Targeted maximum likelihood estimation (TMLE) is a widely used debiasing algorithm for plug-in estimation. While its statistical guarantees, such as double robustness and asymptotic efficiency, are well-studied, the convergence properties of TMLE as an iterative optimization scheme have remained underexplored. To bridge this gap, we study TMLE's iterative updates through an optimization-theoretic lens, establishing global convergence under standard assumptions and regularity conditions. We begin by providing the first complete characterization of different stopping criteria and their relationship to convergence in TMLE. Next, we provide geometric insights.

Targeted maximum likelihood estimation (TMLE) is a widely used debiasing algorithm for plug-in estimation. While its statistical guarantees, such as double robustness and asymptotic efficiency, are well-studied, the convergence properties of TMLE as an iterative optimization scheme have remained underexplored. To bridge this gap, we study TMLE's iterative updates through an optimization-theoretic lens, establishing global convergence under standard assumptions and regularity conditions. We begin by providing the first complete characterization of different stopping criteria and their relationship to convergence in TMLE. Next, we provide geometric insights.

Synthetic tabular data are often evaluated by distributional similarity, privacy distance, or train-on-synthetic-test-on-real predictive performance, but these criteria do not ensure validity for causal inference. We show that fully generative tabular synthesizers, including GAN- and LLM-based models, can preserve predictive utility while distorting average treatment effect (ATE) estimates. The failure is structural: ATE preservation requires both a realistic covariate law and an accurate treatment-effect contrast, whereas prediction loss penalizes treatment-effect error only through an overlap-weighted term. We formalize this mismatch through sensitivity and loss-decomposition results, and identify an analogous decomposition in block-level next-token prediction under log loss. Motivated by the tabular causal analysis, we propose a hybrid synthetic-data framework that generates covariates while modeling treatment and outcome mechanisms separately, allowing causal-purpose treatment assignment such as randomized synthetic assignment. We evaluate this framework in three settings: ATE preservation under fully generative versus hybrid synthesis, targeted augmentation for practical positivity problems, and synthetic simulation engines for comparing OR, IPW, AIPW, and TMLE before real-data analysis. Across synthetic and ACTG experiments, hybrid synthesis improves causal fidelity relative to fully generative baselines; LLM-based hybrid synthesis is often more faithful than CTGAN for ATE preservation and finite-sample estimator benchmarking.

A targeted learning (TL) framework is developed to estimate the difference in the restricted mean survival time (RMST) for a clinical trial with time-to-event outcomes. The approach starts by defining the target estimand as the RMST difference between investigational and control treatments. Next, an efficient estimation method is introduced: a targeted minimum loss estimator (TMLE) utilizing pseudo-observations. Moreover, a version of the copy reference (CR) approach is developed to perform a sensitivity analysis for right-censoring. The proposed TL framework is demonstrated using a real data application.

Covariate adjustment is an approach to improve the precision of trial analyses by adjusting for baseline variables that are prognostic of the primary endpoint. Motivated by the SEARCH Universal HIV Test-and-Treat Trial (2013-2017), we tell our story of developing, evaluating, and implementing a machine learning-based approach for covariate adjustment. We provide the rationale for as well as the practical concerns with such an approach for estimating marginal effects. Using schematics, we illustrate our procedure: targeted machine learning estimation (TMLE) with Adaptive Pre-specification. Briefly, sample-splitting is used to data-adaptively select the combination of estimators of the outcome regression (i.e., the conditional expectation of the outcome given the trial arm and covariates) and known propensity score (i.e., the conditional probability of being randomized to the intervention given the covariates) that minimizes the cross-validated variance estimate and, thereby, maximizes empirical efficiency. We discuss our approach for evaluating finite sample performance with parametric and plasmode simulations, pre-specifying the Statistical Analysis Plan, and unblinding in real-time on video conference with our colleagues from around the world. We present the results from applying our approach in the primary, pre-specified analysis of 8 recently published trials (2022-2024). We conclude with practical recommendations and an invitation to implement our approach in the primary analysis of your next trial.

This note introduces a unified theory for causal inference that integrates Riesz regression, covariate balancing, density-ratio estimation (DRE), targeted maximum likelihood estimation (TMLE), and the matching estimator in average treatment effect (ATE) estimation. In ATE estimation, the balancing weights and the regression functions of the outcome play important roles, where the balancing weights are referred to as the Riesz representer, bias-correction term, and clever covariates, depending on the context. Riesz regression, covariate balancing, DRE, and the matching estimator are methods for estimating the balancing weights, where Riesz regression is essentially equivalent to DRE in the ATE context, the matching estimator is a special case of DRE, and DRE is in a dual relationship with covariate balancing. TMLE is a method for constructing regression function estimators such that the leading bias term becomes zero. Nearest Neighbor Matching is equivalent to Least Squares Density Ratio Estimation and Riesz Regression.

We evaluate the performance of targeted maximum likelihood estimation (TMLE) for estimating the average treatment effect in missing data scenarios under varying levels of positivity violations. We employ model- and design-based simulations, with the latter using undersmoothed highly adaptive lasso on the 'WASH Benefits Bangladesh' dataset to mimic real-world complexities. Five missingness-directed acyclic graphs are considered, capturing common missing data mechanisms in epidemiological research, particularly in one-point exposure studies. These mechanisms include also not-at-random missingness in the exposure, outcome, and confounders. We compare eight missing data methods in conjunction with TMLE as the analysis method, distinguishing between non-multiple imputation (non-MI) and multiple imputation (MI) approaches. The MI approaches use both parametric and machine-learning models. Results show that non-MI methods, particularly complete cases with TMLE incorporating an outcome-missingness model, exhibit lower bias compared to all other evaluated missing data methods and greater robustness against positivity violations across. In Comparison MI with classification and regression trees (CART) achieve lower root mean squared error, while often maintaining nominal coverage rates. Our findings highlight the trade-offs between bias and coverage, and we recommend using complete cases with TMLE incorporating an outcome-missingness model for bias reduction and MI CART when accurate confidence intervals are the priority.