Credible ecological inference for medical decisions with personalized risk assessment

Abstract

This paper studies an identification problem that arises when clinicians seek to personalize patient care by predicting health outcomes conditional on observed patient covariates. Let y be an outcome of interest and let (x=k, w=j) be observed patient covariates. Suppose a clinician wants to choose a care option that maximizes a patient's expected utility conditional on the observed covariates. To accomplish this, the clinician needs to know the conditional probability distribution P(y|x=k, w=j). It is common to have a trustworthy evidence‐based risk assessment that predicts y conditional on a subset of the observed covariates, say x, but not conditional on (x, w). Then the clinician knows P(y|x=k) but not P(y|x=k, w=j). Research on the ecological inference problem studies partial identification of P(y|x, w) given knowledge of P(y|x) and P(w|x). Combining this knowledge with structural assumptions yields tighter conclusions. A psychological literature comparing actuarial predictions and clinical judgments has concluded that clinicians should not attempt to subjectively predict patient outcomes conditional on covariates that are not utilized in evidence‐based risk assessments. I argue that formalizing clinical judgment through analysis of the identification problem can improve risk assessments and care decisions.