’ll start with using one of the specs, and then work our way down into the
internals of `tmle3`

.

```
ate_spec <- tmle_ATE(
treatment_level = "Nutrition + WSH",
control_level = "Control"
)
```

### 7.5.5 Define the learners

Currently, the only other thing a user must define are the `sl3`

learners used
to estimate the relevant factors of the likelihood: Q and g.

This takes the form of a list of `sl3`

learners, one for each likelihood factor
to be estimated with `sl3`

:

```
# choose base learners
lrnr_mean <- make_learner(Lrnr_mean)
lrnr_rf <- make_learner(Lrnr_ranger)
# define metalearners appropriate to data types
ls_metalearner <- make_learner(Lrnr_nnls)
mn_metalearner <- make_learner(
Lrnr_solnp, metalearner_linear_multinomial,
loss_loglik_multinomial
)
sl_Y <- Lrnr_sl$new(
learners = list(lrnr_mean, lrnr_rf),
metalearner = ls_metalearner
)
sl_A <- Lrnr_sl$new(
learners = list(lrnr_mean, lrnr_rf),
metalearner = mn_metalearner
)
learner_list <- list(A = sl_A, Y = sl_Y)
```

Here, we use a Super Learner as defined in the previous chapter. In the future, we plan to include reasonable defaults learners.

### 7.5.6 Fit the TMLE

We now have everything we need to fit the tmle using `tmle3`

:

```
tmle_fit <- tmle3(ate_spec, washb_data, node_list, learner_list)
print(tmle_fit)
#> A tmle3_Fit that took 1 step(s)
#> type param init_est tmle_est se
#> 1: ATE ATE[Y_{A=Nutrition + WSH}-Y_{A=Control}] -0.005231 0.00812 0.050679
#> lower upper psi_transformed lower_transformed upper_transformed
#> 1: -0.091208 0.10745 0.00812 -0.091208 0.10745
```

### 7.5.7 Evaluate the Estimates

We can see the summary results by printing the fit object. Alternatively, we can extra results from the summary by indexing into it:

```
estimates <- tmle_fit$summary$psi_transformed
print(estimates)
#> [1] 0.00812
```

##
7.6 `tmle3`

Components

Now that we’ve successfully used a spec to obtain a TML estimate, let’s look under the hood at the components. The spec has a number of functions that generate the objects necessary to define and fit a TMLE.

###
7.6.1 `tmle3_task`

First is, a `tmle3_Task`

, analogous to an `sl3_Task`

, containing the data we’re
fitting the TMLE to, as well as an NPSEM generated from the `node_list`

defined above, describing the variables and their relationships.

`tmle_task <- ate_spec$make_tmle_task(washb_data, node_list)`

```
tmle_task$npsem
#> $W
#> tmle3_Node: W
#> Variables: month, aged, sex, momedu, hfiacat, Nlt18, Ncomp, watmin, elec, floor, walls, roof, asset_wardrobe, asset_table, asset_chair, asset_khat, asset_chouki, asset_tv, asset_refrig, asset_bike, asset_moto, asset_sewmach, asset_mobile, momage, momheight, delta_momage, delta_momheight
#> Parents:
#>
#> $A
#> tmle3_Node: A
#> Variables: tr
#> Parents: W
#>
#> $Y
#> tmle3_Node: Y
#> Variables: whz
#> Parents: A, W
```

### 7.6.2 Initial Likelihood

Next, is an object representing the likelihood, factorized according to the NPSEM described above:

```
initial_likelihood <- ate_spec$make_initial_likelihood(
tmle_task,
learner_list
)
print(initial_likelihood)
#> W: Lf_emp
#> A: LF_fit
#> Y: LF_fit
```

These components of the likelihood indicate how the factors were estimated: the
marginal distribution of \(W\) was estimated using NP-MLE, and the conditional
distributions of \(A\) and \(Y\) were estimated using `sl3`

fits (as defined with
the `learner_list`

) above.

We can use this in tandem with the `tmle_task`

object to obtain likelihood
estimates for each observation:

```
initial_likelihood$get_likelihoods(tmle_task)
#> W A Y
#> 1: 0.00021299 0.34925 -0.35834
#> 2: 0.00021299 0.36117 -0.93261
#> 3: 0.00021299 0.34740 -0.80873
#> 4: 0.00021299 0.34248 -0.94020
#> 5: 0.00021299 0.34134 -0.57866
#> ---
#> 4691: 0.00021299 0.23375 -0.58997
#> 4692: 0.00021299 0.23366 -0.22769
#> 4693: 0.00021299 0.22660 -0.74235
#> 4694: 0.00021299 0.28944 -0.91796
#> 4695: 0.00021299 0.19533 -1.03878
```

### 7.6.3 Targeted Likelihood (updater)

We also need to define a “Targeted Likelihood” object. This is a special type
of likelihood that is able to be updated using an `tmle3_Update`

object. This
object defines the update strategy (e.g., submodel, loss function, CV-TMLE or
not).

`targeted_likelihood <- Targeted_Likelihood$new(initial_likelihood)`

When constructing the targeted likelihood, you can specify different update
options. See the documentation for `tmle3_Update`

for details of the different
options. For example, you can disable CV-TMLE (the default in `tmle3`

) as
follows:

```
targeted_likelihood_no_cv <-
Targeted_Likelihood$new(initial_likelihood,
updater = list(cvtmle = FALSE)
)
```

### 7.6.4 Parameter Mapping

Finally, we need to define the parameters of interest. Here, the spec defines a single parameter, the ATE. In the next section, we’ll see how to add additional parameters.

```
tmle_params <- ate_spec$make_params(tmle_task, targeted_likelihood)
print(tmle_params)
#> [[1]]
#> Param_ATE: ATE[Y_{A=Nutrition + WSH}-Y_{A=Control}]
```

### 7.6.5 Putting it all together

Having used the spec to manually generate all these components, we can now
manually fit a `tmle3`

:

```
tmle_fit_manual <- fit_tmle3(
tmle_task, targeted_likelihood, tmle_params,
targeted_likelihood$updater
)
print(tmle_fit_manual)
#> A tmle3_Fit that took 1 step(s)
#> type param init_est tmle_est se
#> 1: ATE ATE[Y_{A=Nutrition + WSH}-Y_{A=Control}] -0.0045451 0.01174 0.050807
#> lower upper psi_transformed lower_transformed upper_transformed
#> 1: -0.08784 0.11132 0.01174 -0.08784 0.11132
```

The result is equivalent to fitting using the `tmle3`

function as above.

##
7.7 Fitting `tmle3`

with multiple parameters

Above, we fit a `tmle3`

with just one parameter. `tmle3`

also supports fitting
multiple parameters simultaneously. To illustrate this, we’ll use the
`tmle_TSM_all`

spec:

```
tsm_spec <- tmle_TSM_all()
targeted_likelihood <- Targeted_Likelihood$new(initial_likelihood)
all_tsm_params <- tsm_spec$make_params(tmle_task, targeted_likelihood)
print(all_tsm_params)
#> [[1]]
#> Param_TSM: E[Y_{A=Control}]
#>
#> [[2]]
#> Param_TSM: E[Y_{A=Handwashing}]
#>
#> [[3]]
#> Param_TSM: E[Y_{A=Nutrition}]
#>
#> [[4]]
#> Param_TSM: E[Y_{A=Nutrition + WSH}]
#>
#> [[5]]
#> Param_TSM: E[Y_{A=Sanitation}]
#>
#> [[6]]
#> Param_TSM: E[Y_{A=WSH}]
#>
#> [[7]]
#> Param_TSM: E[Y_{A=Water}]
```

This spec generates a Treatment Specific Mean (TSM) for each level of the exposure variable. Note that we must first generate a new targeted likelihood, as the old one was targeted to the ATE. However, we can recycle the initial likelihood we fit above, saving us a super learner step.

### 7.7.1 Delta Method

We can also define parameters based on Delta Method Transformations of other parameters. For instance, we can estimate a ATE using the delta method and two of the above TSM parameters:

```
ate_param <- define_param(
Param_delta, targeted_likelihood,
delta_param_ATE,
list(all_tsm_params[[1]], all_tsm_params[[4]])
)
print(ate_param)
#> Param_delta: E[Y_{A=Nutrition + WSH}] - E[Y_{A=Control}]
```

This can similarly be used to estimate other derived parameters like Relative Risks, and Population Attributable Risks

### 7.7.2 Fit

We can now fit a TMLE simultaneously for all TSM parameters, as well as the above defined ATE parameter

```
all_params <- c(all_tsm_params, ate_param)
tmle_fit_multiparam <- fit_tmle3(
tmle_task, targeted_likelihood, all_params,
targeted_likelihood$updater
)
print(tmle_fit_multiparam)
#> A tmle3_Fit that took 1 step(s)
#> type param init_est tmle_est
#> 1: TSM E[Y_{A=Control}] -0.5959678 -0.620830
#> 2: TSM E[Y_{A=Handwashing}] -0.6188184 -0.660230
#> 3: TSM E[Y_{A=Nutrition}] -0.6111402 -0.606586
#> 4: TSM E[Y_{A=Nutrition + WSH}] -0.6005128 -0.608949
#> 5: TSM E[Y_{A=Sanitation}] -0.5857464 -0.578472
#> 6: TSM E[Y_{A=WSH}] -0.5205610 -0.448252
#> 7: TSM E[Y_{A=Water}] -0.5657364 -0.537709
#> 8: ATE E[Y_{A=Nutrition + WSH}] - E[Y_{A=Control}] -0.0045451 0.011881
#> se lower upper psi_transformed lower_transformed
#> 1: 0.029901 -0.679435 -0.56223 -0.620830 -0.679435
#> 2: 0.041719 -0.741998 -0.57846 -0.660230 -0.741998
#> 3: 0.042047 -0.688996 -0.52418 -0.606586 -0.688996
#> 4: 0.041285 -0.689867 -0.52803 -0.608949 -0.689867
#> 5: 0.042396 -0.661566 -0.49538 -0.578472 -0.661566
#> 6: 0.045506 -0.537442 -0.35906 -0.448252 -0.537442
#> 7: 0.039253 -0.614644 -0.46077 -0.537709 -0.614644
#> 8: 0.050801 -0.087688 0.11145 0.011881 -0.087688
#> upper_transformed
#> 1: -0.56223
#> 2: -0.57846
#> 3: -0.52418
#> 4: -0.52803
#> 5: -0.49538
#> 6: -0.35906
#> 7: -0.46077
#> 8: 0.11145
```

## 7.8 Exercises

###
7.8.1 Estimation of the ATE with `tmle3`

Follow the steps below to estimate an average treatment effect using data from
the Collaborative Perinatal Project (CPP), available in the `sl3`

package. To
simplify this example, we define a binary intervention variable, `parity01`

–
an indicator of having one or more children before the current child and a
binary outcome, `haz01`

– an indicator of having an above average height for
age.

```
# load the data set
data(cpp)
cpp <- cpp %>%
as_tibble() %>%
dplyr::filter(!is.na(haz)) %>%
mutate(
parity01 = as.numeric(parity > 0),
haz01 = as.numeric(haz > 0)
)
```

- Define the variable roles \((W,A,Y)\) by creating a list of these nodes.
Include the following baseline covariates in \(W\):
`apgar1`

,`apgar5`

,`gagebrth`

,`mage`

,`meducyrs`

,`sexn`

. Both \(A\) and \(Y\) are specified above. The missingness in the data (specifically, the missingness in the columns that are specified in the node list) will need to be taking care of. The`process_missing`

function can be used to accomplish this, like the`washb_data`

example above. - Define a
`tmle3_Spec`

object for the ATE,`tmle_ATE()`

. - Using the same base learning libraries defined above, specify
`sl3`

base learners for estimation of \(\overline{Q}_0 = \mathbb{E}_0(Y \mid A,Y)\) and \(g_0 = \mathbb{P}(A = 1 \mid W)\). - Define the metalearner like below.

```
metalearner <- make_learner(
Lrnr_solnp,
loss_function = loss_loglik_binomial,
learner_function = metalearner_logistic_binomial
)
```

- Define one super learner for estimating \(\overline{Q}_0\) and another for estimating \(g_0\). Use the metalearner above for both super learners.
- Create a list of the two super learners defined in the step above and call
this object
`learner_list`

. The list names should be`A`

(defining the super learner for estimation of \(g_0\)) and`Y`

(defining the super learner for estimation of \(\overline{Q}_0\)). - Fit the TMLE with the
`tmle3`

function by specifying (1) the`tmle3_Spec`

, which we defined in Step 2; (2) the data; (3) the list of nodes, which we specified in Step 1; and (4) the list of super learners for estimation of \(g_0\) and \(\overline{Q}_0\), which we defined in Step 6.*Note*: Like before, you will need to explicitly make a copy of the data (to work around`data.table`

optimizations), e.g., (`cpp2 <- data.table::copy(cpp)`

), then use the`cpp2`

data going forward.

###
7.8.2 Estimation of Strata-Specific ATEs with `tmle3`

For this exercise, we will work with a random sample of 5,000 patients who
participated in the International Stroke Trial (IST). This data is described in
the Chapter 3.2 of the `tlverse`

handbook. We included the data below
and a summarized description that is relevant for this exercise.

The outcome, \(Y\), indicates recurrent ischemic stroke within 14 days after
randomization (`DRSISC`

); the treatment of interest, \(A\), is the randomized
aspirin vs. no aspirin treatment allocation (`RXASP`

in `ist`

); and the
adjustment set, \(W\), consists simply of other variables measured at baseline. In
this data, the outcome is occasionally missing, but there is no need to create a
variable indicating this missingness (such as \(\Delta\)) for analyses in the
`tlverse`

, since the missingness is automatically detected when `NA`

are present
in the outcome. Covariates with missing values (`RATRIAL`

, `RASP3`

and `RHEP24`

)
have already been imputed. Additional covariates were created
(`MISSING_RATRIAL_RASP3`

and `MISSING_RHEP24`

), which indicate whether or not
the covariate was imputed. The missingness was identical for `RATRIAL`

and
`RASP3`

, which is why only one covariate indicating imputation for these two
covariates was created.

- Estimate the average effect of randomized asprin treatment (
`RXASP`

= 1) on recurrent ischemic stroke. Even though the missingness mechanism on \(Y\), \(\Delta\), does not need to be specified in the node list, it does still need to be accounted for in the TMLE. In other words, for this estimation problem, \(\Delta\) is a relevant factor of the likelihood. Thus, when defining the list of`sl3`

learners for each likelihood factor, be sure to include a list of learners for estimation of \(\Delta\), say`sl_Delta`

, and specify this in the learner list, like so`learner_list <- list(A = sl_A, delta_Y = sl_Delta, Y = sl_Y)`

. - Recall that this RCT was conducted internationally. Suposse there is concern
that the dose of asprin may have varied across geographical regions, and an
average across all geographical regions may not be warranted. Calculate the
strata specific ATEs according to geographical region (
`REGION`

).

## 7.9 Summary

`tmle3`

is a general purpose framework for generating TML estimates. The easiest
way to use it is to use a predefined spec, allowing you to just fill in the
blanks for the data, variable roles, and `sl3`

learners. However, digging under
the hood allows users to specify a wide range of TMLEs. In the next sections,
we’ll see how this framework can be used to estimate advanced parameters such as
optimal treatments and stochastic shift interventions.