Abstract: Persistent demographic imbalance in U.S. clinical trials continues to undermine external validity, equity in treatment outcomes, and regulatory confidence in therapeutic efficacy across heterogeneous populations. This study proposes a novel Constrained Multi-Objective Fair Representation Optimization (CMOFRO) framework designed to simultaneously maximize predictive performance and demographic fairness in clinical trial recruitment and cohort construction. The framework integrates constrained optimization theory with advanced machine learning techniques to address representation bias across protected attributes such as race, gender, age, and socioeconomic status. The proposed model formulates trial cohort selection as a multi-objective optimization problem, where competing objectives include (i) maximizing statistical power and predictive accuracy of clinical outcomes, (ii) minimizing demographic disparity metrics such as Demographic Parity Difference (DPD) and Equal Opportunity Gap (EOG), and (iii) ensuring regulatory-compliant representation thresholds. A hybrid architecture combining Pareto-efficient optimization, fairness-aware gradient boosting, and a constraint-regularized deep neural network (CR-DNN) is developed. The system leverages real-world datasets including synthetic EHR-derived cohorts and publicly available trial registries from ClinicalTrials.gov. To benchmark performance, CMOFRO is compared against established fairness-aware algorithms including FairBatch, Adversarial Debiasing, Reweighing, and Pareto Multi-Task Learning (PMTL). Experimental results demonstrate that CMOFRO achieves a 23–31% reduction in demographic disparity metrics while maintaining or improving predictive performance (AUC: 0.87–0.92) relative to baseline models. Notably, the proposed model reduces underrepresentation of minority subgroups by up to 28% in simulated enrollment scenarios without compromising statistical robustness. Graph-based visualizations, including Pareto frontiers and fairness–accuracy trade-off curves, reveal that CMOFRO consistently operates in the optimal efficiency region compared to competing methods. Furthermore, the framework incorporates a dynamic constraint adaptation mechanism that adjusts fairness thresholds in response to evolving recruitment patterns, enabling real-time optimization in decentralized and hybrid clinical trial environments. Sensitivity analysis confirms the robustness of the model across varying population distributions and missing data conditions. The results suggest that integrating constrained multi-objective learning into clinical trial design can significantly enhance inclusivity while preserving scientific rigor. This research contributes a scalable and interpretable solution for regulatory-compliant, fairness-aware clinical trial optimization, with implications for FDA-aligned diversity initiatives and precision medicine advancement. Keywords: Algorithmic Fairness; Clinical Trial Optimization; Multi-Objective Learning; Demographic Representation; Fairness-Constrained Machine Learning. Title: Algorithmic Fairness and Demographic Representation Optimization in U.S. Clinical Trials Using Constrained Multi-Objective Learning Author: Ifiala Agwu Ifiala, Onuh Matthew Ijiga, Emmanuel Igba International Journal of Healthcare Sciences ISSN 2348-5728 (Online) Vol. 14, Issue 1, April 2026 - September 2026 Page No: 40-57 Research Publish Journals Website: www.researchpublish.com Published Date: 20-April-2026 DOI: https://doi.org/10.5281/zenodo.19663894 Paper Download Link (Source) https://www.researchpublish.com/papers/algorithmic-fairness-and-demographic-representation-optimization-in-us-clinical-trials-using-constrained-multi-objective-learning
Ifiala et al. (Mon,) studied this question.