Comparison of Methods to Reduce Bias From Clinical Prediction Models of Postpartum Depression

IMPORTANCE: The lack of standards in methods to reduce bias for clinical algorithms presents various challenges in providing reliable predictions and in addressing health disparities. OBJECTIVE: To evaluate approaches for reducing bias in machine learning models using a real-world clinical scenario. DESIGN, SETTING, AND PARTICIPANTS: Health data for this cohort study were obtained from the IBM MarketScan Medicaid Database. Eligibility criteria were as follows: (1) Female individuals aged 12 to 55 years with a live birth record identified by delivery-related codes from January 1, 2014, through December 31, 2018; (2) greater than 80% enrollment through pregnancy to 60 days post partum; and (3) evidence of coverage for depression screening and mental health services. Statistical analysis was performed in 2020. EXPOSURES: Binarized race (Black individuals and White individuals). MAIN OUTCOMES AND MEASURES: Machine learning models (logistic regression [LR], random forest, and extreme gradient boosting) were trained for 2 binary outcomes: postpartum depression (PPD) and postpartum mental health service utilization. Risk-adjusted generalized linear models were used for each outcome to assess potential disparity in the cohort associated with binarized race (Black or White). Methods for reducing bias, including reweighing, Prejudice Remover, and removing race from the models, were examined by analyzing changes in fairness metrics compared with the base models. Baseline characteristics of female individuals at the top-predicted risk decile were compared for systematic differences. Fairness metrics of disparate impact (DI, 1 indicates fairness) and equal opportunity difference (EOD, 0 indicates fairness). RESULTS: Among 573 634 female individuals initially examined for this study, 314 903 were White (54.9%), 217 899 were Black (38.0%), and the mean (SD) age was 26.1 (5.5) years. The risk-adjusted odds ratio comparing White participants with Black participants was 2.06 (95% CI, 2.02-2.10) for clinically recognized PPD and 1.37 (95% CI, 1.33-1.40) for postpartum mental health service utilization. Taking the LR model for PPD prediction as an example, reweighing reduced bias as measured by improved DI and EOD metrics from 0.31 and −0.19 to 0.79 and 0.02, respectively. Removing race from the models had inferior performance for reducing bias compared with the other methods (PPD: DI = 0.61; EOD = −0.05; mental health service utilization: DI = 0.63; EOD = −0.04). CONCLUSIONS AND RELEVANCE: Clinical prediction models trained on potentially biased data may produce unfair outcomes on the basis of the chosen metrics. This study’s results suggest that the performance varied depending on the model, outcome label, and method for reducing bias. This approach toward evaluating algorithmic bias can be used as an example for the growing number of researchers who wish to examine and address bias in their data and models.