Subgroup performance analysis of adaptation strategies for chest X-ray foundation models

Foundation models are increasingly adapted for downstream medical imaging tasks, yet the influence of the chosen adaptation strategy on subgroup fairness remains poorly understood. We investigate how three parameter-efficient adaptation techniques, including linear heads on the raw CLS token, an MLP, and an attention-pooling module over multi-layer patch features, affect both pathology classification performance and subgroup disparities when applied to the frozen Rad-DINO chest X-ray encoder. Using MIMIC-CXR, we evaluate eight pathologies across race, sex, and imaging-view subgroups on a prevalence-preserving, demographically balanced test set, and additionally probe how strongly each adapter encodes protected attributes. We find that attention pooling achieves the strongest overall discriminative performance and encodes attributes, particularly race, most strongly, but that improved overall performance does not consistently reduce subgroup disparities. Notably, stronger attribute encoding did not correspond to larger disparities: early network layers encoded race most weakly yet produced the largest subgroup performance gaps. Exploring different attention-pooling layer combinations further revealed no consistent relationship between the layers pooled, attribute encoding strength, and subgroup fairness. Our results indicate that richer, more expressive representations can improve accuracy while leaving fairness implications task-dependent and unpredictable, which must be assessed directly and per-task rather than inferred from encoding strength or overall performance alone.

When Is a Conformal Guarantee Fair? Auditing Silent Subgroup Under-Coverage in Alzheimer's Disease Longitudinal Prediction

Longitudinal prediction of Alzheimer's disease biomarkers increasingly informs clinical decisions, and a forecast is only useful if it also reports how much to trust it. Conformal prediction supplies this by wrapping any forecaster in a prediction band with a finite-sample coverage guarantee under exchangeability. However, standard population-level conformal prediction guarantees only marginal coverage and may mask substantial under-coverage within clinically important subgroups. We introduce a general mechanism-driven framework for auditing and repairing such subgroup under-coverage. Across two cohorts (ADNI, OASIS-3), two base forecasters, and nine attributes spanning genetic risk, demographics, and clinical severity, we find that population-level bands under-cover high-risk subgroups in 57 of 68 audited combinations, despite achieving nominal marginal coverage. We trace these failures to two mechanisms: (A) \emph{rarity}, where a group-conditional band calibrated on only $n$ patients covers at most $k/(n+1)$; and (B) \emph{tail-heaviness}, where a population-wide band is too narrow for a heavy-tailed subgroup and additional data cannot close the gap. Under-coverage falls disproportionately on patients with high genetic risk and disease severity (6.1 pp mean deficit, 95\% CI [3.3, 8.9]), while demographic groups remain at the target level on average (0.0 pp, CI [$-1.9$, 1.7]). We pair each mechanism with a corresponding conformal correction: cross-conformal pooling for rarity, per-subgroup calibration for tail-heaviness, and a coverage-safe marginal floor when both arise. Together, these corrections restore target coverage for nearly every high-risk subgroup across both cohorts and forecasters.

COVAriance-Induced Fairness Gap Penalty for Subgroup-Fair Clustering

Fair clustering aims to make cluster assignments independent of sensitive attributes, but this goal becomes challenging when multiple sensitive attributes jointly define many subgroups. In such settings, directly extending existing fair clustering algorithms is computationally expensive or numerically unstable, especially when the number of subgroups grows exponentially and some subgroups contain only a few instances. To address these challenges, we define a subgroup-fairness gap for clustering and derive a covariance-based surrogate that exactly matches this gap. We then introduce a continuous relaxation of the surrogate, enabling efficient gradient-based optimization and yielding our proposed algorithm, COVA-FC. We also show that subgroup fairness alone does not imply marginal fairness, and extend our framework to capture a subgroup-marginal-fairness gap. Experiments on benchmark datasets show that COVA-FC achieves competitive cost-fairness trade-offs and improves computational efficiency over existing baselines in both subgroup and higher-order marginal settings.