Article Text

Download PDFPDF
Utility of the Seattle Heart Failure Model for palliative care referral in advanced ambulatory heart failure
  1. Nicholas Ng Fat Hing1,
  2. Jane MacIver1,
  3. Derrick Chan1,
  4. Helen Liu1,
  5. Yu Tong Linda Lu1,
  6. Abdullah Malik1,
  7. Vicky N Wang1,
  8. Wayne C Levy2,
  9. Heather J Ross1 and
  10. Ana Carolina Alba1
  1. 1 Division of Cardiology, Toronto General Hospital – University Health Network, Toronto, Ontario, Canada
  2. 2 Division of Cardiology, University of Washington Seattle, Seattle, Washington, USA
  1. Correspondence to Nicholas Ng Fat Hing, Division of Cardiology, Toronto General Hospital, Toronto, ON M5G 2N2, Canada; nicholaskvng{at}


Background Physicians face uncertainty when predicting death in heart failure (HF) leading to underutilisation of palliative care. To facilitate decision-making, we assessed the Seattle Heart Failure Model (SHFM) as a referral tool by evaluating its performance in predicting 1-year event-free survival from death, heart transplant (HTx), and ventricular assist device (VAD) implantation.

Methods We retrospectively reviewed the charts of consecutive patients with advanced ambulatory HF with New York Heart Association Class III/IV HF and a left ventricular ejection fraction of ≤40% from 2000 to 2016. We evaluated SHFM’s performance by using the Cox proportional hazards model, its discrimination using the c-statistic, its calibration by comparing the observed and predicted survival and its clinical utility by hypothetically assessing the proportion of patients adequately or inadequately referred to palliative care.

Results We included 612 patients in our study. During the 1-year follow-up, there were 83 deaths, 4 HTx and 1 VAD. Although SHFM showed very good discrimination (c-statistic=0.71) and adequate calibration in medium to low-risk patients, it underestimated event-free survival by 12% in high-risk patients. SHFM’s clinical utility was limited: 33% of eligible patients would have missed the opportunity for referral and only 27% of referred patients would have benefited.

Conclusion Use of SHFM could result in a high proportion of referrals while capturing the majority of patients who may benefit from palliative care. Though this may be a more encompassing and safer alternative than current referral practices, it could lead to many early referrals.

  • Heart failure
  • Prognosis
  • Clinical decisions

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Correction notice This article has been corrected since it was published Online First. The surname of Yu Tong Linda Lu was misspelled and affiliations were incorrect for Ana Carolina Alba.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.