Artificial intelligence surrogates for treatment effect estimation with before-and-after data

Abstract

Estimating the causal effects of medical treatments is difficult when clinically important outcomes are costly to measure or require long follow-up. Short-term or inexpensive surrogate outcomes offer a potential alternative, but surrogate biomarkers may be unavailable or difficult to identify. Advances in artificial intelligence (AI) have enabled increasingly accurate prediction of clinical outcomes from inexpensive, high-dimensional measurements, which creates an opportunity to use AI predictions themselves as surrogates. To this end, we develop a framework for estimating treatment effects from paired measurements obtained before and after treatment for each treated individual. A pretrained AI model is applied to the before and after measurements, and our estimator compares the resulting outcome predictions. We characterize the technical assumptions under which this within-person contrast identifies the average treatment effect on the treated, even when clinical outcomes are never observed for treated individuals. When these assumptions cannot be justified, we use prediction-powered inference to correct bias using a small number of observed clinical outcomes and obtain valid inference. Synthetic and real-world cardio-oncology experiments demonstrate the validity and accuracy of the approach.