A Unified Causal Inference Framework for the Desirability of Outcome Ranking Paradigm in Benefit-Risk Evaluation

• URL: http://arxiv.org/abs/2608.05244v1
• Date: Wed, 05 Aug 2026 14:57:06 GMT
• Title: A Unified Causal Inference Framework for the Desirability of Outcome Ranking Paradigm in Benefit-Risk Evaluation
• Abstract summary: The framework expresses the DOOR probability as a bilinear functional of the marginal ordinal outcome distributions under two treatment strategies.<n>Point-estimation simulations compared G-computation, normalized inverse probability weighting (IPW), augmented IPW (AIPW), and targeted maximum likelihood estimation (TMLE)<n>CVTMLE-SL showed the strongest overall performance across DOOR-scale bias, recovery of the underlying ordinal distributions, standard-error accuracy, and confidence-interval coverage.
• Score: 4.180783670528547
• License: http://creativecommons.org/licenses/by-nc-nd/4.0/
• Abstract: We developed a unified covariate-adjusted causal inference framework for estimating the desirability of outcome ranking (DOOR) probability for benefit-risk evaluation in randomized trials and observational studies. The framework expresses the DOOR probability as a bilinear functional of the marginal ordinal outcome distributions under the two treatment strategies, estimates conditional ordinal distributions through sequential risk-set hazards, and derives the efficient influence function (EIF) of the DOOR probability. The point-estimation simulations compared G-computation, normalized inverse probability weighting (IPW), augmented IPW (AIPW), and targeted maximum likelihood estimation (TMLE), with nuisance functions estimated using generalized linear models or Super Learner (SL). TMLE-SL showed the strongest and most consistent point-estimation performance, with AIPW-SL ranking second. EIF-based inference was then evaluated for AIPW-SL and TMLE-SL, with and without cross-fitting, across settings varying in overlap, treatment-effect heterogeneity, and treatment allocation. CVTMLE-SL showed the strongest overall performance across DOOR-scale bias, recovery of the underlying ordinal distributions, standard-error accuracy, and confidence-interval coverage. We illustrate the methodology using data from the multidrug-resistant organism network of the Antibacterial Resistance Leadership Group.

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