Some clinicians described the diagnosis of heart failure itself as challenging, making it even more difficult to relay information to patients. This subfinding was based on two studies.26, 133, 313 Methodological limitations were rated moderate concerns overall. Both studies were rated as moderate limitations due to lack of context and the role of the researcher, plus data analysis in one study and data richness in the other. Coherence was rated no or very minor concerns overall. Agreement between papers was good and appeared to fit well with related findings in other studies. Relevance was rated no or very minor concerns overall. The relevance of the subfinding to the focus of the review was high. The data stemmed from two papers from the UK in a relevant population. Adequacy was rated as minor concerns. The subfinding was general, and although explicitly supported by only a limited number of studies, other studies found similar themes. The subfinding was descriptive but the richness of data was somewhat lacking. The overall assessment of confidence was moderate, having been downgraded by one increment due to methodological and adequacy limitations. Review subfinding 1b: Timing and setting The reluctance by some GPs to diagnose patients meant that some patients received a shock diagnosis when admitted to secondary care. Receiving the diagnosis during an unplanned hospital admission was deemed unhelpful and inadequate by clinicians, patients and their carers (Simmonds 2015) as diagnosis could not be relayed in a sensitive manner to the patient and family who had no time to assimilate the information in this busy environment. Patients with good access to hospital- and community-based heart failure specialist nursing teams reported more positive experiences of communication regarding diagnosis. This subfinding was based on three studies.26, 117, 313 Methodological limitations were rated moderate concerns overall. 