Evaluating utility of clinical prediction models: A comparison of decision curve analysis and cost curves

Patient-facing triage requires an appropriate care recommendation and recognition of when information is insufficient. We evaluate whether Jev, a decision model that returns probabilities over predefined actions, supports both judgments. Using CARE-Bench, we compare Jev with four general-purpose language models and three input-independent baselines across 925 decision points from 439 public cases. On the public test subset, Jev ranks fourth of five models by macro-F1 (0.461) but has the lowest observed multiclass Brier score (0.610), an 18.7% improvement over uniform prediction (case-bootstrap 95% interval, 4.9--31.1%). Noul has lower binary Brier than Choice (0.215 versus 0.276). A evaluation of 453 HealthBench conversations again gives Jev the lowest observed Brier score (0.299), but measures a distinct emergency-referral judgment. Jev combines lower probability error with missed clarification needs in the four-action task. Asking about information sufficiency separately increases recall but also produces frequent unnecessary clarification assignments.

Objective Prediction models are commonly trained using objectives such as Bernoulli negative log-likelihood (NLL), although downstream clinical decisions may depend on specific risk thresholds. We introduce Smooth Net Benefit ($σ$NB), a differentiable approximation of Net Benefit designed to align model training with threshold-specific clinical utility. Materials and Methods We evaluated $σ$NB as a training objective for logistic regression, generalized additive models (GAMs), and XGBoost with three Hessian implementations. Experiments used the Framingham cardiovascular risk dataset and 44 TabZilla datasets comprising 72 dataset-threshold combinations. Results $σ$NB training did not consistently improve Net Benefit in Framingham. Across the TabZilla benchmark, mean standardized Net Benefit for logistic regression increased from 0.5669 with NLL to 0.5765 with $σ$NB (mean difference 0.0096, 95% CI -0.0001 to 0.0193). For GAMs, mean standardized Net Benefit decreased from 0.5921 to 0.5625 (mean difference -0.0296, 95% CI -0.0721 to 0.0129). For XGBoost, NLL achieved 0.6745 compared with 0.6723--0.6735 across $σ$NB implementations. In logistic regression, $σ$NB gains were positively associated with the performance advantage of XGBoost over NLL-trained logistic regression. Discussion The effect of $σ$NB was context dependent, with modest gains concentrated in logistic regression and little benefit for more flexible model classes. This suggests that decision-focused optimization may be most useful when limited model flexibility leaves greater scope for improvement. Conclusion Our results do not support $σ$NB as a general replacement for NLL training, but support further investigation of decision-focused objectives in settings where conventional likelihood-based training may not adequately capture decision-relevant structure.

As language models are increasingly deployed in real-world scenarios with important outcomes, the impact of their mistakes often extends far beyond what correctness can capture. In domains like medicine, a single error can lead to serious consequences and put patient safety at risk. However, mainstream evaluation protocols still treat all errors as equal, overlooking the spectrum of real-world costs. To address this, we propose a utility-based evaluation paradigm that explicitly incorporates the varying consequences of errors. Guided by this principle, we develop UtilityBench, a large-scale benchmark of 15,000 instances with verifiable answers, quantifying error severity using Best-Worst Scaling to elicit meaningful, data-driven cost estimates. These quantified utilities shape when a model should answer or abstain, guiding it to make decisions that align with the true importance of each scenario. As another merit, we introduce UtilityAUC, a metric that measures the area under the utility curve determined by a model's response ordering, thereby enabling utility preference alignment beyond error frequency. Our theoretical analysis demonstrates that UtilityAUC can distinguish between models where standard accuracy and AURC fall short. Empirically, evaluating 20 state-of-the-art models, we find that greater accuracy or more advanced architectures do not reliably translate to higher UtilityAUC, highlighting a gap between problem-solving ability and responsible decision-making in language model evaluation.