Three studies were rated serious limitations; one study due to the secondary use of data and the subsequent inability to assess their methodology in detail, along with vague description of the analysis. Two studies due to the lack of richness of data, context and the role of the researcher, as well as a lack of information on data collection in one study and the reasoning for the choice of methods in the other. One study had very serious limitations due to limited information on the background and reflection of the researcher, data collection, data richness, relevance of findings and link to conclusions. Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 Coherence was rated minor concerns overall. Agreement between papers was very good with the majority demonstrating patients lack of understanding of their diagnosis. Only very few papers also described that some patients had a very good understanding of their condition. As a certain degree of variability in people s understanding is expected and all papers were in agreement that the majority lacked the understanding, the concerns were rated as minor overall. Relevance was rated no or very minor concerns. The relevance of the subfinding to the focus of the review was very high. The data stemmed from nine studies from the UK in a relevant population. Adequacy was rated as no or very minor concerns. The subfinding was general and supported by numbers of studies; it was descriptive and supported by the richness of data. The overall assessment of confidence was low, having been downgraded by two increments due to concerns over methodology and coherence. 