Radiological imaging is central to diagnosis, treatment planning, and clinical decision-making. Vision-language foundation models have spurred interest in automated radiology report generation (RRG), but safe deployment requires reliable clinical evaluation of generated reports. Existing metrics often rely on surface-level similarity or behave as black boxes, lacking interpretability. We introduce ICARE (Interpretable and Clinically-grounded Agent-based Report Evaluation), an interpretable evaluation framework leveraging large language model agents and dynamic multiple-choice question answering (MCQA). Two agents, each with either the ground-truth or generated report, generate clinically meaningful questions and quiz each other. Agreement on answers captures preservation and consistency of findings, serving as interpretable proxies for clinical precision and recall. By linking scores to question-answer pairs, ICARE enables transparent, and interpretable assessment. Clinician studies show ICARE aligns significantly more with expert judgment than prior metrics. Perturbation analyses confirm sensitivity to clinical content and reproducibility, while model comparisons reveal interpretable error patterns.

Automated radiology report generation (R2Gen) has advanced significantly, introducing challenges in accurate evaluation due to its complexity. Traditional metrics often fall short by relying on rigid word-matching or focusing only on pathological entities, leading to inconsistencies with human assessments. To bridge this gap, we introduce ER2Score, an automatic evaluation metric designed specifically for R2Gen. Our metric utilizes a reward model, guided by our margin-based reward enforcement loss, along with a tailored training data design that enables customization of evaluation criteria to suit user-defined needs. It not only scores reports according to user-specified criteria but also provides detailed sub-scores, enhancing interpretability and allowing users to adjust the criteria between different aspects of reports. Leveraging GPT-4, we designed an easy-to-use data generation pipeline, enabling us to produce extensive training data based on two distinct scoring systems, each containing reports of varying quality along with corresponding scores. These GPT-generated reports are then paired as accepted and rejected samples through our pairing rule to train an LLM towards our fine-grained reward model, which assigns higher rewards to the report with high quality. Our reward-control loss enables this model to simultaneously output multiple individual rewards corresponding to the number of evaluation criteria, with their summation as our final ER2Score. Our experiments demonstrate ER2Score's heightened correlation with human judgments and superior performance in model selection compared to traditional metrics. Notably, our model provides both an overall score and individual scores for each evaluation item, enhancing interpretability. We also demonstrate its flexible training across various evaluation systems.

Computed tomography (CT) report generation is crucial to assist radiologists in interpreting CT volumes, which can be time-consuming and labor-intensive. Existing methods primarily only consider the global features of the entire volume, making it struggle to focus on specific regions and potentially missing abnormalities. To address this issue, we propose Reg2RG, the first region-guided referring and grounding framework for CT report generation, which enhances diagnostic performance by focusing on anatomical regions within the volume. Specifically, we utilize masks from a universal segmentation module to capture local features for each referring region. A local feature decoupling (LFD) strategy is proposed to preserve the local high-resolution details with little computational overhead. Then the local features are integrated with global features to capture inter-regional relationships within a cohesive context. Moreover, we propose a novel region-report alignment (RRA) training strategy. It leverages the recognition of referring regions to guide the generation of region-specific reports, enhancing the model's referring and grounding capabilities while also improving the report's interpretability. A large language model (LLM) is further employed as the language decoder to generate reports from integrated visual features, facilitating region-level comprehension. Extensive experiments on two large-scale chest CT-report datasets demonstrate the superiority of our method, which outperforms several state-of-the-art methods in terms of both natural language generation and clinical efficacy metrics while preserving promising interpretability. The code will be made publicly available.

Given the rapidly expanding capabilities of generative AI models for radiology, there is a need for robust metrics that can accurately measure the quality of AI-generated radiology reports across diverse hospitals. We develop ReXamine-Global, a LLM-powered, multi-site framework that tests metrics across different writing styles and patient populations, exposing gaps in their generalization. First, our method tests whether a metric is undesirably sensitive to reporting style, providing different scores depending on whether AI-generated reports are stylistically similar to ground-truth reports or not. Second, our method measures whether a metric reliably agrees with experts, or whether metric and expert scores of AI-generated report quality diverge for some sites. Using 240 reports from 6 hospitals around the world, we apply ReXamine-Global to 7 established report evaluation metrics and uncover serious gaps in their generalizability. Developers can apply ReXamine-Global when designing new report evaluation metrics, ensuring their robustness across sites. Additionally, our analysis of existing metrics can guide users of those metrics towards evaluation procedures that work reliably at their sites of interest.

The current gold standard for evaluating generated chest x-ray (CXR) reports is through radiologist annotations. However, this process can be extremely time-consuming and costly, especially when evaluating large numbers of reports. In this work, we present FineRad-Score, a Large Language Model (LLM)-based automated evaluation metric for generated CXR reports. Given a candidate report and a ground-truth report, FineRadScore gives the minimum number of line-by-line corrections required to go from the candidate to the ground-truth report. Additionally, FineRadScore provides an error severity rating with each correction and generates comments explaining why the correction was needed. We demonstrate that FineRadScore's corrections and error severity scores align with radiologist opinions. We also show that, when used to judge the quality of the report as a whole, FineRadScore aligns with radiologists as well as current state-of-the-art automated CXR evaluation metrics. Finally, we analyze FineRadScore's shortcomings to provide suggestions for future improvements. Code to run FineRadScore can be found here.