Investigating real-world consequences of biases in commonly used clinical calculators

Am J Manag Care. 2023 Jan 1;29(1):e1-e7. doi: 10.37765/ajmc.2023.89306.


Objectives: To evaluate whether one summary metric of calculator performance sufficiently conveys equity across different demographic subgroups, as well as to evaluate how calculator predictive performance affects downstream health outcomes.

Study design: We evaluate 3 commonly used clinical calculators-Model for End-Stage Liver Disease (MELD), CHA2DS2-VASc, and simplified Pulmonary Embolism Severity Index (sPESI)-on the cohort extracted from the Stanford Medicine Research Data Repository, following the cohort selection process as described in respective calculator derivation papers.

Methods: We quantified the predictive performance of the 3 clinical calculators across sex and race. Then, using the clinical guidelines that guide care based on these calculators' output, we quantified potential disparities in subsequent health outcomes.

Results: Across the examined subgroups, the MELD calculator exhibited worse performance for female and White populations, CHA2DS2-VASc calculator for the male population, and sPESI for the Black population. The extent to which such performance differences translated into differential health outcomes depended on the distribution of the calculators' scores around the thresholds used to trigger a care action via the corresponding guidelines. In particular, under the old guideline for CHA2DS2-VASc, among those who would not have been offered anticoagulant therapy, the Hispanic subgroup exhibited the highest rate of stroke.

Conclusions: Clinical calculators, even when they do not include variables such as sex and race as inputs, can have very different care consequences across those subgroups. These differences in health care outcomes across subgroups can be explained by examining the distribution of scores and their calibration around the thresholds encoded in the accompanying care guidelines.

MeSH terms

  • Anticoagulants / therapeutic use
  • Atrial Fibrillation* / complications
  • Atrial Fibrillation* / drug therapy
  • Bias
  • End Stage Liver Disease*
  • Female
  • Humans
  • Male
  • Risk Assessment
  • Risk Factors
  • Severity of Illness Index
  • Stroke*


  • Anticoagulants