Neuro-Symbolic AI for Automated Pathology Quality Measurement

Background. Clinical quality measurement often relies on manual abstraction of medical records, an approach that is costly, burdensome, and often infeasible for measures requiring interpretation of narrative text; these constraints have shaped measure development itself, filtering out clinically important measures that are too difficult to operationalize. We evaluated whether neuro-symbolic artificial intelligence (NSAI), which combines large language model extraction with symbolic reasoning, could reliably abstract complex quality measures from narrative pathology reports. Methods. The NSAI system decomposes each measure into atomic questions and is aligned to real-world reports through case-based refinement, an iterative human-in-the-loop process. Using 2,000 independently double-abstracted reports, we compared NSAI-based abstraction against trained human abstractors across four pathology quality measures established by the College of American Pathologists. Results. The NSAI system's agreement with the adjudicated gold standard (Cohen's kappa = 0.95) matched or modestly exceeded that of the trained human abstractors measured against the same standard (kappa = 0.92), with particularly strong performance on Gastrointestinal Metaplasia (CAP 43). In component analyses, case-based refinement drove the largest accuracy gains (up to 0.25 in kappa), whereas architectural decomposition primarily reduced performance variance across language-model backends more than tenfold, a property essential for clinical deployment. Conclusions. These findings suggest that automated abstraction could enable census-level quality measurement, reduce reporting burden, and expand the range of clinically meaningful measures that can be operationalized from narrative clinical documentation.