Median Optimal Treatment Regimes

Optimal treatment regimes are personalized policies for making a treatment decision based on subject characteristics, with the policy chosen to maximize some value. It is common to aim to maximize the mean outcome in the population, via a regime assigning treatment only to those whose mean outcome is higher under treatment versus control. However, the mean can be an unstable measure of centrality, resulting in imprecise statistical procedures, as well as unfair decisions that can be overly influenced by a small fraction of subjects. In this work, we propose a new median optimal treatment regime that instead treats individuals whose conditional median is higher under treatment. This ensures that optimal decisions for individuals from the same group are not overly influenced either by (i) a small fraction of the group (unlike the mean criterion), or (ii) unrelated subjects from different groups (unlike marginal median/quantile criteria). We introduce a new measure of value, the Average Conditional Median Effect (ACME), which summarizes across-group median treatment outcomes of a policy, and which the optimal median treatment regime maximizes. After developing key motivating examples that distinguish median optimal treatment regimes from mean and marginal median optimal treatment regimes, we give a nonparametric efficiency bound for estimating the ACME of a policy, and propose a new doubly robust-style estimator that achieves the efficiency bound under weak conditions. Finite-sample properties of the estimator are explored via numerical simulations and the proposed algorithm is illustrated using data from a randomized clinical trial in patients with HIV.