Abstract

Abstract

Abstract
Algorithmic bias in healthcare mirrors existing data biases. However, the factors driving unfairness are not always known. Medical devices capture significant amounts of data but are prone to errors; for instance, pulse oximeters overestimate the arterial oxygen saturation of darker-skinned individuals, leading to worse outcomes. The impact of this bias in machine learning (ML) models remains unclear. This study addresses the technical challenges of quantifying the impact of medical device bias in downstream ML. Our experiments compare a “perfect world”, without pulse oximetry bias, using SaO2 (blood-gas), to the “actual world”, with biased measurements, using SpO2 (pulse oximetry). Under this counterfactual design, two models are trained with identical data, features, and settings, except for the method of measuring oxygen saturation: models using SaO2 are a “control” and models using SpO2 a “treatment”. The blood-gas oximetry linked dataset was a suitable test-bed, containing 163,396 nearly-simultaneous SpO2 - SaO2 paired measurements, aligned with a wide array of clinical features and outcomes. We studied three classification tasks: in-hospital mortality, respiratory SOFA score in the next 24 h, and SOFA score increase by two points. Models using SaO2 instead of SpO2 generally showed better performance. Patients with overestimation of O2 by pulse oximetry of = 3% had significant decreases in mortality prediction recall, from 0.63 to 0.59, P < 0.001. This mirrors clinical processes where biased pulse oximetry readings provide clinicians with false reassurance of patients’ oxygen levels. A similar degradation happened in ML models, with pulse oximetry biases leading to more false negatives in predicting adverse outcomes. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2025.

Abstract

Abstract

Abstract
In the healthcare context, artificial intelligence (AI) has the potential to power decision support systems and help health professionals in their clinical decisions. However, given its complexity, AI is usually seen as a black box that receives data and outputs a prediction. This behavior may jeopardize the adoption of this technology by the healthcare community, which values the existence of explanations to justify a clinical decision. Besides, the developers must have a strategy to assess and audit these systems to ensure their reproducibility and quality in production. The field of interpretable artificial intelligence emerged to study how these algorithms work and clarify their behavior. This chapter reviews several interpretability of AI algorithms for medical imaging, discussing their functioning, limitations, benefits, applications, and evaluation strategies. The chapter concludes with considerations that might contribute to bringing these methods closer to the daily routine of healthcare professionals. © 2025 Elsevier Inc. All rights reserved.