Clinically-Grounded Hierarchical Classification for Consistent Chest X-ray Interpretation

Accurate and efficient classification of thoracic diseases in chest X-ray (CXR) images is crucial for timely diagnosis and treatment. However, the presence of multiple pathologies with overlapping visual characteristics poses significant challenges for automated classification systems. In this study, we propose two novel hierarchical multi-label classification techniques, namely the loss-based and logit-based methods, to address these challenges by leveraging the hierarchical relationships among different thoracic pathologies. The loss-based technique integrates hierarchical information directly into the optimization process, while the logit-based method adjusts the predicted probabilities of each class based on its parent class in the disease taxonomy. We evaluate the performance of both techniques using three large-scale CXR datasets: CheXpert (224,316 CXRs), PADCHEST (160,000 CXRs), and NIH (112,120 CXRs). The experimental results demonstrate significant improvements in accuracy, AUC, and F1 scores compared to the baseline method across various pathologies. The logit-based and loss-based methods improve accuracy by 12% and 11%, AUC by 13% and 10%, and F1 scores by 24% and 12%, respectively compared to the baseline. These results represent a substantial improvement over the baseline method. Furthermore, we conduct a comprehensive statistical analysis to validate the robustness and reliability of the proposed techniques. The integration of domain-specific hierarchical knowledge not only enhances the classification performance but also provides a more interpretable output for clinical decision support. Our findings highlight the potential of hierarchical multi-label classification in advancing computer-aided diagnosis systems for chest radiography.

Automated chest X-ray classification remains challenging due to severe class imbalance, co-occurring pathologies, and the loss of localized features in conventional architectures. To address these, we propose an explainable hierarchical multi-view ensemble framework for the robust classification of 14 thoracic pathologies. The framework employs view-specific training by independently modeling frontal and lateral radiographs using an ensemble of five complementary convolutional neural networks. Replacing global average pooling, a multi-scale feature fusion strategy augmented with Convolutional Block Attention Modules (CBAM) preserves fine-grained intermediate representations while emphasizing high-level pathology-specific semantic features. To mitigate positive-negative imbalance and varying inter-class difficulty, models are optimized using a novel hybrid objective combining Asymmetric Loss with Adaptive Focal Loss. Beyond simple probability averaging, the framework incorporates a hierarchical meta-learning strategy where test-time augmentation (TTA) predictions and cross-model uncertainty measures are integrated into Level-1 gradient-boosting meta-learners (XGBoost, LightGBM, and CatBoost), followed by Level-2 stacking with optimized alpha blending. Evaluated on a large-scale CheXpert-style dataset, the framework achieves state-of-the-art macro-average AUROC scores of 0.9319 for frontal and 0.9154 for lateral radiographs. Furthermore, comprehensive explainability analysis using seven post-hoc attribution techniques demonstrates strong anatomical consistency and clinically meaningful decision localization. By integrating architectural diversity, multi-scale attention, hierarchical meta-learning, and rigorous explainability, the proposed framework provides a transparent, highly accurate, and clinically practical computer-aided diagnosis system for thoracic disease classification.

Chest X-ray interpretation is one of the most frequently performed diagnostic tasks in medicine and a primary target for AI development, yet current vision-language models are primarily trained on datasets of paired images and reports, not the cognitive processes and visual attention that underlie clinical reasoning. Here, we present CheXthought, a global, multimodal resource containing 103,592 chain-of-thought reasoning traces and 6,609,082 synchronized visual attention annotations across 50,312 multi-read chest X-rays from 501 radiologists in 71 countries. Our analysis reveals clinical reasoning patterns in how experts deploy distinct visual search strategies, integrate clinical context, and communicate uncertainty. We demonstrate the clinical utility of CheXthought across four dimensions. First, CheXthought reasoning significantly outperforms state-of-the-art vision-language model chain-of-thought in factual accuracy and spatial grounding. Second, visual attention data used as an inference-time hint recovers missed findings and significantly reduces hallucinations. Third, vision-language models trained on CheXthought data achieve significantly stronger pathology classification, visual faithfulness, temporal reasoning and uncertainty communication. Fourth, leveraging CheXthought's multi-reader annotations, we predict both human-human and human-AI disagreement directly from an image, enabling transparent communication of case difficulty, uncertainty and model reliability. These findings establish CheXthought as a resource for advancing multimodal clinical reasoning and the development of more transparent, interpretable vision-language models.