Improving fairness of large language model-based ICU mortality prediction via case-based prompting

Accurately predicting mortality risk in intensive care unit (ICU) patients is critical for clinical decision-making. Large language models (LLMs) are increasingly explored for clinical prediction using structured medical data, but their outputs may exhibit demographic disparities. Mitigating such disparities without degrading predictive performance remains challenging. We systematically investigate demographic bias in LLM-based ICU mortality prediction and propose Case-Based Prompting (CAP), a training-free framework designed to improve the empirical balance between predictive performance and subgroup fairness. CAP retrieves clinically similar historical misprediction and demographic-sensitive cases with known outcomes and incorporates them as case-level contextual evidence. We further evaluate model discrimination, subgroup fairness, and feature-dependence consistency. On MIMIC-IV, CAP improved AUROC from 0.806 to 0.873 and AUPRC from 0.497 to 0.694 compared with the Baseline Prompt. CAP also reduced several subgroup disparities, particularly for sex and White-Black comparisons, although age-related disparities remained non-negligible. Controlled demographic-information ablations showed that removing demographic information did not uniformly improve both predictive performance and subgroup fairness, indicating distinct performance-fairness patterns rather than a uniform benefit from demographic suppression. Feature-dependence analysis showed generally consistent expressed clinical factor patterns across demographic subgroups. These findings suggest that CAP is a promising inference-time strategy for LLM-based clinical prediction under the evaluated retrospective setting. Further validation across additional LLMs, external datasets, and prospective clinical scenarios is required before deployment.