One study was rated very serious limitations due to the limited information on the background and reflection of the researcher, data collection, data richness, relevance of findings and link to conclusions. Coherence was rated minor concerns overall. Although the suggestions for how to improve access to information varied, overall the agreement between papers was good. 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 six studies from the UK in a relevant population. Adequacy was rated as no or very minor concerns. The findings were supported by a few studies in much detail. The overall assessment of confidence was moderate, having been downgraded by one increment due to moderate methodological and minor coherence limitations. Referral and approach to care Chronic Heart Failure NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 9.4.3.4 Qualitative evidence summary Table 140: Summary of evidence Study design and sample size Finding Quality assessment Number of studies contributing to the finding Design Criteria Rating Overall assessment of confidence Diagnosis of heart failure 1a. Communication is challenging Individual interviews with pt + carers and focus groups with HCPs Ethnographic study (in-depth interviews, observation, impromptu interviews, field notes, patient and carer diaries, patient medical records) involving pt and HCPs Clinicians find the diagnosis itself and the ensuing communication around diagnosis challenging. Limitations Moderate concerns about methodological limitations MODERATE Coherence No or very minor concerns about coherence Relevance No or very minor concerns about relevance Adequacy Minor concerns about adequacy Diagnosis of heart failure 1b. 