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Abstract BackgroundMeasuring parathyroid hormone-related peptide (PTHrP) helps diagnose the humoral hypercalcemia of malignancy, but is often ordered for patients with low pretest probability, resulting in poor test utilization. Manual review of results to identify inappropriate PTHrP orders is a cumbersome process. MethodsUsing a dataset of 1330 patients from a single institute, we developed a machine learning (ML) model to predict abnormal PTHrP results. We then evaluated the performance of the model on two external datasets. Different strategies (model transporting, retraining, rebuilding, and fine-tuning) were investigated to improve model generalizability. Maximum mean discrepancy (MMD) was adopted to quantify the shift of data distributions across different datasets. ResultsThe model achieved an area under the receiver operating characteristic curve (AUROC) of 0.936, and a specificity of 0.842 at 0.900 sensitivity in the development cohort. Directly transporting this model to two external datasets resulted in a deterioration of AUROC to 0.838 and 0.737, with the latter having a larger MMD corresponding to a greater data shift compared to the original dataset. Model rebuilding using site-specific data improved AUROC to 0.891 and 0.837 on the two sites, respectively. When external data is insufficient for retraining, a fine-tuning strategy also improved model utility. ConclusionsML offers promise to improve PTHrP test utilization while relieving the burden of manual review. Transporting a ready-made model to external datasets may lead to performance deterioration due to data distribution shift. Model retraining or rebuilding could improve generalizability when there are enough data, and model fine-tuning may be favorable when site-specific data is limited. 

Identifying the causal pathways of unfairness is a critical objective for improving policy design and algorithmic decision-making. Prior work in causal fairness analysis often requires knowledge of the causal graph, hindering practical applications in complex or low-knowledge domains. Moreover, global discovery methods that learn causal structure from data can display unstable performance on finite samples, preventing robust fairness conclusions. To mitigate these challenges, we introduce local discovery for direct discrimination (LD3): a method that uncovers structural evidence of direct unfairness by identifying the causal parents of an outcome variable. LD3 performs a linear number of conditional independence tests relative to variable set size, and allows for latent confounding under the sufficient condition that all parents of the outcome are observed. We show that LD3 returns a valid adjustment set (VAS) under a new graphical criterion for the weighted controlled direct effect, a qualitative indicator of direct discrimination. LD3 limits unnecessary adjustment, providing interpretable VAS for assessing unfairness. We use LD3 to analyze causal fairness in two complex decision systems: criminal recidivism prediction and liver transplant allocation. LD3 was more time-efficient and returned more plausible results on real-world data than baselines, which took 46× to 5870× longer to execute.