Clinical Prediction

Large language models (LLMs), trained on vast datasets, encode extensive real-world knowledge within their parameters, yet their black-box nature obscures the mechanisms and extent of this encoding. Surrogate modeling, which uses simplified models to approximate complex systems, can offer a path toward better interpretability of black-box models. We propose a surrogate modeling framework that quantitatively explains LLM-encoded knowledge. For a specific hypothesis derived from domain knowledge, this framework approximates the latent LLM knowledge space using observable elements (input-output pairs) through extensive prompting across a comprehensive range of simulated scenarios. Through proof-of-concept experiments in medical predictions, we demonstrate our framework's effectiveness in revealing the extent to which LLMs "perceive" each input variable in relation to the output. Particularly, given concerns that LLMs may perpetuate inaccuracies and societal biases embedded in their training data, our experiments using this framework quantitatively revealed both associations that contradict established medical knowledge and the persistence of scientifically refuted racial assumptions within LLM-encoded knowledge. By disclosing these issues, our framework can act as a red-flag indicator to support the safe and reliable application of these models.

Coronary artery disease (CAD) remains one of the leading causes of death globally, highlighting the need for reliable predictive systems to support early diagnosis and risk assessment. While traditional machine learning models perform well on structured clinical data, large language models (LLMs) present new possibilities to interpret medical information expressed in natural language. In this work, we develop a hybrid framework that bridges structured clinical data and natural-language representations for CAD prediction. Using a publicly available dataset of 1,190 patient records with 11 clinical attributes, structured variables are converted into interpretable feature representations and synthetic clinical narratives using LLMs. A validation pipeline performs reverse extraction of clinical variables and computes a consistency score with the original records, achieving an average fidelity of 94.61%. We then evaluate four conventional machine learning models and compare their performance with LLM-based classification under zero-shot and few-shot prompting settings. We use two LLMs here, GPT and Gemini. Experimental results show that Random Forest achieves the highest accuracy. Despite this advantage, LLM-based classification remains beneficial in real-world clinical settings. This is because LLMs operate directly on natural language patient descriptions, meaning that sensitive numerical patient data such as exact lab values, blood pressure readings, and diagnostic codes are kept private. Findings suggest that combining structured clinical data with LLM-generated narratives can enable new directions for hybrid clinical prediction systems.

Scientists have long sought to accurately predict outcomes of real-world events before they happen. Can AI systems do so more reliably? We study this question through clinical trial outcome prediction, a high-stakes open challenge even for domain experts. We introduce CT Open, an open-access, live platform that will run four challenge every year. Anyone can submit predictions for each challenge. CT Open evaluates those submissions on trials whose outcomes were not yet public at the time of submission but were made public afterwards. Determining if a trial's outcome is public on the internet before a certain date is surprisingly difficult. Outcomes posted on official registries may lag behind by years, while the first mention may appear in obscure articles. To address this, we propose a novel, fully automated decontamination pipeline that uses iterative LLM-powered web search to identify the earliest mention of trial outcomes. We validate the pipeline's quality and accuracy by human expert's annotations. Since CT Open's pipeline ensures that every evaluated trial had no publicly reported outcome when the prediction was made, it allows participants to use any methodology and any data source. In this paper, we release a training set and two time-stamped test benchmarks, Winter 2025 and Summer 2025. We believe CT Open can serve as a central hub for advancing AI research on forecasting real-world outcomes before they occur, while also informing biomedical research and improving clinical trial design. CT Open Platform is hosted at $\href{https://ct-open.net/}{https://ct-open.net/}$

Chronic rhinosinusitis (CRS) is a common heterogeneous inflammatory disorder that causes substantial morbidity and healthcare costs. CRS is difficult to identify early from routine encounters, as symptom presentations overlap with common conditions such as allergic rhinitis, and heterogeneous phenotypes further obscure risk patterns. Prior predictive studies often rely on single-institutional cohorts , which reduce population-level generalizability. To overcome this, we leveraged nationwide longitudinal EHR data from the \textit{All of Us} Research Program to predict CRS diagnosis using two years of pre-diagnostic history. To address extreme feature sparsity and dimensionality in coded EHR data, we implemented a hybrid feature-selection pipeline that combines prevalence-based statistical screening with model-based importance ranking, compressing approximately 110,000 candidate codes into 100 interpretable features. To capture demographic heterogeneity, we trained demographic stratified models across six adult sex and life-stage subgroups with subgroup-specific hyperparameter tuning. Our framework achieved an overall AUC of 0.8461, improving discrimination by 0.0168 over the best baseline. These results demonstrate that routinely collected EHR data may support population-representative CRS risk stratification and inform earlier triage and referral prioritization in primary care.

Clinical language models (LMs) are increasingly applied to support clinical risk prediction from free-text notes, yet their uncertainty estimates often remain poorly calibrated and clinically unreliable. In this work, we propose Clinical Uncertainty Risk Alignment (CURA), a framework that aligns clinical LM-based risk estimates and uncertainty with both individual error likelihoods and cohort-level ambiguities. CURA first fine-tunes domain-specific clinical LMs to obtain task-adapted patient embeddings, and then performs uncertainty fine-tuning of a multi-head classifier using a bi-level uncertainty objective. Specifically, an individual-level calibration term aligns predictive uncertainty with each patient's likelihood of error, while a cohort-aware regularizer pulls risk estimates toward event rates in their local neighborhoods in the embedding space and places extra weight on ambiguous cohorts near the decision boundary. We further show that this cohort-aware term can be interpreted as a cross-entropy loss with neighborhood-informed soft labels, providing a label-smoothing view of our method. Extensive experiments on MIMIC-IV clinical risk prediction tasks across various clinical LMs show that CURA consistently improves calibration metrics without substantially compromising discrimination. Further analysis illustrates that CURA reduces overconfident false reassurance and yields more trustworthy uncertainty estimates for downstream clinical decision support.

Objective: Post-traumatic epilepsy (PTE) is a debilitating neurological disorder that develops after traumatic brain injury (TBI). Early prediction of PTE remains challenging due to heterogeneous clinical data, limited positive cases, and reliance on resource-intensive neuroimaging data. We investigate whether routinely collected acute clinical records alone can support early PTE prediction using language model-based approaches. Methods: Using a curated subset of the TRACK-TBI cohort, we developed an automated PTE prediction framework that implements pretrained large language models (LLMs) as fixed feature extractors to encode clinical records. Tabular features, LLM-generated embeddings, and hybrid feature representations were evaluated using gradient-boosted tree classifiers under stratified cross-validation. Results: LLM embeddings achieved performance improvements by capturing contextual clinical information compared to using tabular features alone. The best performance was achieved by a modality-aware feature fusion strategy combining tabular features and LLM embeddings, achieving an AUC-ROC of 0.892 and AUPRC of 0.798. Acute post-traumatic seizures, injury severity, neurosurgical intervention, and ICU stay are key contributors to the predictive performance. Significance: These findings demonstrate that routine acute clinical records contain information suitable for early PTE risk prediction using LLM embeddings in conjunction with gradient-boosted tree classifiers. This approach represents a promising complement to imaging-based prediction.

Virtual-cell models aim to predict how cell populations respond to perturbations, but control and treated cells are measured as unpaired populations, complicating the learning of perturbation-specific effects. We present SCALE, a conditional transport model that represents cells as unordered sets and predicts treated populations without cell-level matching. A shared set-aware encoder and conditional DiT backbone learn latent transport, making endpoint supervision directly delta-aligned without an auxiliary delta objective. Across genetic, chemical, developmental and immune perturbations, SCALE recovered gene-expression changes, response directions and population structure. In CRISPR data with dominant cell-line effects, SCALE outperformed competing methods across seven metrics and maintained separation among gene-target representations rather than collapsing them into a shared region. SCALE further prioritized cytokines predicted to produce distinct immune activation and inflammatory responses. Experiments using matched PBMC samples from three donors confirmed these predicted differences. Together, SCALE enables perturbation-specific prediction from unpaired populations and supports experimental prioritization.

Rare-event prediction is critical in domains such as healthcare, finance, reliability engineering, customer support, aviation safety, where positive outcomes are infrequent yet potentially catastrophic. Extreme class imbalance biases conventional models toward majority-class predictions, limiting recall, calibration, and operational usefulness. We propose LPCORP (Low-Prevalence CORrector for Prediction)*, a two-stage framework that combines reasoning-enhanced prediction with confidence-based outcome correction. A reasoning model first produces enriched predictions from narrative inputs, after which a lightweight classifier evaluates and selectively corrects these outputs to mitigate prevalence-driven bias. In this study we used Logistic-Regression (LR) and a simple Multilayer Perceptron (MLP) classifiers for this purpose. We evaluate LPCORP on real-world datasets from medical and consumer service domains. The results show that this method transforms the original rare-event prediction problem into a more balanced supervised correction task without discarding or resampling observations. Test-set evaluation demonstrates substantially improved performance, particularly in precision, which is a known weakness in low-prevalence data. We further provide a cost-reduction analysis comparing the expenses associated with rare-event damage control without preventive measures to those incurred when low-cost, prediction-based preventive interventions are applied that showed up to 40+% reduction in some cases.

The existence of multiple, equally accurate models for a given predictive task leads to predictive multiplicity, where a Rashomon set of models achieve similar accuracy but diverge in their individual predictions. This inconsistency undermines trust in high-stakes applications where we want consistent predictions. We propose three approaches to reduce inconsistency among predictions for the members of the Rashomon set. The first approach is outlier correction. An outlier has a label that none of the good models are capable of predicting correctly. Outliers can cause the Rashomon set to have high variance predictions in a local area, so fixing them can lower variance. Our second approach is local patching. In a local region around a test point, models may disagree with each other because some of them are biased. We can detect and fix such biases using a validation set, which also reduces multiplicity. Our third approach is pairwise reconciliation, where we find pairs of models that disagree on a region around the test point. We modify predictions that disagree, making them less biased. These three approaches can be used together or separately, and they each have distinct advantages. The reconciled predictions can then be distilled into a single interpretable model for real-world deployment. In experiments across multiple datasets, our methods reduce disagreement metrics while maintaining competitive accuracy.

Feature selection (FS) is essential for biomarker discovery and clinical predictive modeling. Over the past decades, methodological literature on FS has become rich and mature, offering a wide spectrum of algorithmic approaches. However, much of this methodological progress has not fully translated into applied biomedical research. Moreover, challenges inherent in biomedical data, such as high-dimensional feature space, low sample size, multicollinearity, and missing values, make FS non-trivial. To help bridge this gap between methodological development and practical application, we propose ROOFS (RObust biOmarker Feature Selection), a Python package available at https://gitlab.inria.fr/compo/roofs, designed to help researchers in the choice of FS method adapted to their problem. ROOFS benchmarks multiple FS methods on the user's data and generates reports summarizing a comprehensive set of evaluation metrics, including downstream predictive performance estimated using optimism correction, stability, robustness of individual features, and true positive and false positive rates assessed on semi-synthetic data with a simulated outcome. We demonstrate the utility of ROOFS on data from the PIONeeR clinical trial, aimed at identifying predictors of resistance to anti-PD-(L)1 immunotherapy in lung cancer. Of the 34 FS methods gathered in ROOFS, we evaluated 23 in combination with 11 classifiers (253 models) and identified a filter based on the union of Benjamini-Hochberg false discovery rate-adjusted p-values from t-test and logistic regression as the optimal approach, outperforming other methods including widely used LASSO. We conclude that comprehensive benchmarking with ROOFS has the potential to improve the reproducibility of FS discoveries and increase the translational value of clinical models.

Effective HFMD surveillance requires forecasts capturing both time-series patterns and contextual drivers such as school calendars, weather, and policy or surveillance reports. In clinical settings, forecasts must be trusted and actionable; thus, beyond point accuracy, decision-makers require concise, auditable explanations of why risk is expected to rise or fall. Classical models (e.g., ARIMA and Prophet) and foundation models (e.g., Chronos, Moirai, and TimesFM) treat external covariates as numerical inputs, lacking semantic reasoning to reflect epidemiological mechanisms or resolve conflicting signals. We propose a two-agent neuro-symbolic framework that decouples contextual interpretation from probabilistic forecasting. An LLM-based Event Interpreter ingests heterogeneous signals -- school schedules, weather summaries, government reports, and clinical guidelines -- and outputs a scalar transmission-impact signal. A Forecast Generator combines this signal with historical case counts to produce point forecasts that are mapped to probabilistic predictions through Poisson/negative-binomial moment matching. We focus on one-week-ahead rolling forecasts, aligning with weekly hospital-capacity planning and the rapid, context-driven inflections typical of HFMD. We evaluate on two datasets: Hong Kong surveillance (90 target weeks in 2023--2024) and Lishui hospital visits (33 target weeks in 2024). Against traditional and foundation-model baselines, our approach achieves competitive point accuracy while providing robust 90% intervals (coverage approximately 0.85--1.00) and concise rationales. This demonstrates that integrating domain knowledge through LLM-based agents can match strong numerical forecasters while yielding interpretable, context-aware forecasts aligned with public-health decision-making.

Clinical language models often assign high confidence to incorrect predictions, particularly in high-severity and out-of-distribution cases. We present MedBayes-Lite, a retraining-free uncertainty governance layer for transformer-based clinical predictors. It combines Monte Carlo dropout, predictive calibration, and confidence-guided abstention to defer low-confidence predictions for human review, adding no trainable parameters. Evaluated on MedMCQA and MedQA-USMLE, MedBayes-Lite reduces expected calibration error by 0.23 to 0.33 and drives harmful overconfident errors (confident, incorrect, high-severity predictions) toward zero. Under domain shift from MedMCQA to MedQA-USMLE, it reduces confident high-severity errors from about 21% to near zero while roughly halving calibration drift. We also introduce the Clinical Uncertainty Score (CUS), which strongly correlates with harmful overconfidence (r approximately 0.88). Although the framework does not improve risk-coverage ranking, and temperature scaling or deep ensembles may provide advantages in calibration cost or risk ranking, MedBayes-Lite offers a practical calibration-and-abstention layer that reduces confident high-severity errors in clinical question-answering benchmarks.

Data augmentation is a widely used strategy to improve model robustness and generalization by enriching training datasets with synthetic examples. While large language models (LLMs) have demonstrated strong generative capabilities for this purpose, their applications in high-stakes domains like healthcare present unique challenges due to the risk of generating clinically incorrect or misleading information. In this work, we propose a novel query-based model collaboration framework that integrates expert-level domain knowledge to guide the augmentation process to preserve critical medical information. Compared to existing LLM-based and traditional augmentation methods, our generated data significantly improves preservation of critical medical information and reduces hallucinations at both the token and concept levels. Experiments on downstream clinical prediction tasks demonstrate consistent performance gains over existing augmentation methods. This lightweight collaborative framework addresses the gap between LLM augmentation potential and the safety requirements of specialized domains.

Many prediction tasks can admit multiple models that can perform almost equally well. This phenomenon can undermine interpretability and safety when competing models assign conflicting predictions to individuals. In this work, we study how arbitrariness can arise in probabilistic classification tasks as a result of an effect that we call \emph{observational multiplicity}. We discuss how this effect arises in a broad class of practical applications where we learn a classifier to predict probabilities $p_i \in [0,1]$ but are given a dataset of observations $y_i \in \{0,1\}$. We propose to evaluate the arbitrariness of individual probability predictions through the lens of \emph{regret}. We introduce a measure of regret for probabilistic classification tasks, which measures how the predictions of a model could change as a result of different training labels. We present a general-purpose method to estimate the regret in a probabilistic classification task. We use our measure to show that regret is often higher for certain groups in the dataset and discuss potential applications of regret. We demonstrate how estimating regret can be used to promote safety in real-world applications by abstention and data collection.

Domain generalization has become a critical challenge in predictive healthcare, where different patient groups exhibit shifting data distributions that degrade model performance. Still, regular domain generalization approaches often struggle in clinical settings due to (1) the absence of domain labels and (2) the lack of clinical insight integration. To address these challenges in healthcare, we aim to explore how medical ontologies can be used to discover dynamic yet hierarchy-grounded patient domains, a partitioning strategy that remains under-explored in prior work. Hence, we introduce UdonCare, a hierarchy-pruning method that iteratively divides patients into latent domains and retrieves domain-invariant (label) information from patient data. On public datasets (MIMIC-III, MIMIC-IV, and eICU), UdonCare shows superiority over eight generalization baselines across four representative clinical prediction tasks with substantial domain gaps, highlighting the potential of medical knowledge for enhancing model generalization.

Multimodal prediction models based on imaging and clinical data are increasingly used for clinical decision support, yet their interpretability remains limited. We present multimodal Deep Transformation Models (DTMs) combining statistical approaches and neural networks to achieve strong predictive performance while preserving interpretability for tabular data. A key contribution of this work is the adaption of the xAI methods Grad-CAM and Occlusion to DTMs relying on 3D CNNs, enabling interpretation of the image branch through the generation of explanation maps. We developed DTMs to predict functional independence three months after stroke using diffusion-weighted imaging and clinical data from 407 patients. In a ten-fold cross-validation, the models achieved state-of-the-art predictive performance (AUC 0.81 [0.75, 0.87]) while maintaining interpretability for tabular features, with functional independence before stroke and stroke severity on admission emerging as the strongest predictors. Explanation maps from both xAI methods highlighted consistent regions, including frontal lobe areas which are known to be associated with age, a strong predictor of functional outcome. Notably, these regions disappeared once age was included as an explicit tabular predictor. Similarity analyses of explanation maps revealed distinct spatial patterns, providing meaningful insights into stroke pathophysiology, systematic error analysis and hypothesis generation.

Background: Neurosymbolic (NeSy) artificial intelligence describes the combination of logic or rule-based techniques with neural networks. Compared to neural approaches, NeSy methods often possess enhanced interpretability, which is particularly promising for biomedical applications like drug discovery. However, no clear guidelines exist to assess the biological plausibility of model interpretations. Methods: To assess interpretability in the context of drug discovery, we devise a novel prediction task, called drug mechanism-of-action (MoA) deconvolution, with an associated, tailored knowledge graph (KG), MoA-net. We then develop the MoA Retrieval System (MARS), a NeSy approach for drug discovery which leverages logical rules with learned rule weights. Results: Using MARS' interpretable features alongside domain knowledge, we find that MARS and other NeSy approaches on KGs are susceptible to reasoning shortcuts, in which the prediction of true labels is driven by ``degree-bias'' rather than the domain-based rules. Subsequently, we demonstrate ways to identify and mitigate this. Thereafter, MARS achieves performance on par with current state-of-the-art models while producing model interpretations aligned with known MoAs. Conclusion: Through MARS, we showcase the novel task of computational MoA deconvolution. Our results emphasize the importance of using interpretable models, like NeSy ones, for applications in drug discovery. Specifically, by identifying and mitigating reasoning shortcuts, MARS MoA predictions which are biologically meaningful and, therefore, more reliable for downstream drug discovery research.

Building trustworthy machine learning algorithms for biological applications requires adapting to data heterogeneity from different sources, batches, distributions, or studies. We propose the 'Cross-Cluster Weighted Forest' (CCWF), an ensembling approach that explicitly leverages heterogeneity in the feature distribution to produce more accurate and more generalizable predictors than the standard Random Forest in cases when data can be naturally clustered. CCWF generalizes the RF architecture to an outer unsupervised layer, supervised subtasks, and ensembling. Specifically it involves unsupervised clustering of the training data, fitting a Random Forest on each cluster, and combining the forests via stacked regression weights that reward cross-cluster generalizability. We provide a theoretical analysis of an analytically tractable forest model showing that cluster-based ensembling is asymptotically more accurate than training a single forest on the full data, with the gain driven by bias reduction. In simulations, we find that CCWF is robust across data-generating regimes and outcome models; furthermore, we explore the influence of data partitioning and ensemble weighting strategies on the benefits of our method. Finally, we apply our approach to cancer molecular profiling and gene expression datasets that are naturally divisible into clusters; in both simulations and real data examples, we illustrate that our approach outperforms classic Random Forest by margins of 30-40%, aligning with our theoretical results. Overall, we show that CCWF provides a statistically grounded prediction algorithm for data spanning multiple domains or sub-populations, a structure common in biological applications.

Longitudinal mammography screening has become an important source of information for improving future breast cancer risk prediction. However, the performance of current longitudinal mammography models degrades when prior examinations are unavailable at inference, creating a structured privileged-information setting in which temporal context is available during training but absent at deployment. We propose Single-Exam Mammography risk prediction with privileged History Distillation (SEM-HD), a framework that uses longitudinal history as privileged information available only during training to preserve the predictive benefits of longitudinal modeling while requiring only the current screening examination at deployment. During training, the student relies on the current examination to predict latent representations of prior visits, while horizon-specific teachers provide additional supervision from the observed longitudinal history. Together, latent history prediction and teacher distillation preserve the temporal modeling structure of longitudinal predictors under current-exam-only inference. We validate SEM-HD on three longitudinal mammography cohorts, the CSAW-CC, EMBED, and OMI-DB, using the transformer-based Longitudinal Mammography Risk (LoMaR) and recurrent Visual Memory Recurrent Attention (VMRA) backbones. Under current-exam-only inference, SEM-HD consistently improves long-horizon AUC and pAUC over longitudinal models evaluated without history, particularly in the clinically relevant low false-positive-rate region. It also recovers much of the performance gap with respect to full-history inference across datasets and backbones. Ablations further show that these gains are not reproduced by masking or heuristic history imputation. The strongest performance is achieved by combining patient-specific latent history prediction with distilled temporal risk supervision.