Sparsh Roy, Samuel Girmachew, Nishita Chavancs.LG q-bio.QM
Clinical risk models routinely achieve strong aggregate performance while producing materially different error rates across patient subgroups. Audit pipelines have been proposed to catch this, but their components are rarely stress-tested, so it is unclear which parts of an audit can be trusted and under what conditions. We present KAISEN, a five-phase audit pipeline covering subgroup stratification, disparity measurement, mechanism diagnostics, post-hoc mitigation, and drift monitoring, evaluated to the point of failure on a synthetic benchmark of 16 disease tasks, 15 social-determinant axes from Healthy People 2030, and three prespecified intersections. Four findings follow. (i) Significance tracks each axis's gap against its own minimum detectable effect: rank correlation between significance count and raw equalized-odds difference (EOD) across the 15 axes is rho = 0.56, rising to rho = 0.78 once EOD is standardized by that floor. (ii) Per-group threshold optimization reduces EOD in 48 of 48 held-out runs (paired delta = -0.285, 95% CI [-0.313, -0.252]), while group-wise Platt scaling -- the better calibrator -- behaves as a coin flip on EOD (19 of 48 runs improved, 95% CI [0.26, 0.55]) with mean effect near zero, so what an audit should report is the variance, not the average. (iii) The mechanism diagnostic classifies 144 of 144 controlled cases correctly but recovers none of 48 model-driven cases under proxy misspecification, with no signal that it failed. (iv) CUSUM failures and false alarms track cohort realization far more than disease: at the reference threshold, all 27 false alarms and 7 of 8 missed shifts come from different seeds (chi-squared p = 0.002), so a threshold tuned on one cohort fails to transfer. All results are synthetic with known ground truth and do not establish clinical validity. Code, artifacts, and scripts reproducing every number are released.
AI governance for medical imaging is formalizing: the 2026 ACR-SIIM Practice Parameter recommends local acceptance testing and ongoing drift monitoring, and the ACR Assess-AI registry monitors AI outputs using DICOM metadata for context. We argue that a necessary, currently unmonitored layer sits beneath output metrics: whether incoming studies remain within the acquisition envelope a model was validated on. Using a LUNA16-trained MONAI RetinaNet lung-nodule detector, we test whether acquisition state behaves as a structured, measurable variable. On real paired CT differing only in reconstruction kernel (NLST B30f vs B80f), kernel alone shifted AI-measured diameter and flipped a Fleischner size category in 5.2% (8 of 155) of nodules at fixed patient and acquisition, while detection confidence was unchanged (Wilcoxon p=0.22). Under controlled LIDC-IDRI perturbations the effects dissociated by axis: the noise axis degraded detection confidence (p=5.9e-32, concentrated in nodules under 6 mm) but not measurement, while the frequency/kernel axis corrupted measurement (p=8.6e-13) but not detection. A 4-feature pixel fingerprint recovered reconstruction identity (patient-level AUC about 0.95 on real CT, 0.995 on a QIBA phantom) where the ConvolutionKernel DICOM tag was uninformative (identical labels across reconstructions). The kernel axis transported across four manufacturers (leave-one-vendor-out AUC 0.94-0.98, matching the within-vendor ceiling). Acquisition state thus maps to distinct AI failure modes, frequency content to measurement reliability and noise to detection sensitivity, and is not recoverable from metadata. Acquisition-aware, input-side validation is the missing layer for the acceptance-testing and drift-monitoring requirements now entering imaging-AI accreditation.