Investigating for bias in healthcare algorithms: a sex-stratified analysis of supervised machine learning models in liver disease prediction

OBJECTIVES: The Indian Liver Patient Dataset (ILPD) is used extensively to create algorithms that predict liver disease. Given the existing research describing demographic inequities in liver disease diagnosis and management, these algorithms require scrutiny for potential biases. We address this overlooked issue by investigating ILPD models for sex bias. METHODS: Following our literature review of ILPD papers, the models reported in existing studies are recreated and then interrogated for bias. We define four experiments, training on sex-unbalanced/balanced data, with and without feature selection. We build random forests (RFs), support vector machines (SVMs), Gaussian Naïve Bayes and logistic regression (LR) classifiers, running experiments 100 times, reporting average results with SD. RESULTS: We reproduce published models achieving accuracies of >70% (LR 71.31% (2.37 SD) – SVM 79.40% (2.50 SD)) and demonstrate a previously unobserved performance disparity. Across all classifiers females suffer from a higher false negative rate (FNR). Presently, RF and LR classifiers are reported as the most effective models, yet in our experiments they demonstrate the greatest FNR disparity (RF; −21.02%; LR; −24.07%). DISCUSSION: We demonstrate a sex disparity that exists in published ILPD classifiers. In practice, the higher FNR for females would manifest as increased rates of missed diagnosis for female patients and a consequent lack of appropriate care. Our study demonstrates that evaluating biases in the initial stages of machine learning can provide insights into inequalities in current clinical practice, reveal pathophysiological differences between the male and females, and can mitigate the digitisation of inequalities into algorithmic systems. CONCLUSION: Our findings are important to medical data scientists, clinicians and policy-makers involved in the implementation medical artificial intelligence systems. An awareness of the potential biases of these systems is essential in preventing the digital exacerbation of healthcare inequalities.