AT-CXR: Uncertainty-Aware Agentic Triage for Chest X-rays

Abstract

Agentic AI is advancing rapidly, yet truly autonomous medical-imaging triage, where a system decides when to stop, escalate, or defer under real constraints, remains relatively underexplored. To address this gap, we introduce AT-CXR, an uncertainty-aware agent for chest X-rays. The system estimates per-case confidence and distributional fit, then follows a stepwise policy to issue an automated decision or abstain with a suggested label for human intervention. We evaluate two router designs that share the same inputs and actions: a deterministic rule-based router and an LLM-decided router. Across five-fold evaluation on a balanced subset of NIH ChestX-ray14 dataset, both variants outperform strong zero-shot vision-language models and state-of-the-art supervised classifiers, achieving higher full-coverage accuracy and superior selective-prediction performance, evidenced by a lower area under the risk-coverage curve (AURC) and a lower error rate at high coverage, while operating with lower latency that meets practical clinical constraints. The two routers provide complementary operating points, enabling deployments to prioritize maximal throughput or maximal accuracy. Our code is available at https://github.com/XLIAaron/uncertainty-aware-cxr-agent.