Uncertainty Reliability Under Domain Shift: An Investigation for Data-Driven Blood Pressure Estimation in Photoplethysmography
Authors: Mohammad Moulaeifard, Ciaran Bench, Philip J. Aston, Nils Strodthoff
Organizations: AI4Health Department, University of Oldenburg, Oldenburg, Germany · Department of Data Science and AI, National Physical Laboratory, Teddington, United Kingdom · School of Mathematics and Physics, University of Surrey, Surrey, United Kingdom
Abstract
Uncertainty quantification (UQ) is critical for safety-critical domains like healthcare, yet it is rarely evaluated under realistic out-of-distribution (OOD) conditions. Here, we assessed predictive performance and uncertainty reliability for deep learning-based blood pressure (BP) estimation from photoplethysmography (PPG) signals under both in-distribution (ID) and OOD settings. Using an XResNet1D-50 trained on PulseDB and tested on four external datasets, we compared deep ensembles (DE) and Monte Carlo dropout (MCD) with Gaussian negative log-likelihood (GNLL) and mean squared error (MSE) losses, optionally followed by post-hoc recalibration via conformal prediction (CP), temperature scaling (TS), and isotonic regression (IR). The key findings of our study are as follows: (1) DE provides stronger predictive robustness under domain shift than MCD, an advantage that becomes clear primarily under external shift. (2) Recalibrated GNLL-based methods yield the best uncertainty calibration (e.g., GNLL+DE+CP for systolic blood pressure (SBP), GNLL+DE+TS for diastolic blood pressure (DBP)), while MSE-based uncertainty requires recalibration to become practically useful. (3) Across settings, CP and TS offer the most consistent gains, with IR remaining competitive in several cases. Overall, our results identify DE-based methods as most robust for predictive performance under domain shift, GNLL as strongest for native UQ, and recalibration as essential for making MSE-based uncertainty practical. These findings highlight the need to jointly assess predictive accuracy and calibration on external data for trustworthy cuffless BP estimation
In principle, deep generative models can be used to perform domain adaptation; i.e. align the input feature representations of test data with that of a separate discriminative model's training data. This can help improve the discriminative model's performance on the test data. However, generative models are prone to producing hallucinations and artefacts that may degrade the quality of generated data, and therefore, predictive performance when processed by the discriminative model. While uncertainty quantification can provide a means to assess the quality of adapted data, the standard framework for evaluating the quality of predicted uncertainties may not easily extend to generative models due to the common lack of ground truths (among other reasons). Even with ground truths, this evaluation is agnostic to how the generated outputs are used on the downstream task, limiting the extent to which the uncertainty reliability analysis provides insights about the utility of the uncertainties with respect to the intended use case of the adapted examples. Here, we describe how decision-theoretic uncertainty quantification can address these concerns and provide a convenient framework for evaluating the trustworthiness of generated outputs, in particular, for domain adaptation. We consider a case study in photoplethysmography time series denoising for Atrial Fibrillation classification. This formalises a well-known heuristic method of using a downstream classifier to assess the quality of generated outputs.
This Good Practice Guide presents work done in the QUMPHY project (Uncertainty quantification for machine learning models applied to photoplethysmography signals) that considered both machine learning and uncertainty quantification for problems which used photoplethysmography (PPG) signals from wearable devices as input. It provides high-level guidance on what types of machine learning model might be used and how different models compare when applied to both regression and classification tasks. It provides guidance on the implementation of different methods for uncertainty quantification, covering both model-dependent and model-independent techniques, and on the validation of the results provided by those methods. It also describes six benchmark problems together with pointers to different benchmark datasets for each problem. Software is described that can assist practitioners in implementing the methods described herein and there is a brief consideration of ethical issues. It concludes with a summary and recommendations.
Continuous cuffless blood pressure (BP) monitoring is essential for connected health systems and wearable devices, enabling early detection, longitudinal tracking, and personalized management of cardiovascular disease. Many prior approaches attempt to estimate BP indirectly by reconstructing electrocardiography (ECG) from photoplethysmography (PPG), assuming ECG provides a stronger physiological link to BP. However, ECG sensing is less accessible in wearable settings and may introduce unnecessary complexity. In this work, we first perform a large-scale physiological correlation analysis on the MIMIC-III waveform database, revealing that PPG exhibits substantially stronger coupling with arterial blood pressure (ABP) (∣r∣=0.247, p<0.001) than ECG does (r=0.018, p=0.187), challenging the assumption that ECG provides a superior intermediate representation. Motivated by this insight, we conduct a systematic comparison between direct PPG-to-BP prediction and ECG-mediated pipelines using multiple state-of-the-art deep learning models. Across 1.74M segments from 3,127 patients, direct PPG-to-BP prediction achieves British Hypertension Society Grade A performance (MAESBP=4.82mmHg, MAEDBP=4.31mmHg), outperforming all ECG-mediated approaches, which achieve only Grade B accuracy. Our findings suggest that accurate continuous BP monitoring can be achieved directly from wearable PPG signals, enabling simpler, more efficient pipelines for real-world connected health systems.