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Fairness in clinical decision-making is a critical element of health equity, but assessing fairness of clinical decisions from observational data is challenging. Recently, many fairness notions have been proposed to quantify fairness in decision-making, among which causality-based fairness notions have gained increasing attention due to its potential in adjusting for confounding and reasoning about bias. However, causal fairness notions remain under-explored in the context of clinical decision-making with large-scale healthcare data. In this work, we propose a Bayesian causal inference approach for assessing a causal fairness notion called principal fairness in clinical settings. We demonstrate our approach using both simulated data and electronic health records (EHR) data.

Data-driven clinical prediction algorithms are used widely by clinicians. Understanding what factors can impact the performance and fairness of data-driven algorithms is an important step towards achieving equitable healthcare. To investigate the impact of modeling choices on the algorithmic performance and fairness, we make use of a case study to build a prediction algorithm for estimating glomerular filtration rate (GFR) based on the patient's electronic health record (EHR). We compare three distinct approaches for estimating GFR: CKD-EPI equations, epidemiological models, and EHR-based models. For epidemiological models and EHR-based models, four machine learning models of varying computational complexity (i.e., linear regression, support vector machine, random forest regression, and neural network) were compared. Performance metrics included root mean squared error (RMSE), median difference, and the proportion of GFR estimates within 30% of the measured GFR value (P30). Differential performance between non-African American and African American group was used to assess algorithmic fairness with respect to race. Our study showed that the variable race had a negligible effect on error, accuracy, and differential performance. Furthermore, including more relevant clinical features (e.g., common comorbidities of chronic kidney disease) and using more complex machine learning models, namely random forest regression, significantly lowered the estimation error of GFR. However, the difference in performance between African American and non-African American patients did not decrease, where the estimation error for African American patients remained consistently higher than non-African American patients, indicating that more objective patient characteristics should be discovered and included to improve algorithm performance.