Generalization in Healthcare AI: Evaluation of a Clinical Large Language Model

Advances in large language models (LLMs) provide new opportunities in healthcare for improved patient care, clinical decision-making, and enhancement of physician and administrator workflows. However, the potential of these models importantly depends on their ability to generalize effectively across clinical environments and populations, a challenge often underestimated in early development. To better understand reasons for these challenges and inform mitigation approaches, we evaluated ClinicLLM, an LLM trained on [HOSPITAL]'s clinical notes, analyzing its performance on 30-day all-cause readmission prediction focusing on variability across hospitals and patient characteristics. We found poorer generalization particularly in hospitals with fewer samples, among patients with government and unspecified insurance, the elderly, and those with high comorbidities. To understand reasons for lack of generalization, we investigated sample sizes for fine-tuning, note content (number of words per note), patient characteristics (comorbidity level, age, insurance type, borough), and health system aspects (hospital, all-cause 30-day readmission, and mortality rates). We used descriptive statistics and supervised classification to identify features. We found that, along with sample size, patient age, number of comorbidities, and the number of words in notes are all important factors related to generalization. Finally, we compared local fine-tuning (hospital specific), instance-based augmented fine-tuning and cluster-based fine-tuning for improving generalization. Among these, local fine-tuning proved most effective, increasing AUC by 0.25% to 11.74% (most helpful in settings with limited data). Overall, this study provides new insights for enhancing the deployment of large language models in the societally important domain of healthcare, and improving their performance for broader populations.

Impact on Public Health Decision Making by Utilizing Big Data Without Domain Knowledge

New data sources, and artificial intelligence (AI) methods to extract information from them are becoming plentiful, and relevant to decision making in many societal applications. An important example is street view imagery, available in over 100 countries, and considered for applications such as assessing built environment aspects in relation to community health outcomes. Relevant to such uses, important examples of bias in the use of AI are evident when decision-making based on data fails to account for the robustness of the data, or predictions are based on spurious correlations. To study this risk, we utilize 2.02 million GSV images along with health, demographic, and socioeconomic data from New York City. Initially, we demonstrate that built environment characteristics inferred from GSV labels at the intra-city level may exhibit inadequate alignment with the ground truth. We also find that the average individual-level behavior of physical inactivity significantly mediates the impact of built environment features by census tract, as measured through GSV. Finally, using a causal framework which accounts for these mediators of environmental impacts on health, we find that altering 10% of samples in the two lowest tertiles would result in a 4.17 (95% CI 3.84 to 4.55) or 17.2 (95% CI 14.4 to 21.3) times bigger decrease on the prevalence of obesity or diabetes, than the same proportional intervention on the number of crosswalks by census tract. This work illustrates important issues of robustness and model specification for informing effective allocation of interventions using new data sources.

Understanding Disparities in Post Hoc Machine Learning Explanation

Previous work has highlighted that existing post-hoc explanation methods exhibit disparities in explanation fidelity (across 'race' and 'gender' as sensitive attributes), and while a large body of work focuses on mitigating these issues at the explanation metric level, the role of the data generating process and black box model in relation to explanation disparities remains largely unexplored. Accordingly, through both simulations as well as experiments on a real-world dataset, we specifically assess challenges to explanation disparities that originate from properties of the data: limited sample size, covariate shift, concept shift, omitted variable bias, and challenges based on model properties: inclusion of the sensitive attribute and appropriate functional form. Through controlled simulation analyses, our study demonstrates that increased covariate shift, concept shift, and omission of covariates increase explanation disparities, with the effect pronounced higher for neural network models that are better able to capture the underlying functional form in comparison to linear models. We also observe consistent findings regarding the effect of concept shift and omitted variable bias on explanation disparities in the Adult income dataset. Overall, results indicate that disparities in model explanations can also depend on data and model properties. Based on this systematic investigation, we provide recommendations for the design of explanation methods that mitigate undesirable disparities.