Many studies also did not report calibration data and these were downgraded for risk of bias. Some studies were also downgraded for indirectness as the patients in the cohorts were recruited prior to 2001, when best practice medical treatment for heart failure changed to include beta-blockers. This means that these data may not reflect accuracy of the tools in a population treated in Chronic Heart Failure Advanced heart failure and palliative care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 accordance with current usual care. The committee agreed that the most important accuracy data for establishing the utility of a risk tool was the sensitivity and specificity of the tool at clinically relevant thresholds (for example, at a threshold of 50% risk of mortality at 1 year). As the main aim of the tools was to identify patients who may benefit from a palliative care approach, sensitivity was agreed to be of great importance. However, depending on how the tool was used, high specificity was also crucial as wrongly categorising a person at high risk of death could have negative consequences for that person and their family. Only 1 study reported sensitivity and specificity data at specific thresholds (50% and 20% predicted mortality) for 2 tools (Seattle Heart Failure Model (SHFM) and the MAGGIC project heart failure risk score). The sensitivity and specificity data was graded high quality for the SHFM and moderate quality for the MAGGIC risk score (the latter was downgraded due to poor calibration and failure to recalibrate). Trade-off between clinical benefits and harms Overall, the committee were not persuaded that any of the risks tools included in the review identified patients with a high risk of mortality with sufficient accuracy to support their use. 