A Transfer Learning Causal Approach to Evaluate Racial/Ethnic and Geographic Variation in Outcomes Following Congenital Heart Surgery

Congenital heart defects (CHD) are the most prevalent birth defects in the United States and surgical outcomes vary considerably across the country. The outcomes of treatment for CHD differ for specific patient subgroups, with non-Hispanic Black and Hispanic populations experiencing higher rates of mortality and morbidity. A valid comparison of outcomes within racial/ethnic subgroups is difficult given large differences in case-mix and small subgroup sizes. We propose a causal inference framework for outcome assessment and leverage advances in transfer learning to incorporate data from both target and source populations to help estimate causal effects while accounting for different sources of risk factor and outcome differences across populations. Using the Society of Thoracic Surgeons' Congenital Heart Surgery Database (STS-CHSD), we focus on a national cohort of patients undergoing the Norwood operation from 2016-2022 to assess operative mortality and morbidity outcomes across U.S. geographic regions by race/ethnicity. We find racial and ethnic outcome differences after controlling for potential confounding factors. While geography does not have a causal effect on outcomes for non-Hispanic Caucasian patients, non-Hispanic Black patients experience wide variability in outcomes with estimated 30-day mortality ranging from 5.9% (standard error 2.2%) to 21.6% (4.4%) across U.S. regions.

Multiply Robust Federated Estimation of Targeted Average Treatment Effects

Federated or multi-site studies have distinct advantages over single-site studies, including increased generalizability, the ability to study underrepresented populations, and the opportunity to study rare exposures and outcomes. However, these studies are challenging due to the need to preserve the privacy of each individual's data and the heterogeneity in their covariate distributions. We propose a novel federated approach to derive valid causal inferences for a target population using multi-site data. We adjust for covariate shift and covariate mismatch between sites by developing multiply-robust and privacy-preserving nuisance function estimation. Our methodology incorporates transfer learning to estimate ensemble weights to combine information from source sites. We show that these learned weights are efficient and optimal under different scenarios. We showcase the finite sample advantages of our approach in terms of efficiency and robustness compared to existing approaches.