Confounding Masquerading as Improvement: A Systematic Evaluation of Offline Reinforcement Learning for Stroke Antithrombotic Treatment in a 129,000-Patient Registry

This article explores the application of covariate balance diagnostics for detecting the presence of hidden confounding/model miss-specification in studies applying offline reinforcement learning (RL) to deriving optimal treatment recommendations. The results demonstrate that, either there is a high risk of bias within existing offline RL studies for treatment recommendations or, existing covariate balance metrics are not sufficient to assess such studies. Regardless, existing offline RL studies cannot be concluded as being statistically robust. The conclusions propose future research directions for obtaining more methodologically robust applications of offline RL to treatment recommendation problems.

In offline Reinforcement Learning, immediate rewards in logged batch data are often unobserved due to sparse or irregular record-keeping, or censored beyond certain reward values. This issue arises in practical settings, including health care and marketing. We investigate off-policy evaluation (OPE) in finite-horizon Markov decision processes when rewards are missing not at random (MNAR), which breaks ignorability and induces selection bias even after conditioning on states and actions. To address this, we formalize a reward-dependent propensity model and use future states as shadow variables to identify the full-data conditional mean reward. We further introduce a bridge function that recovers the conditional mean reward without explicitly modeling the MNAR mechanism, and estimate it via a min-max procedure to avoid double sampling. Building upon these identification results, we propose an Fitted-Q-Evaluation-style estimator that propagates the recovered rewards while allowing target policies to depend on past missingness indicators. Finally, we establish consistency and finite-sample error bounds for our OPE estimator, and show through experiments the strong performance of our method compared to existing methods on simulated and MIMIC-III Sepsis data.

We propose a model-free offline multi-step reinforcement learning (RL) algorithm, Conservative Peng's Q($λ$) (CPQL). Our algorithm adapts the Peng's Q($λ$) (PQL) operator for conservative value estimation as an alternative to the Bellman operator. To the best of our knowledge, this is the first work in offline RL to theoretically and empirically demonstrate the effectiveness of conservative value estimation with a \textit{multi-step} operator by fully leveraging offline trajectories. The fixed point of the PQL operator in offline RL lies closer to the value function of the behavior policy, thereby naturally inducing implicit behavior regularization. CPQL simultaneously mitigates over-pessimistic value estimation, achieves performance greater than (or equal to) that of the behavior policy, and provides near-optimal performance guarantees -- a milestone that previous conservative approaches could not achieve. Extensive numerical experiments on the D4RL benchmark demonstrate that CPQL consistently and significantly outperforms existing offline single-step baselines. In addition to the contributions of CPQL in offline RL, our proposed method also contributes to the offline-to-online learning framework. Using the Q-function pre-trained by CPQL in offline settings enables the online PQL agent to avoid the performance drop typically observed at the start of fine-tuning and to attain robust performance improvements. Our code is available at https://github.com/oh-lab/CPQL.