The value of explicitly emulating a target trial when using real world evidence: an application to colorectal cancer screening

Eur J Epidemiol. 2017 Jun;32(6):495-500. doi: 10.1007/s10654-017-0287-2. Epub 2017 Jul 26.


Observational analyses for causal inference often rely on real world data collected for purposes other than research. A frequent goal of these observational analyses is to use the data to emulate a hypothetical randomized experiment, i.e., the target trial, that mimics the design features of a true experiment, including a clear definition of time zero with synchronization of treatment assignment and determination of eligibility. We review a recent observational analysis that explicitly emulated a target trial of screening colonoscopy using insurance claims from U.S. Medicare. We then compare this explicit emulation with alternative, simpler observational analyses that do not synchronize treatment assignment and eligibility determination at time zero and/or do not allow for repeated eligibility. This empirical comparison suggests that lack of an explicit emulation of the target trial leads to biased estimates, and shows that allowing for repeated eligibility increases the statistical efficiency of the estimates.

Keywords: Causal inference; Colon cancer screening; Target trial.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Colorectal Neoplasms / diagnosis*
  • Comparative Effectiveness Research / statistics & numerical data
  • Early Detection of Cancer*
  • Humans
  • Mass Screening / methods*
  • Medicare / statistics & numerical data*
  • Observational Studies as Topic / statistics & numerical data*
  • United States