# Using the weighted area under the net benefit curve for decision curve analysis

- Rajesh Talluri
^{1}and - Sanjay Shete
^{1, 2}Email author

**16**:94

https://doi.org/10.1186/s12911-016-0336-x

© The Author(s). 2016

**Received: **22 January 2016

**Accepted: **9 July 2016

**Published: **18 July 2016

## Abstract

### Background

Risk prediction models have been proposed for various diseases and are being improved as new predictors are identified. A major challenge is to determine whether the newly discovered predictors improve risk prediction. Decision curve analysis has been proposed as an alternative to the area under the curve and net reclassification index to evaluate the performance of prediction models in clinical scenarios. The decision curve computed using the net benefit can evaluate the predictive performance of risk models at a given or range of threshold probabilities. However, when the decision curves for 2 competing models cross in the range of interest, it is difficult to identify the best model as there is no readily available summary measure for evaluating the predictive performance. The key deterrent for using simple measures such as the area under the net benefit curve is the assumption that the threshold probabilities are uniformly distributed among patients.

### Methods

We propose a novel measure for performing decision curve analysis. The approach estimates the distribution of threshold probabilities without the need of additional data. Using the estimated distribution of threshold probabilities, the weighted area under the net benefit curve serves as the summary measure to compare risk prediction models in a range of interest.

### Results

We compared 3 different approaches, the standard method, the area under the net benefit curve, and the weighted area under the net benefit curve. Type 1 error and power comparisons demonstrate that the weighted area under the net benefit curve has higher power compared to the other methods. Several simulation studies are presented to demonstrate the improvement in model comparison using the weighted area under the net benefit curve compared to the standard method.

### Conclusions

The proposed measure improves decision curve analysis by using the weighted area under the curve and thereby improves the power of the decision curve analysis to compare risk prediction models in a clinical scenario.

### Keywords

Decision curve analysis Clinical decision making Area under the curve Net benefit curves Threshold probabilities## Background

Risk prediction models are used to predict the probability of occurrence of future events for individuals based on several predictors. Predicting the risk of malignant events is of major importance for public health as such information can be used to improve outcomes and personalize clinical care. Risk prediction models have been developed for several cancers [1–3], a variety of conditions and general public health issues (e.g., hypertension, diabetes, cardiovascular disease, smoking experimentation) [4–7]. These risk prediction models are being constantly improved with the identification of new predictors (e.g., genetic markers) associated with the disease or condition of interest. However, assessing the contribution of these predictors in improving risk prediction is challenging.

The area under the receiver operating characteristic curve (AUC) is generally used to determine the predictive accuracy of a model [8]. The AUC provides a natural tool to select optimal models across all thresholds of sensitivity and specificity. However, in clinical settings, there may be situations in which a model with higher AUC may not be desirable. For example, if a treatment involves high risk, the model with a low false positive rate would be the best model to use despite its lower AUC compared to those for other models. Also, in clinical settings, the models need not be accurate at the extreme ranges. For example, consider a scenario in which, if the predicted probability for the disease were below 0.2, the individual would not be screened/treated, and if the predicted probability was above 0.8, the individual would be screened/treated. Small differences in the predicted probabilities from 2 competing models would not make a significant clinical difference in the decision made by individuals at these extremes. However, the model that is accurate in predicting probabilities between the 0.2 - 0.8 range will be more useful in a clinical setting compared to the model that predicts probabilities well at the extremes. Hence, AUC may be a poor measure of performance for risk prediction models in certain clinical scenarios (Additional file 1: Figure S1). Importantly, the increase in AUC value may not be significant even when the new predictor is statistically associated with the response [9]. To alleviate the problem of low power, the net reclassification index [10] was proposed. However, several concerns have been raised regarding its appropriate use, interpretation, and associated high false positive rates [11, 12], suggesting the need for alternate measures for model comparison. One of the suggested methods was decision curve analysis (DCA) [13, 14].

DCA is used to evaluate the performance of prediction models in clinical decision making. The typical scenario for the application of DCA is when patients have symptoms that suggest a disease but they have not yet been diagnosed with the disease. The clinician has to make a decision regarding whether a biopsy/screening should be performed to diagnose the disease. The biopsy or other screening procedure is associated with various risks or side effects. The decision thus depends on the probability of the disease for that patient, the patient’s preferences, the possible side effects and the clinician’s experience. If the probability of the disease is too high or too low, the decision is generally clear. DCA provides a way to assess the performance of a model in a specific range of interest. DCA has been extensively used to compare competing methods in several diseases [15–17].

DCA is based on the computation of the net benefit for a model. The decision curve computed using the net benefit details the performance of the model at a given threshold probability or in a range of threshold probabilities that is of interest to the clinician making the decision. In several situations, when the net benefit curves for 2 competing models cross in the range of interest, it is difficult to select the best model. There is no available summary measure that can determine the better model. The key deterrent for using the area under the net benefit curve as the summary measure is the assumption that the threshold probabilities would need to follow a uniform distribution. And, if they do not follow a uniform distribution, additional data such as the exact threshold probabilities and patient preferences need to be collected to estimate the threshold probabilities, which limits the application of DCA to data sets that lack these additional data [18].

In this manuscript, we propose a novel way to estimate the distribution of threshold probabilities without collecting additional data by using only a binary clinical decision made by the clinician (e.g., whether screening is performed or not based on the disease probability) that is readily available for most of the data sets. Using the estimated distribution of threshold probabilities, we propose the weighted area under the net benefit curve in the range of interest as a summary statistic for model comparison. We performed several simulation studies to demonstrate the improvement in model comparison for the weighted area under the net benefit curve statistic compared to the standard method that uses confidence intervals to assess whether one model is statistically better than another [13].

## Methods

### Clinical scenario for decision curve analysis

Our guiding example will be the same clinical scenario used by Vickers and Elkin for DCA [14]. Individuals with prostate cancer face the possibility that the cancer could invade either one or both of their seminal vesicles, a condition described as seminal vesicle invasion (SVI). However, SVI is not officially diagnosed until after surgery, following an examination of the surgical sample by a pathologist. Hence, the surgeon has to make a decision regarding the removal of seminal vesicles before prostate surgery, based on the predicted probability of SVI. Several models have been proposed for assessing the probability of SVI prior to prostate surgery, based on predictors such as prostate specific antigen (PSA) and Gleason score (GS) [19, 20]. After estimating the probability of SVI using one of the risk prediction models, the clinician or the patient has a decision to make regarding whether or not the seminal vesicles will be removed during surgery. If the probability of SVI is low, the tip of the seminal vesicles is preserved in surgery to prevent long-term loss of urinary continence [21]. If the probability of SVI is high, and the seminal vesicles are not removed, there is a risk of recurrence of prostate cancer. The decision to remove the seminal vesicles is made using a threshold probability *p*_{
t
}, which depends on many factors such as the preference of the patient and the clinician and other covariates such as the age of the patient. If the predicted probability of SVI is greater than the threshold probability, *p*_{
t
}, then the seminal vesicles are removed.

### Data simulation

*n*patients with prostate cancer. For simulation purposes, we assumed the risk of SVI depends on GS [22, 23], PSA [22, 23], and a generic covariate labeled X

_{1}(additional covariates such as age, body mass index, and ethnicity can be added to this model). We simulated PSA using an exponential distribution because, typically, PSA levels in prostate cancer patients are heavily skewed towards larger values, which can be simulated using a heavy tailed distribution. We chose a rate parameter of 0.1 to correspond closely to prostate cancer cohorts [24]. We simulated primary and secondary grades for tumors using binomial distributions. The final GS values in the range of 2 to10 were obtained by adding the primary and secondary grades (GS = 2+ binomial (

*n*= 4,

*p*= 0.5) + binomial (

*n*= 4,

*p*= 0.5)). The mean for the GS score was 6, which corresponds closely to the average GS score for prostate cancer cohorts [25]. Finally, we simulated

*X*

_{1}using a normal distribution, with a mean of 27 and a standard deviation of 6. We modeled

*X*

_{1}based on the values for the mean and standard deviation of the BMI from the 2010 US census. Let

*Y*= 1 and

*Y*= 0 correspond to the presence and absence of SVI, respectively, in the cohort of

*n*prostate cancer patients, and let

*p*

_{ d }denote the probability of SVI (

*p*

_{ d }=

*P*[

*Y*= 1]). The simulation model is as follows:

We calculated the probability of SVI in individuals with prostate cancer using this model. We needed to simulate another decision indicator *Z* = [0,1], which indicates whether the clinician or the patient decided to have the seminal vesicles removed. This is dependent on the threshold probability *p*_{
t
}. The distribution of *p*_{
t
} in the population is generally unknown. However, *p*_{
t
} is likely to be on the lower side for diseases with serious consequences and to be higher for diseases with minimal consequences. For simulation purposes, we simulated *p*_{
t
} using a beta distribution, *Beta* (2,7). If the disease probability *p*_{
d
} was greater than or equal to the threshold probability *p*_{
t
}, the decision would be made to remove the seminal vesicles during surgery (*Z* = 1), otherwise the seminal vesicles would not be removed (*Z* = 0). The above simulation process was used for all the data simulations we report here, with changes to the distribution of *p*_{
t
} and the addition of new predictors for SVI based on the simulation scenario. The number of needed replicates was determined by using a method proposed in [26]. Using the desired precision (half width of the 95 % confidence interval) to be 5, we needed 743 replicates. Therefore, all simulation results are based on 1000 replicates of a cohort of 10000 individuals.

### Data analysis

*p*

_{ t }is the threshold probability and

*n*is the total number of individuals.

The general approach for DCA involves computing the net benefit for the 2 models and selecting the model that has higher net benefit at a particular threshold *p*_{
t
} or in a range of thresholds [14]. The standard method uses confidence intervals for the net benefit curve to assess whether one model is statistically better than another [13]. We implemented this approach as described below. To evaluate the confidence intervals, we first resampled the data set with replacement *K* times. We then used these *K* data sets to estimate *K* corresponding net benefit curves. The confidence interval for the net benefit curves at each probability threshold *p*_{
t
} was estimated using α/2 and 1−α/2 percentiles for the bootstrap distribution for a confidence interval coverage of 1−α.

When comparing 2 models using DCA, it is recommended to use the same bootstrap samples for calculating the net benefit for the 2 competing models in order to produce accurate and shorter confidence intervals [13]. Hence, the difference in the net benefit curves for the 2 models as a function of *p*_{
t
} is the statistic used for model comparison. Two models are said to be equivalent if the confidence interval for the difference in the net benefit curves includes zero, we refer to this standard approach as C-NBC. This decision can be made at a particular threshold probability or in a range of threshold probabilities of interest. However, in some situations (i.e., if model 1 is better for some values of *p*_{
t
} and model 2 is better for other values of *p*_{
t
} in the range of interest), it is difficult to identify the best model. Therefore, we initially propose the area under the net benefit curve (A-NBC) as a summary statistic for the performance of the model in the range of threshold probabilities of interest. When comparing 2 models using A-NBC, the statistic of interest is the difference in the area under the net benefit curves for the 2 competing models. The area under the net benefit curve in a range of *p*_{
t
} is computed using trapezoidal numerical integration. Two models are said to be equivalent if the difference in the A-NBC includes zero. The confidence intervals for the A-NBC statistic were obtained from the bootstrap distribution of the statistic.

### Drawback to using the area under the net benefit curve

The drawback to using the A-NBC as a summary statistic is that the integral used to calculate the area assumes that the threshold probabilities are uniformly distributed in the range of interest [18]. In most of the clinical decision making scenarios, this is not a reasonable assumption. For example, most individuals would have lower values of *p*_{
t
} for highly malignant diseases (e.g., cancer) and higher values of *p*_{
t
} for comparatively harmless diseases (e.g., appendicitis). Hence, the distribution of *p*_{
t
} will depend on the disease, cost and benefits of the treatment and patient characteristics such as age, sex, etc. Because the A-NBC statistic does not utilize this information, a clinical decision using the A-NBC may not be practically optimal. By attributing the same weight to model performance at all threshold probabilities, the A-NBC statistic over weights the performance of the model when the clinical significance is comparatively lower and underweights the performance of the model at threshold probabilities where the clinical significance is higher. To overcome this obstacle, we proposed a novel method to estimate the distribution of *p*_{
t
} without any additional data, and calculated the weighted area under the net benefit curve based on the distribution of *p*_{
t
} to obtain improved estimates of model performance.

### Estimating the distribution of *p*_{
t
}

*p*

_{ t }using the clinical decision of

*Z*(i.e., removing or not removing the seminal vesicles during prostate surgery), and the predicted probability of SVI (

*p*

_{ d }). The detailed derivation of the cumulative probability distribution of

*p*

_{ t }is provided in the Appendix. Briefly, the cumulative probability distribution of

*p*

_{ t }can be expressed as

*p*

_{ t }can be expressed as

*p*

_{ t }. After initializing the starting distribution, the distribution of

*p*

_{ t }is updated using equation (2). In the next iteration, the estimated distribution of

*p*

_{ t }is used as the input value to equation (2). The process is repeated until the distribution converges (see Fig. 1).

### Weighted area under the net benefit curves

*p*

_{ t }, we proposed the weighted area under the net benefit curve (WA-NBC), as an improved summary statistic for comparing risk prediction models. The WA-NBC statistic is calculated as

*NBC*(

*p*

_{ t }) is the net benefit curve for the corresponding model,

*f*(

*p*

_{ t }) is the density of

*p*

_{ t }and the integration is over the range of interest of threshold probabilities. When 2 competing models are compared using the WA-NBC method, the statistic of interest is the difference in the WA-NBC statistics that correspond to the 2 models. The confidence intervals for the statistic were obtained using the standard bootstrap approach.

## Results

We used 3 different approaches, C-NBC; A-NBC; and WA-NBC to compare 2 competing risk prediction models in the range of interest of threshold probabilities.

### Simulation 1: Type 1 error and power

The type 1 error rates were based on the comparison of models M1 and M2. M1 included predictor variables PSA, GS, and X_{1} as in equation (1) and 3 non-causal predictors (i.e., coefficient zero). M2 included PSA, GS, and X_{1} as in equation (1) and 3 different non-causal predictors. The purpose of including different non-causal predictors in M1 and M2 was to evaluate the type 1 error rate when 2 models were equivalent but not identical. Therefore, we considered 2 models, M1 and M2, which had identical causal variables but different non-causal variables. In this simulation scenario, the models are equivalent, *M*1 ≡ *M*2, because the non-causal predictors have an effect size of zero. All the non-causal predictors were simulated using the standard normal distribution. The type 1 errors and powers were calculated using the bootstrap confidence interval approach. The type 1 errors for the 3 different approaches, C-NBC, A-NBC, and WA-NBC, were well controlled.

The power for the methods was based on comparing the 2 models, M1 and M2, where M1 included all risk factors, PSA, X_{1}, GS, and *n*_{1} and 2 non-causal predictors, *n*_{2},*n*_{3}. M2 included PSA, X_{1}, and GS, but not *n*_{1}, and 3 additional independent, non-causal predictors. The predictors *n*_{1},*n*_{2}…,*n*_{6} were simulated using a standard normal distribution. M1 was superior to M2 because it included all the causal predictors. To compare the competing models, we simulated data using 3 values of γ (0.3,0.35 and 0.4) to illustrate the change in power while varying the effect of the causal predictor. For this simulation scenario, the range of interest for *p*_{
t
} was considered to be between 30 % to 50 % (i.e., we compared the performance of the methods in this range of *p*_{
t
}). The power for the C-NBC method was computed for threshold probabilities within the range of interest and averaged over the range (Table 1).

At γ=0.3, the statistical power achieved when using the C-NBC method was 0.31, which was lower than that achieved by the proposed WA-NBC method (0.53) at the 0.05 level of significance. For γ = (0.35,0.4) the power achieved by using the C-NBC method (0.46, 0.61) was lower than the power for the WA-NBC method (0.68, 0.79).

### Simulation 2: Convergence of the iterative process of estimating the distribution of *p*_{
t
}

The patient threshold probabilities were modeled using a beta distribution *Beta* (2,7). The simulated data were used to estimate the distribution of the threshold probabilities using the recursive method (detailed in Methods). At each iteration, the estimated distribution of the threshold probabilities *p*_{
t
} approaches the true distribution of *p*_{
t
}. The final estimated distribution of *p*_{
t
} computed after 100 iterations converged to the original simulated distribution of threshold probabilities, as shown in Fig. 1. The convergence to the original simulated distribution of threshold probabilities when the patient threshold probabilities were modeled using a truncated exponential distribution (rate parameter 10 and truncated to the right at 1) is shown in Additional file 1: Figure S2.

### Simulation 3: Impact of weighting the net benefit using the distribution of *p*_{
t
}

*p*

_{ t }that we proposed to use in calculating the WA-NBC statistic compared to simply using a uniform distribution for

*p*

_{ t }that is used to calculate the A-NBC. The statistic of interest is the total net benefit for all the patients in the cohort, which summarizes the performance of a model for the cohort. We compared the total net benefit in 2 scenarios: 1) when the true threshold probabilities (

*p*

_{ t }) were uniformly distributed; and 2) when the true threshold probabilities (

*p*

_{ t }) were distributed as a beta distribution (Beta (2,7)). The model

*p*

_{ t }used in the simulation; 2) using the estimated distribution of

*p*

_{ t }; and 3) using a uniform distribution. We simulated 1000 replicates to evaluate the confidence intervals for the total net benefit using the 3 methods (Table 2).

When the threshold probabilities were simulated using a uniform distribution, the net benefit obtained by using the estimated distribution compared to the uniform distribution was 1685.7 (1682.0–1689.3) compared to 1689.5 (1686.4–1692.5), respectively, which, as expected, was equivalent to the true net benefit of 1689.4 (1686.5–1692.3) obtained using the true values of *p*_{
t
} in the simulation. However, when the threshold probabilities were simulated using a beta distribution, the net benefit obtained by using the estimated distribution compared to the uniform distribution was 3013.9 (3010.5–3017.2) compared to 1692.1 (1689.2–1695.0), respectively. In this scenario, the true net benefit for the cohort, obtained using the true values of *p*_{
t
} used in the simulation, was 3013.7 (3010.3–3017.2), which is closer to the net benefit computed using the estimated distribution of *p*_{
t
}. The net benefit computed using the uniform distribution underestimated the total net benefit of the method and therefore underestimated model performance.

### Simulation 4: Example showcasing the utility of WA-NBC

*p*

_{ t }range of 15 % to 45 %. The models are

## Discussion

In this paper, we present a novel method for estimating the distribution of threshold probabilities for individuals in clinical scenarios. This work was motivated by the absence of a straightforward way to compare 2 risk prediction models when the decision curves cross in the range of threshold probabilities of interest. The key deterrent for the use of a simple summary measure such as the area under the net benefit curve is its unrealistic assumption that the threshold probabilities are uniformly distributed in the range of interest. That assumption is largely unrealistic as the threshold probabilities depend on the given disease and other patient characteristics. For malignant diseases, these probabilities are right-skewed and for non-life-threatening diseases, they are left-skewed.

It is important to note that the individual values of *p*_{
t
} cannot be estimated without additional data; however, the distribution of the values of *p*_{
t
} can be estimated using existing data by solving the recursive equation for cumulative distribution of *p*_{
t
}. The recursive equation does not have a closed form solution because the cumulative distribution function is present in both the numerator and denominator in different forms. Therefore, an iterative solution was adopted to solve the equation to estimate the cumulative distribution of *p*_{
t
}. The rate of convergence was quick for several forms of hypothesized distributions of *p*_{
t
} (i.e., beta, uniform and truncated exponential) and almost always converged within 100 iterations, which took less than 3 min on a computer with a single processor and a speed of 3.4 GHz. We then used the estimated distribution to propose the weighted area under the net benefit curve as a novel summary measure for model comparison in the range of threshold probabilities of interest.

We performed several simulations to assess the performance of the proposed WA-NBC statistic and compared it to A-NBC and the standard approach, C-NBC. The type 1 errors were well controlled for all the methods. The statistical power for WA-NBC was higher than the power achieved when using the C-NBC method. We also showed that the total net benefit for the cohort obtained by using the estimated distribution was closer to the true total net benefit compared to using the uniform distribution to calculate the area under the net benefit curve. Thus, using the estimated threshold probability distribution accurately quantifies the model performance.

To demonstrate the utility of the weighted area under the curve, we simulated a scenario in which 2 competing models, M1 and M2, cross in the region of interest. In this scenario, it was difficult to make a decision using the C-NBC method. Using the A-NBC method led to the false conclusion that M1 was equivalent to M2, and using the proposed WA-NBC method provided the correct conclusion that M1 was superior to M2. The proposed weighted area under the net benefit curve is a superior measure for comparing risk prediction models when there is a crossover of net benefit curves in the region of interest. Importantly, we recommend using this measure even when the curves do not cross because this measure weights the net benefit curve with respect to the distribution of *p*_{
t
}, leading to a more practical estimation of the net benefit for future study participants.

The net harm can also include cost effectiveness of the risk prediction models and other measures of utility. Accounting for the net harm will provide a more practical measure to identify the model that is most relevant to a particular clinical scenario.

The proposed methodology is generally used to compare 2 predefined risk prediction models. However, we can improve the efficiency of decision curve analysis using relative utility curves [28]. Relative utility curves are based on the contribution of the risk prediction model to clinical utility compared to a hypothesized perfect prediction. The test trade off, which is analogous to the net harm (discussed above) for net benefit curves, can then be used to evaluate the practical utility of the models when using relative utility curves. The main contribution of the proposed methodology is to recursively estimate the distribution of *p*_{
t
}, and subsequently use a weighted summary measure. This framework can be used to improve the performance of relative utility curves in the same manner as net benefit curves.

## Conclusions

We have proposed a novel way to estimate the distribution of threshold probabilities without any additional data. Using the estimated distribution of threshold probabilities, we proposed the weighted area under the net benefit curve as a novel summary statistic for model comparison. We performed several simulation studies to demonstrate the improvement in model comparison using the weighted area under the net benefit curve statistic compared to the standard net benefit curves in various scenarios.

## Abbreviations

A-NBC, Area based net benefit curve method; AUC, Area under the curve; C-NBC, Confidence interval based net benefit curve method; DCA, Decision curve analysis; PSA, Prostate specific antigen; GS, Gleason score; SVI, Seminal vesicular invasion; WA-NBC: Weighted area based net benefit curve method

## Declarations

### Acknowledgements

We wish to thank 2 anonymous reviewers and associate editor for constructive comments on earlier version of the manuscript. We also thank Lee Ann Chastain for editing the manuscript.

### Funding

This work was supported in part by the National Institutes of Health [grants R01CA131324, R01DE022891, and R25DA026120 to S. Shete]; a cancer prevention fellowship for R. Talluri supported by a grant from the National Institute of Drug Abuse [NIH R25DA026120]; the Barnhart Family Distinguished Professorship in Targeted Therapy (to S. Shete); and the Cancer Prevention Research Institute of Texas grant RP130123 (to S. Shete) and the National Cancer Institute grant CA016672 (to S. Shete).

### Availability of data and materials

Power comparison results using the net benefit curves (C-NBC) method and weighted area under the net benefit curves (WA-NBC) method to compare two models. The table shows the variation in power as the simulated coefficient of the causal predictor included in the superior model varied from 0.3 to 0.4

Method | Coefficient | ||
---|---|---|---|

0.3 | 0.35 | 0.4 | |

C-NBC | 0.31 | 0.46 | 0.61 |

WA-NBC | 0.53 | 0.68 | 0.79 |

Total net benefit comparison results using the estimated distribution of *p*_{
t
} and the uniform distribution. The two columns indicate the model for simulating *p*_{
t
}

Simulated | ||
---|---|---|

Method | Uniform (0,1) | Beta (2,10) |

True net benefit | 1689.4 (1686.5–1692.3) | 3013.7 (3010.3–3017.2), |

Estimated net benefit | 1685.7 (1682.0–1689.3) | 3013.9 (3010.5–3017.2) |

Uniform net benefit | 1689.5 (1686.4–1692.5) | 1692.1 (1689.2–1695.0) |

### Authors’ contributions

RT and SS conceived and designed the methodology. RT implemented the method. RT and SS wrote the manuscript. All authors reviewed the manuscript. All authors read and approved the final manuscript.

### Competing interests

The authors declare no competing financial interests.

### Consent for publication

Not applicable.

### Ethics approval and consent to participate

Not applicable.

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## Authors’ Affiliations

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