Maarten J.G. Leening, MD, MSc; Moniek M. Vedder, MSc; Jacqueline C.M. Witteman, PhD; Michael J. Pencina, PhD; Ewout W. Steyerberg, PhD
Grant Support: By the Netherlands Organisation for Health Research and Development (ZonMw) and the Netherlands Organisation for Scientific Research (NWO) (ZonMw HTA grant 80-82500-98-10208; Vici grant 918-76-619) and the Center for Translational Molecular Medicine (PCMM project grant). The funding sources had no role in the design or conduct of the study; the collection, management, analysis, or interpretation of the data; or the preparation, review, or approval of the manuscript.
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-1522.
Requests for Single Reprints: Maarten J.G. Leening, MD, MSc, Department of Epidemiology, Erasmus MC - University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, the Netherlands; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Leening and Witteman: Department of Epidemiology, Erasmus MC - University Medical Center Rotterdam, Dr. Molenwaterplein 50, 3015 GE Rotterdam, the Netherlands.
Ms. Vedder and Dr. Steyerberg: Department of Public Health, Erasmus MC - University Medical Center Rotterdam, Dr. Molenwaterplein 50, 3015 GE Rotterdam, the Netherlands.
Dr. Pencina: Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University, 2400 Pratt Street, Durham, NC 27715.
Author Contributions: Conception and design: M.J.G. Leening, E.W. Steyerberg.
Analysis and interpretation of the data: M.J.G. Leening, M.M. Vedder, E.W. Steyerberg.
Drafting of the article: M.J.G. Leening.
Critical revision of the article for important intellectual content: M.J.G. Leening, M.M. Vedder, J.C.M. Witteman, M.J. Pencina, E.W. Steyerberg.
Final approval of the article: M.J.G. Leening, M.M. Vedder, J.C.M. Witteman, M.J. Pencina, E.W. Steyerberg.
Statistical expertise: M.J.G. Leening, M.J. Pencina, E.W. Steyerberg.
Obtaining of funding: E.W. Steyerberg.
Administrative, technical, or logistic support: M.J.G. Leening.
Collection and assembly of data: M.J.G. Leening, M.M. Vedder.
Leening MJ, Vedder MM, Witteman JC, Pencina MJ, Steyerberg EW. Net Reclassification Improvement: Computation, Interpretation, and Controversies: A Literature Review and Clinician's Guide. Ann Intern Med. 2014;160:122-131. doi: 10.7326/M13-1522
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Published: Ann Intern Med. 2014;160(2):122-131.
The net reclassification improvement (NRI) is an increasingly popular measure for evaluating improvements in risk predictions. This article details a review of 67 publications in high-impact general clinical journals that considered the NRI. Incomplete reporting of NRI methods, incorrect calculation, and common misinterpretations were found. To aid improved applications of the NRI, the article elaborates on several aspects of the computation and interpretation in various settings. Limitations and controversies are discussed, including the effect of miscalibration of prediction models, the use of the continuous NRI and “clinical NRI,” and the relation with decision analytic measures. A systematic approach toward presenting NRI analysis is proposed: Detail and motivate the methods used for computation of the NRI, use clinically meaningful risk cutoffs for the category-based NRI, report both NRI components, address issues of calibration, and do not interpret the overall NRI as a percentage of the study population reclassified. Promising NRI findings need to be followed with decision analytic or formal cost-effectiveness evaluations.
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