When Participant Disjoint Validation Is Not Enough to Establish Generalization in Parkinson's Gait Classification

Participant-disjoint cross-validation prevents direct participant overlap, but it may still produce optimistic estimates when acquisition site and diagnosis are structurally dependent. We examined Parkinson's disease classification using 159 pressure-walkway summary features from 133 WearGait-PD participants, including 65 participants with Parkinson's disease and 68 controls. The cohort was non-factorial: two sites contained only one diagnostic group, whereas VA-Seattle was the only site containing both groups. In repeated participant-level nested cross-validation, site alone achieved an area under the receiver operating characteristic curve (AUC) of 0.955 plus or minus 0.003, exceeding the gait-feature model (0.882 plus or minus 0.014). Under the evaluated logistic-regression pipelines, adding gait features to site, age, and sex produced no measurable improvement in pooled discrimination. More site-controlled evaluations produced lower and imprecise estimates: VA-Seattle same-site AUC was 0.668 (95% bootstrap confidence interval 0.477 to 0.836), and the JHOC + Bayview-to-VA-Seattle transport stress test achieved 0.576 (0.375 to 0.770). Supporting within-diagnosis site-prediction and site-conditioned permutation analyses showed that the gait representation retained substantial acquisition-site structure. These findings indicate that participant-disjoint pooled validation did not isolate disease-related discrimination from site-associated variation. They encourage careful examination of site-label dependence and, where possible, support for pooled results through within-site or independent validation before broader claims are made about generalization across institutions.