Death by Round Numbers and Sharp Thresholds: How to Avoid Dangerous AI EHR Recommendations

Real-world evidence is confounded by treatments, so data-driven systems can learn to recapitulate biases that influenced treatment decisions. This confounding presents a challenge: uninterpretable black-box systems can put patients at risk by confusing treatment benefits with intrinsic risk, but also an opportunity: interpretable "glass-box" models can improve medical practice by highlighting unexpected patterns which suggest biases in medical practice. We propose a glass-box model that enables clinical experts to find unexpected changes in patient mortality risk. By applying this model to four datasets, we identify two characteristic types of biases: (1) discontinuities where sharp treatment thresholds produce step-function changes in risk near clinically-important round-number cutoffs, and (2) counter-causal paradoxes where aggressive treatment produces non-monotone risk curves that contradict underlying causal risk by lowering the risk of treated patients below that of healthier, but untreated, patients. While these effects are learned by all accurate models, they are only revealed by interpretable models. We show that because these effects are the result of clinical practice rather than statistical aberration, they are pervasive even in large, canonical datasets. Finally, we apply this method to uncover opportunities for improvements in clinical practice, including 8000 excess deaths per year in the US, where paradoxically, patients with moderately-elevated serum creatinine have higher mortality risk than patients with severely-elevated serum creatinine.