The proposed 'concordance-statistic for benefit' provided a useful metric when modeling heterogeneous treatment effects

J Clin Epidemiol. 2018 Feb;94:59-68. doi: 10.1016/j.jclinepi.2017.10.021. Epub 2017 Nov 11.


Objectives: Clinical prediction models that support treatment decisions are usually evaluated for their ability to predict the risk of an outcome rather than treatment benefit-the difference between outcome risk with vs. without therapy. We aimed to define performance metrics for a model's ability to predict treatment benefit.

Study design and setting: We analyzed data of the Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) trial and of three recombinant tissue plasminogen activator trials. We assessed alternative prediction models with a conventional risk concordance-statistic (c-statistic) and a novel c-statistic for benefit. We defined observed treatment benefit by the outcomes in pairs of patients matched on predicted benefit but discordant for treatment assignment. The 'c-for-benefit' represents the probability that from two randomly chosen matched patient pairs with unequal observed benefit, the pair with greater observed benefit also has a higher predicted benefit.

Results: Compared to a model without treatment interactions, the SYNTAX score II had improved ability to discriminate treatment benefit (c-for-benefit 0.590 vs. 0.552), despite having similar risk discrimination (c-statistic 0.725 vs. 0.719). However, for the simplified stroke-thrombolytic predictive instrument (TPI) vs. the original stroke-TPI, the c-for-benefit (0.584 vs. 0.578) was similar.

Conclusion: The proposed methodology has the potential to measure a model's ability to predict treatment benefit not captured with conventional performance metrics.

Keywords: Acute ischemic stroke; Concordance; Coronary artery disease; Discrimination; Individualized treatment decisions; Prediction models; Treatment benefit.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Aged
  • Clinical Trials as Topic
  • Coronary Artery Disease / therapy*
  • Decision Support Systems, Clinical
  • Female
  • Humans
  • Male
  • Middle Aged
  • Models, Theoretical*
  • Percutaneous Coronary Intervention
  • Precision Medicine
  • Tissue Plasminogen Activator / administration & dosage*


  • Tissue Plasminogen Activator