Ranking-optimized survival models can underperform fixed-horizon clinical prediction: a SUPPORT2 reanalysis of machine learning, attending-physician judgment, and the original SUPPORT model at 60- and 180-day mortality

Machine-learning survival models are increasingly proposed for intensive-care mortality prediction and are almost always selected and reported using the concordance index, a ranking metric averaged over follow-up. Yet most bedside decisions hinge on a probability at a specific time, such as 60- or 180-day mortality. We asked whether ranking-optimized models remain competitive at fixed clinical horizons against two reference points clinicians actually rely on: unaided attending-physician judgment and the original 1995 SUPPORT logistic model. Reanalyzing the SUPPORT2 cohort (9,105 critically ill adults from five United States centers, 1989-1994) under a stratified 70/15/15 split, we compared a gradient-boosted survival model, the physician's recorded prognosis, and the 1995 model at 60 and 180 days, alongside several alternative learners. The survival model achieved competitive ranking concordance (0.705) yet underperformed both comparators at fixed horizons: at 60 days its area under the ROC curve was 0.750, against 0.808 for physicians on the matched sample and 0.827 for the 1995 model, a gap that held across eight independent data splits and remained statistically reliable after multiplicity correction. The shortfall was not miscalibration, since post-hoc recalibration left discrimination unchanged, nor limited capacity, since neural networks, a deep ranking model, and two timepoint-aware discrete-time models also failed to close it; replacing the ranking objective with timepoint-matched binary training recovered roughly half the gap, pointing to an objective-horizon mismatch. Discrimination was equitable across sex, race, and age, but leave-one-disease-out validation exposed severe failure for disease groups absent from training, and the physician advantage was conditional on a physician electing to provide an estimate. We recommend reporting timepoint-specific discrimination alongside concordance, timepoint-matched training when fixed-horizon predictions drive care, leave-one-subgroup validation, and distribution-free prediction intervals to support selective deployment.