Agreement between papers was good, and is supported by many of the other studies in an implicit way. Relevance was rated no or very minor concerns overall. The relevance of the sub-finding to the focus of the review was very high, as communication was flagged as an issue during transitions between care settings. Concern was due to two studies being from outside the UK, and some being more than ten years old but more recent studies report similar findings, suggesting that this issue has not significantly changed over time and probably generalises well. Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 Adequacy was rated as no or very minor concerns. The sub-finding is fairly general and descriptive, and was sufficiently supported by the number of studies and the richness of data. The overall assessment of confidence was moderate, having been downgraded by one increment due to methodological limitations. Review sub-finding 3b: Barriers to communication Healthcare professionals identified the following barriers to cross-boundary communication: fragmented and incompatible information systems, and a lack of time. HF nurses describe in one study, for example, how they struggle to speak to GPs when they have concerns about their patients (GPs are in surgery or on house-calls during most of office hours). This sub-finding was based on 2 studies202, 209 . Methodological limitations were rated moderate overall. One paper was rated serious limitations due to lack of depth and explanations. One paper was rated as moderate limitations due to little description of participants. More data came from the latter, therefore rated as moderate overall. Coherence was rated no or very minor concerns overall. Agreement between papers was good. Agreement with related findings in other studies was also good. 