Can LLM Agents Generate Real-World Evidence? Evaluating Observational Studies in Medical Databases

Observational studies can yield clinically actionable evidence at scale, but executing them on real-world databases is open-ended and requires coherent decisions across cohort construction, analysis, and reporting. Prior evaluations of LLM agents emphasize isolated steps or single answers, missing the integrity and internal structure of the resulting evidence bundle. To address this gap, we introduce RWE-bench, a benchmark grounded in MIMIC-IV and derived from peer-reviewed observational studies. Each task provides the corresponding study protocol as the reference standard, requiring agents to execute experiments in a real database and iteratively generate tree-structured evidence bundles. We evaluate six LLMs (three open-source, three closed-source) under three agent scaffolds using both question-level correctness and end-to-end task metrics. Across 162 tasks, task success is low: the best agent reaches 39.9%, and the best open-source model reaches 30.4%. Agent scaffolds also matter substantially, causing over 30% variation in performance metrics. Furthermore, we implement an automated cohort evaluation method to rapidly localize errors and identify agent failure modes. Overall, the results highlight persistent limitations in agents' ability to produce end-to-end evidence bundles, and efficient validation remains an important direction for future work. Code and data are available at https://github.com/somewordstoolate/RWE-bench.

Precision over Diversity: High-Precision Reward Generalizes to Robust Instruction Following

A central belief in scaling reinforcement learning with verifiable rewards for instruction following (IF) tasks is that, a diverse mixture of verifiable hard and unverifiable soft constraints is essential for generalizing to unseen instructions. In this work, we challenge this prevailing consensus through a systematic empirical investigation. Counter-intuitively, we find that models trained on hard-only constraints consistently outperform those trained on mixed datasets. Extensive experiments reveal that reward precision, rather than constraint diversity, is the primary driver of effective alignment. The LLM judge suffers from a low recall rate in detecting false response, which leads to severe reward hacking, thereby undermining the benefits of diversity. Furthermore, analysis of the attention mechanism reveals that high-precision rewards develop a transferable meta-skill for IF. Motivated by these insights, we propose a simple yet effective data-centric refinement strategy that prioritizes reward precision. Evaluated on five benchmarks, our approach outperforms competitive baselines by 13.4\% in performance while achieving a 58\% reduction in training time, maintaining strong generalization beyond instruction following. Our findings advocate for a paradigm shift: moving away from the indiscriminate pursuit of data diversity toward high-precision rewards.