Where Do Target Trials Come From? Specifying the Protocol of a Target Trial When Repurposing Data for Causal...

Descriptions of the target trial framework often appear to assume that investigators knew the protocol of the target trial from the start of the investigation. In practical applications, however, the protocol of the target trial is constrained by the observational data that investigators have access to. When using preexisting observational databases, the target trial protocol typically needs to be iteratively developed as investigators learn about the data. Here we examine the process by which investigators adapt their original causal question, operationalized into the protocol of a hypothetical trial (the index trial), to the available data. This adaptive process results in a final causal question, operationalized into the protocol of another hypothetical trial (the target trial), that depends both on the original causal question and on the available data. As a result, prespecification of an emulatable target trial protocol is not generally possible because adaptations are expected after inspecting the data. The adaptive nature of the specification of the target trial protocol raises important questions about the types of data examinations that are permissible to guide the adaptations, the procedures for transparent reporting of each adaptation and its rationale, and the possibility of prespecifying the rules that will govern the investigators' decisions to adapt the protocol to the data.