Population-Level Decision Curve Analysis May Mislead the Evaluation of Prediction Model Usefulness under Subgroup Utility Heterogeneity
Background Decision curve analysis (DCA) evaluates prediction model usefulness using net benefit (NB). Population-level NB is often interpreted as a proxy for population-level expected utility, but this assumes comparability of utility across subgroups. We aimed to characterize when subgroup utility heterogeneity may invalidate population-level DCA conclusions. Methods We compared prediction-driven treatment with default strategies in populations containing subgroups with different utility values. We derived an inconsistency region: combinations of subgroup-specific ΔNB values for which population-level NB and utility favor different strategies. We also developed a practical robustness framework. Results Opposite signs of subgroup-specific ΔNB provide a warning signal for possible inconsistency. The inconsistency region is larger when subgroup sizes are more similar and subgroup-specific \(a-c\) values are more different, where \(a-c\) is the incremental utility of a true positive relative to a false negative. When \(a-c\) differs across subgroups, population-level NB combines quantities on different implicit utility scales and may conflict with population utility. A real-world case study illustrates the problem. Conclusions Using population-level NB as a proxy for population utility implicitly assumes homogeneous \(a-c\) across subgroups. Subgroup DCA and our framework can identify and assess when utility heterogeneity may invalidate population-level conclusions.