LOWa due to risk of bias The mean SF-physical in the control groups was The mean SF-physical in the intervention groups was 0.3 lower (worse) (3.25 lower to 2.65 higher) Quality of life (mental) SF-36 mental health composite, final score. higher=better. Scale from: 0 to 100. LOWa due to risk of bias The mean SF-mental in the control groups was The mean SF-mental in the intervention groups was 0.1 lower (worse) (3.5 lower to 3.5 higher) Prescribed double therapy of ACE-I/ARB and B- blocker LOWa due to risk of bias (from 115 fewer to 144 more) Referral and approach to care Chronic Heart Failure NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: (a) Downgraded by 1 increment if the majority of the evidence was at high risk of bias, and downgraded by 2 increments if the majority of the evidence was at very high risk of bias. (b) Downgraded by 1 increment if the confidence interval crossed one MID or by 2 increments if the confidence interval crossed both MIDs. Table 125: Clinical Evidence Summary: Martensson 2005: Non-specialist case management (MDTcm) vs Primary care (1 control) > 6 months for high risk HF Outcomes No of Participants (studies) Follow up Quality of the evidence (GRADE) Relative effect Anticipated absolute effects Risk with primary care Risk difference with MDTcm (95% CI) VERY LOWa, b due to risk of bias, imprecision (from 3 fewer to 418 more) Prescribed ACE-I at target dose 130 VERY LOWa, b due to risk of bias, imprecision 574 ACE-I per 92 fewer ACE-I per 1000 (from 224 fewer to 97 more) Prescribed beta-blocker at target dose 130 VERY LOWa, b due to risk of bias, imprecision 235 B-blocker per 9 fewer B-blocker per 1000 (from 115 fewer to 188 more) (a) Downgraded by 1 increment if the majority of the evidence was at high risk of bias, and downgraded by 2 increments if the majority of the evidence was at very high risk of bias. (b) Downgraded by one increment as confidence interval crosses one MID or two increments as confidence interval crosses both MID. Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 9.2.4 Economic evidence Published literature Five health economic studies were identified with the relevant comparison and have been included in this review. 22 To maintain consistency with the clinical review these have also been reported according to the clinical categories specified above. One health economic study was identified for the high risk, mid-length intervention, MDT clinic category; 2 health economic studies were identified for the high risk, long intervention, MDT clinic category; 1 health economic study was identified for the high risk, long intervention, nurse led MDT; and 1 health economic study was identified for the high risk, long intervention, case management MDT. No economic evaluations were identified for the remaining categories. These are summarised in the health economic evidence profiles below (Table 126, Table 127, Table 128 and Table 129) and the health economic evidence tables in Appendix G. One economic evaluation was selectively excluded due to the availability of more applicable evidence. This is listed in appendix J, with reasons for exclusion given. See also the health economic study selection flow chart in Appendix D. Referral and approach to care Chronic Heart Failure NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: Table 126: Health economic evidence profile: Home-based MDT clinic (mid-length intervention) vs usual care in high risk patients Study Applicability Limitations Other comments Incremental cost Incremental effects Cost- effectiveness Uncertainty Sahlen [Sweden] Partially applicable (a) Potentially serious limitations (b) Cost-utility analysis (health outcome: QALYs) Within-trial analysis of a RCT Population: adults with chronic heart failure with NYHA class III-IV symptoms and a marker of severity Interventions: 1. Usual care 2. MDT - consisting of a heart failure nurse, palliative care nurse, cardiologist, palliative care physician, physiotherapist and occupational therapist 6 month follow-up saving of QALYs (more effective and less costly) Uncertainty not reported for cost effectiveness Conclusions robust to sensitivity analyses. Abbreviations: QALY: quality-adjusted life years; RCT: randomised controlled trial (a) Single centre study from a county council hospital in V sterbotten County, Sweden and therefore resource use and 2012 costs may not reflect current UK NHS context. (b) Short time horizon may not capture full costs and effects of the intervention. EQ-5D reported differently to the clinical trial evidence. Only minimal sensitivity analyses were carried out to quantify uncertainty. Table 127: Health economic evidence profile: MDT clinic (long intervention) vs usual care in high risk patients Study Applicability Limitations Other comments Incremental cost Incremental effects Cost- effectiveness Uncertainty Atienza [Spain] Partially applicable (a) Potentially serious limitations Cost-consequence analysis (health outcomes: 1 year mortality rate, all-cause saving of See clinical review of same paper n/a None undertaken. Referral and approach to care Chronic Heart Failure NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: Study Applicability Limitations Other comments Incremental cost Incremental effects Cost- effectiveness Uncertainty (b) readmissions, quality of life as measured by the MLWHFQ) Within-trial analysis of same paper in clinical review Population: people discharged from cardiology wards with a primary diagnosis of heart failure. Interventions: 1. Usual care 2. MDT - consisting of a specialist cardiac nurse, primary care physician and cardiologist. 16 month follow up (mortality, all- cause hospitalisation, quality of life). Pulignano [Italy] Partially applicable (c) Potentially serious limitations (d) Cost-effectiveness analysis (health outcomes: death or readmission for heart failure and all-cause admission rate) Within-trial analysis of a RCT Population: people over the age of 70 with heart failure with reduced and normal ejection fraction, discharged home after a hospitalisation. Interventions: 1. Usual care (primary/ secondary care) 2. Multidisciplinary team saving of See clinical review of Del Int 2 saves death and/or heart failure- related admission avoided. Int 2 saves 2,155 per all- cause admission avoided. None undertaken. Referral and approach to care Chronic Heart Failure NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: Study Applicability Limitations Other comments Incremental cost Incremental effects Cost- effectiveness Uncertainty consisting of a cardiologist, experienced in geriatrics (case managers), two to four specialised nurses, and the patient s primary care physician. 2 year follow up Abbreviations: QALY: quality-adjusted life years; RCT: randomised controlled trial (a) Spanish resource use data and unit costs (year not reported, assumed to be 2004) may not reflect current NHS context. QALYs were not used as the health outcome measure (b) Within-trial analysis and so does not reflect the full body of available evidence available for this intervention. Atienza is 1 of 5 studies included comparing MDT clinic to usual care in high risk patients. No exploration of uncertainty. (c) Italian national health service resource use and unit costs may not reflect current UK NHS context. QALY data was not reported clearly enough to report and therefore were not used as the health outcome measure. Discounting was not applied. (d) Within-trial analysis and therefore does not reflect the full body of evidence available for this comparison. Pulignano is 1 of 5 studies included comparing MDT clinic to usual care in high risk patients. No exploration of uncertainty. Table 128: Health economic evidence profile: Home-based MDT (long intervention) vs nurse led MDT clinic (long intervention) vs usual care in high risk patients Study Applicability Limitations Other comments Incremental cost Incremental effects Cost- effectiveness Uncertainty [Netherlands] Partially applicable (a) Potentially serious limitations (b) Cost-utility analysis (health outcome: QALYs) Within-trial analysis of a RCT Population: Patients >18 years old with evidence of structural cardiac dysfunction Interventions: 1. Usual care (cardiology clinic) 2-1: cost saving and 3 (more effective and less costly) (c) Probability intervention 2 Conclusions robust to sensitivity analysis. Referral and approach to care Chronic Heart Failure NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: Study Applicability Limitations Other comments Incremental cost Incremental effects Cost- effectiveness Uncertainty 2. Basic MDT 3. Intensive MDT 18 month follow-up Abbreviations: QALY: quality-adjusted life years; RCT: randomised controlled trial (a) This analysis has been undertaken from a Dutch perspective using 2009 unit costs and therefore may not reflect current NHS context. Does not include important cost aspects such as procedures during hospital admission. EQ-5D was not used. (b) Probabilistic sensitivity analysis was not presented at 20k/QALY. No discounting was undertaken; however the time-horizon was only 18 months and so is unlikely to have a significant effect. Excluded drug costs, cost of procedures conducted during hospitalisation or short term hospital admission as not rigorously reported in associated trial. (c) This study also reports results for sub-groups according to NYHA class. In patients with less severe heart failure (NYHA class I-II) intervention 2 dominates interventions 1 and 3. However, in patients with severe heart failure (NYHA class III-IV) intervention 1 is the most cost effective option. Table 129: Health economic evidence profile: MDT (long intervention - case-management) vs usual care (primary +/- secondary) in high risk patients Study Applicability Limitations Other comments Incremental cost Incremental effects Cost- effectiveness Uncertainty Moertl [Austrian] Partially applicable (a) Potentially serious limitations (b) Cost-utility analysis, Markov model Population: Patients with heart failure discharged after a heart failure hospitalisation Comparators: 1. Usual care in community 2. Nurse-led MDT 20 year time horizon modelled QALYs per QALY gained (c) Uncertainty not reported for cost effectiveness Conclusions robust to sensitivity analyses (including discount rate to 3% and 0%). Abbreviations: ICER: Incremental cost effectiveness ratio; MDT: multidisciplinary team; QALY: quality-adjusted life years. (a) Austrian payer perspective. EQ-5D not used to capture quality of life - utility scores converted from MLWHF questionnaire using previously published algorithm. Costs and effects discounted at 5%. (b) Cost of GP visits and drug costs were not collected and not included in the analysis of the clinical trial phase. (c) An additional comparator was also included in the study that involved intensive NT-proBNP guided patient management in addition to multidisciplinary care. This comparator dominates (more effective, less costly) both usual care and the nurse-led MDT alone. Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 9.2.5 Evidence statements Clinical Overall 22 studies were included in the review. No meta-analysis was conducted due to the heterogeneous nature of the interventions and populations in the included studies. The studies were grouped into strata based on the population risk level (high, low) and the length of the intervention (long, mid, short), and were also categorised into one of four intervention types (home-based MDT, MDT clinic, nurse-led or pharmacist-led clinic, or case management). High risk Short Home-based MDT No studies were identified in this category. MDT clinic This category included two studies with high risk populations exposed to a short MDT clinic intervention. For the outcome of all-cause hospitalisations, the evidence was inconsistent, with one study (n=98) suggesting a clinically important reduction and the other (n=112) suggesting a clinically important increase (moderate to low quality evidence). The evidence from both studies did not demonstrate a clear effect with the confidence interval ranging from a decrease and increase in all- cause mortality.One of the studies (n=112) showed a clinically important increase in prescribing of ACE inhibitors and beta-blockers (high to moderate quality evidence). Nurse-led or pharmacist-led clinic No studies were identified in this category. Case-management No studies were identified in this category. High risk, Mid-length Home-based MDT This category included one study (n=72) with a high risk population exposed to a mid-length home- based MDT intervention. The evidence showed a clinically important reduction in hospitalisations (high quality evidence) and a clinically important improvement in quality of life (very low quality evidence). Mortality did not demonstrate a clear effect with the confidence interval ranging from a decrease and increase in all-cause mortality. MDT clinic This category included three studies with high risk populations exposed to mid-length MDT clinic interventions. The evidence on hospitalisations was low to very low quality and inconsistent, with two studies (n=7117 and n=230) suggesting a clinically important reduction, and the third study (n=200) suggesting no clinical difference. Evidence on mortality was also low to very low quality and did not demonstrate a clear effect with the confidence interval ranging from a decrease and increase Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 in all-cause mortality The third study also provided evidence on quality of life and heart failure medication prescribing and adherence. Very low quality evidence suggested no clinically important difference in quality of life. The evidence on medications was moderate to very low quality and inconsistent, with evidence of a clinically important decrease in prescription of beta-blockers, but no clinical difference in prescribing of ACE inhibitors or taking prescribed medication. Most of the evidence had very wide confidence intervals around the effect estimates. Nurse-led or pharmacist-led clinic This category included 2 studies (n=25 and n=158) with high risk populations exposed to a mid-length nurse-led clinic intervention. For the outcome of hospitalisations, low to very low quality evidence suggested a clinically important reduction. Very low quality evidence suggested mortality did not demonstrate a clear effect with the confidence interval ranging from a decrease and increase in all- cause mortality The smaller study provided low quality evidence for quality of life which suggested no clinically important difference. Very low quality evidence from the same study also suggested a clinically important increase in prescribing of optimal beta-blocker doses. Evidence on all of the outcomes except for beta-blocker prescribing had very wide confidence intervals around the effect estimates. The larger study provided low quality evidence for NYHA class change and prescribing of ACE-inhibitors which showed no clinical difference in the former and a clinical benefit for the latter. Case management This category included one study (n=161) with a high risk population exposed to a mid-length case management intervention. Very low quality evidence showed a clinically important decrease in hospitalisations. Very low quality evidence on mortality did not demonstrate a clear effect with the confidence interval ranging from a decrease and increase in all-cause mortality Low to very low quality evidence on quality of life suggested no clinically important difference. High risk, Long Home-based MDT This category included one study (n=683) with a high risk population exposed to a long home- based MDT intervention. Low quality evidence suggested a clinically important increase in hospitalisations . Mortality did not demonstrate a clear effect with the confidence interval ranging from a decrease and increase in all-cause mortality. MDT clinic This category included five studies (n=338, n=173, n=240, n=234, n=197) with high risk populations exposed to a long MDT clinic intervention. Moderate to very low quality evidence from the five studies consistently showed a clinically important reduction in hospitalisations or days in hospital. High to very low quality evidence from four of the studies also suggested a clinically important reduction in mortality or cardiac mortality in two studies,no clear effect in two studies and the fifth study suggested a clinically important increase. Low to very low quality evidence on quality of life reported in three of the studies (n=220, n=210, n=197) suggested a clinically important benefit. Moderate to low quality evidence on prescribing of beta-blockers from two studies (n=153, n=210) suggested a clinically important benefit. Evidence on ACE inhibitor prescribing was inconsistent, with two studies (n=210, n=154, moderate to low quality) suggesting a clinically important benefit and a third (n=153, low quality) suggesting no clinical difference. Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 Nurse-led or pharmacist-led clinic This category included two studies (n=679 and n=208) with high risk populations exposed to a long nurse-led clinic intervention. Evidence for hospitalisations was of moderate to low quality and showed no clinical difference in the former study but a clinical benefit for the latter. The evidence for mortality was of low quality and did not demonstrate a clear effect with the confidence interval ranging from a decrease and increase in all-cause mortality. One study (n=208) also reported quality of life and medication prescription. The evidence for quality of life was of low quality and showed no clinical difference. Evidence for prescribed ACE-inhibitors and beta-blockers were of low to very low quality and showed a clinically important reduction for both outcomes. Case management One study (n=186) with a high risk population undergoing a long case-management programme was included in this category. Low to very low quality evidence suggested a clinically important reduction in hospitalisations, deaths and prescription of beta-blockers. Moderate quality evidence suggested no difference in the prescription of ACE-inhibitors or ARB. Quality of life was not reported. Low risk, Short No studies were identified in these categories. Low risk, Mid-length No studies were identified in these categories. Low risk, Long Home-based MDT No studies were identified in this category. MDT clinic One study (n=920) offering an extended follow-up in an MDT clinic for low risk stable HFREF patients was included in this category. High quality evidence showed a clinically important reduction in admissions. Low quality evidence for mortality did not demonstrate a clear effect with the confidence interval ranging from a decrease and increase in all-cause mortality. The evidence for the remaining outcomes quality of life, prescribed ACE-inhibitors, prescribed beta-blockers, and three adverse events (serum creatinine increase, hyperkalaemia and hypotension) all showed no clinical difference and were of moderate to very low quality. Nurse-led clinic This category included one study (n=160) with a long nurse-led clinic for low risk HFREF patients. Low to very low quality evidence showed a clinically important reduction in the number of admissions. Mortality did not demonstrate a clear effect with the confidence interval ranging from a decrease and increase in all-cause mortality .Low quality evidence also showed a clinically important increase in prescribed ACE-inhibitors or ARB. No difference was found for the outcomes of prescribed beta- blockers and renal function serum creatinine, which were of moderate to low quality. Quality of life was not reported. Pharmacist-led clinic Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 One study (n=83) with a long, pharmacist-led clinic for a low risk HF population was included in this category. The evidence for admissions was of very low quality and showed a clinical reduction for both. Mortality did not demonstrate a clear effect with the confidence interval ranging from a decrease and increase in all-cause mortality .Very low quality evidence for quality of life also showed a clinical benefit for the intervention. Self-reported taking of prescribed medication showed no clinical difference and was of low quality. An automated measure of taking prescribed medication, however, showed a clinically important increase; the evidence of which was of very low quality. Case management Two studies with a long, non-specialist case management approach for a low risk HF population were included in this category (n=149 and n=190). The evidence for mortality was of very low quality and did not demonstrate a clear effect with the confidence interval ranging from a decrease and increase in all-cause mortality. One study (n=149) reported two medication outcomes: prescribed ACE- inhibitors at target dose and prescribed beta-blocker at target dose, both of which were of very low quality. The former outcome showed clinical harm for case management while the latter showed no difference. The second study (n=190) also reported a few other outcomes such as hospitalisations, which was of very low quality showing clinical harm for case management. This study also reported quality of life using the Kansas City Cardiomyopathy Questionnaire (very low quality showing clinical benefit for case management) and the SF-36 mental and physical components (low quality evidence demonstrating no difference for both). This study also reported prescribed double therapy of ACE- I/ARB and B-blocker which was of low quality evidence showing no difference between the interventions. Economic One cost-utility analysis found that mid-length intervention MDT clinic dominates (more effective and less costly) usual care in people with heart failure who are high risk. This was assessed as partially applicable with potentially serious limitations. One cost-consequence analysis found that a long intervention MDT clinic was less costly with mixed effects on health outcomes (hospitalisations: RR 0.67, mortality: RR 1.80, quality of life (MLWHFQ) MD 6.60 lower, prescribed ACEi: RR 0.97, prescribed BB: RR 1.62) compared to usual care in people with heart failure that are high risk. This was assessed as partially applicable with potentially serious limitations. One cost-effectiveness analysis found that a long intervention MDT clinic was less costly and more effective (saves 4,042 per death and/or heart failure-related admission avoided; saves 2,155 per all-cause admission avoided) compared to usual care in people with heart failure that are high risk. This was assessed as partially applicable with potentially serious limitations. One economic evaluation found that a long intervention, basic MDT dominates (more effective and less costly) both usual care and a long intervention, intensive MDT in people with heart failure who are high risk. This was assessed as partially applicable with potentially serious limitations. One economic evaluation found that a long intervention, case-management MDT is cost effective (ICER: 3,072 per QALY gained) compared to usual care. This was assessed as partially applicable with potentially serious limitations. 9.2.6 Recommendations and link to evidence Recommendations The core specialist heart failure multidisciplinary team (MDT) should work in collaboration with the primary care team, and should include: a lead physician with a subspecialty interest in heart failure (usually Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 a consultant cardiologist) who is responsible for making the clinical diagnosis a specialist heart failure nurse a healthcare professional with expertise in specialist prescribing for heart failure. [2018] The specialist heart failure MDT should directly involve, or refer people to, other services, including rehabilitation services, and tertiary and palliative care, as needed. [2018] The specialist heart failure MDT should: diagnose heart failure give information to people newly diagnosed with heart failure (see manage newly diagnosed, recently decompensated or advanced heart failure (NYHA [New York Heart Association] class III to IV) optimise treatment start new medicines that need specialist supervision continue to manage heart failure after an interventional procedure such as implantation of a cardioverter defibrillator or cardiac resynchronisation device manage heart failure that is not responding to treatment. [2018] Relative values of different outcomes The critical outcomes were identified as all-cause hospitalisations, mortality and quality of life. Important outcomes included medicine optimisation (including the proportion of people prescribed medication and the proportion taking the medication as prescribed). Also important were outcomes felt by the committee to indicate potential adverse events from over-treatment: renal failure, hyperkalaemia and hypotension. Patient and carer preferences, and dying in preferred place of death for palliative care patients, were also considered important, but these outcomes were not reported by any study. Quality of the clinical evidence Twenty two studies (23 comparisons) were identified. The studies were stratified into 2 categories of heart failure risk (high risk and low risk) and 3 lengths of intervention duration (3 months or less, between 3 and 6 months and over 6 months). The population risk (high versus low) was based on the existing recommendations for people who may benefit more from an MDT. The included those with a new diagnosis; requiring medication titration and/or surgical procedure; recent deterioration and severe and/or unresponsive disease. In the current review 14 of the 17 studies in the high risk category selected patients on the basis of recent deterioration, with only 1 selecting new patients, 1 specifically targeting patients requiring medication titration, and 1 selecting on the basis of severe HF with a need for palliation. Population risk in the studies was also described by the average number of all-cause hospital admissions per person per year in the control arms, where this could be calculated. There were only 3 studies that were 3 months or less; and all studies included in the low risk category were over 6 months long. The studies had a heterogeneous mix of populations, interventions and standards of usual care. The studies also ranged in scale from 25 participants followed for 6 months to 920 participants followed for an average of 4 years. Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 Due to the heterogeneity, meta-analysis of the studies was not considered appropriate. The quality was variable, with the main reasons for downgrading due to risk of bias being a lack of detail about randomisation/allocation concealment and imprecision due to small study size. Many of the studies had small numbers of patients or events, with large confidence intervals around the effect estimates ranging from a clinically important harm to a clinically important benefit. Quality of life was downgraded for performance bias in all studies, as it was not possible to blind participants. There was also concern that some larger studies stated intent to measure quality of life in the study protocol, but with limited or no results presented, suggesting selective reporting. The committee considered that overall, the evidence was of low quality, often imprecise, and noted that even the direction of effect was inconsistent between outcomes and between studies. The numbers of hospitalisation and deaths in many of the studies was less than might be expected, and that this may represent selection bias towards healthier patients in these trials. Therefore, there may be problems generalising the evidence to the current heart failure population in the UK. In addition, many of the studies were over twenty years old, and most not in the context of current NHS practice, further restricting their applicability. The committee considered whether further research in this area would improve recommendations in this area. While the current evaluation is hampered by heterogeneous small trials, there were some larger trials such as COACH and NorthStar, which have given some moderate and high quality findings. It was not felt to be worthwhile to prioritise research that aimed to add to or improve on these at the current time. Trade-off between clinical benefits and harms There was substantial heterogeneity in the study designs, patient populations, types of intervention and lengths of follow-up, and the evidence was of poor quality for many of the outcomes. Because of this, the committee generally found it challenging to identify which MDT interventions and team compositions were likely to be of the greatest benefit, and for whom. In patients in the high risk categories identified in the last guideline, there was some evidence that the involvement of the MDT may lead to the prescription of more appropriate medication, decrease number of hospitalisations and improve quality of life. It was discussed that in high risk patients, while most interventions did decrease hospitalisations, there were increased deaths in some of these studies. The possibility was raised that the avoidance of hospitalisation could have increased the risk of mortality, but as the evidence on mortality was very imprecise and based on small numbers, it was felt this was likely to be a chance finding. There seemed to be evidence of a general effect of extra hours of contact being associated with improved outcomes in high risk patients, with some Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 caveats. First, there seems to be a ceiling effect: although some shorter interventions delivered improvement, extended follow-up (over years) in a clinic offered little benefit; and delivering 40 hours of contact gave only the same benefit of 20 hours of contact. Secondly, expertise appeared to count, as contact with a primary care nurse delivering a heart-failure intervention without specialist expertise in heart failure had no benefit. The committee agreed that the overall evidence supported the general approach that the MDT be used to stabilise and optimise patients. There was no convincing evidence for substantial changes to the previous recommendation regarding which patients should be cared for by the specialist multidisciplinary heart failure team, though the committee agreed by consensus on some clarifications to the previous recommendation text. These included a referral to the MDT should be considered when there was a need to optimise medication or consider specialist options in medication, and implantation of device therapy. The committee discussed specifying the competencies that should be present in the specialist multidisciplinary heart failure team. Clearly, a lead physician with specialist expertise in heart failure was critical, and this will usually be a consultant cardiologist, but there may be areas where other consultants would also be suitable, such as a consultant in elderly care, . The committee noted that the main professionals involved in delivering or co- ordinating interventions in the included studies were cardiovascular or heart failure specialist nurses. Based on this evidence, the committee agreed that a nursing element was needed, and emphasised that a specialist heart failure nursing competency was necessary; as the evidence suggested that it was not possible to get the same clinical improvements from generalist nurses. There was also evidence that the presence of prescribing expertise (whether by a nurse prescriber or pharmacist) can improve the prescription of some medications, and the committee agreed that the MDT should also include specific prescribing expertise. The committee also noted that there was evidence that involvement of the patient s primary care team was shown to be beneficial, and this was in accordance with the negative experiences of some of the committee members when primary care was not involved in the management plans. It was felt that the multidisciplinary specialist HF team members provide input to the management of patients with heart failure defined above in collaboration with their primary care team. In this way, the primary care team can help facilitate communication and collaboration between healthcare professionals wherever the patient s care is being delivered across different settings. This may include a GP who has completed a course for special interest registration Trade-off between net clinical effects and costs Five relevant economic evaluations were included in this review which compared an MDT to usual care. All of these studies were assessed as partially applicable with potentially serious or very serious limitations. One economic evaluation assessed high risk patients receiving a mid-length (3-6 month) home-based MDT clinic including a cardiologist, heart failure nurse, palliative care physician, palliative care nurse, physiotherapist and Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 occupational therapist. This was based on the PREFER trial by Brannstrom et al. 2014 included in the clinical review. This within-trial cost-utility analysis found that this multidisciplinary approach is more effective and less costly, and therefore dominated (more effective, less costly) usual care. This study suggests that an MDT is likely to be cost saving compared to usual care. The remaining 4 economic evaluations assessed high risk patients receiving long term (greater than 6 months) MDT interventions. All of these economic evaluations were within-trial analyses based on RCTs included in the clinical review. One economic evaluation compared a basic MDT, an intensive MDT and usual care. Both MDT approaches involved a cardiologist and a specialist heart failure nurse. The basic MDT consisted of 20 hours of contact time, whereas the intensive MDT consisted of 40 hours contact time. This within- trial cost-utility analysis was based on the COACH trial by Jaarsma et al. 2008 included in the clinical review. The analysis found that the basic MDT intervention dominated (more effective, less costly) both the intensive MDT intervention and usual care. This paper also undertook sub-group analyses for patients with severe (NYHA class III/IV) and less severe (NYHA class I/II) heart failure. For patients with less severe HF again the basic MDT dominated both the intensive MDT and usual care. However, for patients with severe heart failure neither the basic or intensive MDT interventions were cost effective at 20,000 per QALY threshold compared to usual care (Intensive MDT ICER: 44,625). The committee discussed that those with severe heart failure are likely to be having much more input from specialists, similar to an MDT, when receiving usual care and therefore were not surprised that a formal MDT was not cost effective in this group of patients. One economic evaluation compared MDT involving a cardiologist and a specialist heart failure nurse compared to usual care. This was based on a RCT by Berger 201034 included in the clinical review. This cost-utility analysis found that the MDT was cost effective compared to usual care (ICER: 3,072 per QALY gained). This study also reported a third intervention consisting of NT-proBNP guided management in addition to multidisciplinary care. When this comparator is included in the analysis it dominates both MDT alone and usual care. One economic evaluation compared MDT involving a cardiologist experienced in geriatrics, specialist heart failure nurses, and a primary care physician to usual care. This was based on a RCT by Del Sindaco et al. 2007 included in the clinical review. This within-trial cost-effectiveness analysis found that the MDT approach saves 4,042 per death and/or heart failure- related admission avoided, and saves 2,155 per all-cause admission avoided. One economic evaluation compared MDT involving a cardiologist, specialist cardiac nurse and primary care physician to usual care. This was based on the PRICE RCT by Atienza 2004 included in the clinical review which also reported intervention costs. This study found that the MDT approach was less costly than usual care; however, the overall effects of the MDT were uncertain. The outcomes extracted in the clinical review show moderate quality evidence of a clinical harm of the MDT for mortality, but moderate quality evidence of a clinical benefit from reduced hospitalisations, and low quality evidence of an improvement in quality of life. As mentioned above, the evidence on mortality was very imprecise and based on small numbers. Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 Overall the committee considered that overall the MDT may be cost saving and provide a clinical benefit; however, this is uncertain. No studies were identified that assessed the cost effectiveness of short term MDT intervention in high risk heart failure patients or any length MDT intervention in low risk heart failure patients. The committee agreed that the economic evidence suggests that an MDT reduces costs overall compared to usual care due to reduced hospitalisations, and noted that although each of the studies consisted of different competencies, the committee noted that a cardiologist and specialist nurse were included in all of the economic studies reviewed and therefore agreed that a physician with a subspecialty interest in heart failure, and a specialist heart failure nurse should be included in the core MDT. The committee discussed that the current composition of MDTs in clinical practice varies. The core professionals in most teams currently consist of a cardiologist and a specialist nurse as a minimum and in some cases can include many other professionals from other specialties. The committee therefore considered that the recommendation to have an MDT with a core team consisting of a physician with subspecialty interest in heart failure, a specialist heart failure nurse, competencies to manage prescribing, that could refer to other specialties if necessary, would not have an overall cost impact. Other considerations Current NHS practise in this area is variable. It was said that in some areas there is a lack of access to specialist heart failure teams, despite the previous recommendations. The committee was aware of the BHF Heart Failure Audit: this was carried out in a large proportion of NHS hospitals in England and Wales, and shows that following a decompensation 70% of patients receive an appointment for a cardiologist, and 60% of patients have a referral to a specialist cardiac nurse. The committee heard from the cardiologists in the group, who considered the HF nurses to be invaluable in managing their caseloads and clinics. The specialist nurses could often take on the management of the heart failure patients who were in need of more comprehensive support. They reported that the psychological support and care that specialist nurses provide could not be replicated by a cardiologist stand-alone clinic. They also noted that it has been the practice in the UK in many areas for specialist nurses or prescribers to optimise evidence-based medication (that is, ACE-inhibitors and beta-blockers, with MRA where appropriate), but that this is currently determined locally. From another perspective, the committee heard that patients very much valued someone to speak to about their illness, and that this is currently often delivered by HF nurses. They also spoke about how the MDT can encourage self-management, and this was more than just giving information or education, but included giving a patient confidence. They felt this was often not provided to the same level in primary care, and it may not be picked up by the studies. Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 The committee heard from the general practitioners that they recognised that there were high risk HF patients who need more intensive support, particularly patients who had just been discharged from hospital after an acute decompensation. However, they felt that specialist input may not be required for people who are stable. They emphasised the importance of holistic care, which is best delivered by primary care professionals, particularly as most patients with heart failure have several other conditions. They would value a system that would offer timely extra support to patients and GPs when necessary, but kept primary care at the centre. The concept of medicines optimisation in HF was discussed. Often the studies reported adding medication and up-titration, but optimisation is about more: starting, stopping, adjusting, and monitoring, all tailored to the individual patient. It is especially important in this population that the prescriber is adjusting their approach depending on comorbidities, and whether this occurred is not well reported in the studies. The NICE guidelines on multi-morbidity (https://www.nice.org.uk/guidance/ng56) were referred to as helpful in this area. Given the large and increasing population of patients with heart failure, with limited NHS resources, the committee agreed that the recommendations needed to prioritise specialist MDT access for those in greatest need who will gain the greatest benefit. If stable patients are managed in general practice, they will need regular review, informed by their needs. The committee emphasised the importance of a personalised approach, such as that described in the NICE multi-morbidity guideline (https://www.nice.org.uk/guidance/ng56). Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 9.3 Transition between heart failure care settings Given the chronic nature of heart failure and its occurrence in populations in whom multiple morbidities are common, management of heart failure involves interaction between primary and secondary care services. People with heart failure are often admitted to secondary care settings with acute deterioration in heart failure (see NICE acute heart failure; CG187) and then transferred to the care of the heart failure multidisciplinary team (MDT) for management in the community. Once their clinical care has been optimised, people with heart failure are discharged back to the care of the routine primary care service but may need to re-access care thorugh the MDT. Evidence has accumulated that that the complicated nature of these transfer processes and the complexity of liaison between different teams can affect the quality of care delivered to people with heart failure. This question reviewed patient and staff experiences of these transfer processes and sought to find evidence on how these could be improved. 9.3.2 Review question: What are the experiences/preferences of staff and patients during transition between different heart failure care settings (including primary, secondary and community care)? For full details see review protocol in Appendix A. Table 130: Characteristics of review question Objective Explore patient and staff experiences and preferences regarding transition and continuity of care at the interface of different care settings in heart failure. This may enable the identification of barriers (where the problems are) and facilitators (examples of good practice) to continuity of care when transitioning between heart failure care settings. Population and setting Patients with heart failure in a primary care, outpatient or community setting. Carers for such patients, both family/informal carers, and health-care professionals (HCP) Context Any description of patient or staff member experiences or preferences regarding transition and continuity of care at the interface of different care settings. Review strategy Synthesis of qualitative research. Quality of the evidence will be assessed by a GRADE CerQual approach for each review finding. 9.3.3 Qualitative evidence A search was conducted for qualitative studies exploring experiences or preferences of people with heart failure (CHF) or health care professionals (HCP) regarding transition and continuity of care at the interface of different heart failure care settings. Fifteen qualitative studies were included in the these are summarised in Table 131 below. Key findings from these studies are described in the qualitative evidence synthesis (section 9.3.3.4) and summarised in the qualitative evidence summary (section 9.3.3.5). See also the study selection flow chart in Appendix C, study evidence tables in Appendix F, and excluded studies lists in Appendix I. Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 9.3.3.2 Qualitative synthesis The guideline committee was aware that the issue of continuity is covered in the Patient experience in adult NHS services NICE Clinical Guidance February 2012 (CG138)233 , and wished to build on that guidance. Therefore, this review used the framework of the recommendations from that guidance to synthesise the heart failure specific findings from this review, while also collecting heart failure specific themes not covered in that guidance. The most relevant recommendations from CG138 are as follows: Assess each patient s requirement for continuity of care and how that requirement will be met. This may involve the patient seeing the same healthcare professional throughout a single episode of care, or ensuring continuity within a healthcare team. (Continuity) For patients who use a number of different services (for example, services in both primary and secondary care, or attending different clinics in a hospital), ensure effective coordination and prioritisation of care to minimise the impact on the patient. (Co-ordination) Ensure clear and timely exchange of patient information: (Communication) o between healthcare professionals (particularly at the point of any transitions in care) o between healthcare and social care professionals (with the patient s consent). Give the patient (and their family members and/or carers if appropriate) information about what to do and who to contact in different situations, such as out of hours or in an emergency. (Contact and Access) This review uses these recommendations to define four findings in which to group the subfindings of our review. We fitted evidence to this framework, and separately collected evidence that did not fit into this framework, as shown in the figure below. Figure 6: Framework for synthesising review results Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 9.3.3.3 Summary of included studies Table 131: Summary of studies included in the review. Abbreviations: Pt = patients with CHF, HCP = health care professionals, NYHA = New York Heart Association Functional Classification Study Design Population Research aim Comments Semi-structured interviews with pt + carers, taped and transcribed verbatim. Data coded and analysed by two researchers. Four themes most relevant to aims presented. N=10 CHF pt recently discharged from hospital and one person each that they lived with and nominated a carer. Age: mean 72 (SD 5) Severity NYHA II-IV (6/10 NYHA III) Explore the impact of heart failure on the lives of older pt and their informal carers. Part of larger study on palliative needs. Setting: UK, Barnsley. Andersson Semi-structured interviews with pt about daily life with CHF, and their experience of information-giving and follow-up. Informed by grounded theory. N= 4 pt who had been treated in a HF clinic, and were now discharged to primary care. Severity: Not stated Investigating whether pt need for information, education and knowledge are met to the same extent in the HF clinic and primary care. Setting: Small town in Sweden. Baudendistal Pt interviews with open section and a second more focused part. Content analysis by two researchers independently, then discussed within the research team. N= 17 pt identified by GPs with CHF with LVEF<35%. Age: mean 72 (SD Severity: Not stated Explore perspectives of pt with CHF on their treatment across multiple care settings and to what extent these perspectives are represented in current quality indicators. Part of QUALIPAT heart project, which aims to find patient-centric quality indicators for care. Setting: Academic GP practices, Heidelberg, Germany. Semi-structured interviews with pt with advanced CHF, carers, health and care professionals. Pt interviewed every three months for up to a year. Interviews were followed by focus groups. Concurrent analysis using narrative analysis framework. N= 20 pt with advanced CHF and their carers interviews, interviews). Five died during follow- up and family gave bereavement interview. Age: mean 70 (range Severity: NYHA IV Provide a patient- centric account of the changing and evolving needs of people with advanced heart failure, and how services address these. Part of larger palliative care project. Setting: UK, region unclear Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 Study Design Population Research aim Comments Semi-structured interview with CHF-HCP. Analysis follows pragmatic variant grounded theory with a degree of constant comparison. N= 12 HCP involved in specialist HF services (cardiologists, geriatricians, general physicians and specialist GPs). Explore reasons for the variations in the diagnosis and management of heart failure and identify barriers to the provision of uniformly high standards of care. Setting: UK, Durham and Tees SHA Gallacher Qualitative secondary analysis. Use archived interviews with pt collected for related research (unpublished). Analysis used Normalisation Process . Two authors designed a coding framework, while a third adjudicated. N= 47 pt with a CHF diagnosis based on echo, taking ACE- inhibitors and a diuretic, sampled from primary care to mirror demographics of CHF. Age: mean 73 (range Severity: Not stated Identify and understand the components of treatment burden to inform the development of tools to measure this, HF being a condition likely to have high treatment burden and comorbidity. Setting: UK, not clear where or when. Gastelurrutia Semi-structured interviews with HCP about health problems commonly comorbid with CHF (hyperuricemia, anti- platelet agents, anaemia and diabetes). Analysed using a total sample, open coding, constant comparative approach. N= 5 internal medicine specialists and cardiologists from a tertiary hospital HF clinic. Explore experiences in the pharmacological management of common comorbid health problems in heart failure in order to help clinical pharmacists provide real and practical help. Setting: HF clinic in Spanish hospital. Glogowska In-depth interviews with HCPs using a topic guide. Also allowed participants to raise their own issues, which could be carried forward to subsequent interviews. Analysed using the constant comparative method and systematic open coding. N= 24 clinicians (doctors, nurses and rehab workers) sampled from three healthcare settings: primary, community, and hospital in each of three geographical locations (i.e. nine settings total). Gain an understanding of the issues facing clinicians as they care for people with heart failure in the light of recent developments including the introduction of specialist heart failure nurses. Setting: UK. Locations were healthcare networks in South West, South Central and the Midlands with different models for providing HF care. Heckman Qualitative descriptive study about HF management in care homes, nested in a mixed- methods protocol. Three semi-structured focus groups of HCP. Data was analysed using thematic primary care physicians and 2 nurse practitioners who provided care to one of three long- term care facilities chosen to offer Explore perceptions of HCP regarding HF care in care homes, particularly why these HF pt were less likely to be receiving medication, despite the high burden of Part of programme aiming to develop care processes to manage HF in care homes. Setting: Northern Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 Study Design Population Research aim Comments content analysis by two researchers. Findings were presented back to the participants. variety. disease and acute care episodes. Ontario, Canada Qualitative, service evaluation study. Semi- structured interviews with HCP. Data collated and analysed using Framework Method. Initial findings were fed back to the participants. N= 21 HCP involved in the delivery of HF from three trusts with different models of providing HF care: 8 nurses, 6 consultants, 2 senior commissioners & 4 GPs. Understand how HF services are delivered in three different trusts, and especially care interact to provide continuity of care for HF pt in a context of increasing demand and financial pressure. Setting: UK, three settings in Birmingham and the Black Country. Macdonald Secondary analysis of qualitative data of transcripts of interviews with pt. Use form of amplified analysis to fit themes to the Candidacy framework. N=20 CHF pt (a selection of transcripts from two previous HF studies) Age: range 56-86 advanced and 10 stable Contrast the help- seeking and access to care in cancer and heart disease in order to extend concepts about illness identity, and its relationship to the concept of Candidacy Compares CHF with cancer. Data was taken from the Colorectal Cancer, End-Stage HF and Stable HF studies. Setting: UK, region not stated MacKenzie Mixed methods service evaluation of a new HF nurse service. Used a questionnaire sent to HCP for gathering quantitative and qualitative data. Free text boxes allowed for responses to four sections. No detail on analysis. of those mailed) and all 3 HF specialist nurses returned questionnaires, although not stated how many added free text. To assess acceptability and effectiveness of a new community based nurse-led HF service in an area with a dispersed population; assess the knowledge and needs of the GPs and assess the perceptions of national guidance. Setting: UK, the Highlands Although in context of the NHS, the new HF nurse posts were funded by a charity. Nordgren Qualitative study from lifeworld perspective. Unstructured interviews with middle-aged pt with CHF(65 and under), with focus on eliciting lived experience of care. Used phenomenological analysis. N= 7 pt currently attending HF clinic aged 65 and under, chosen for richness and variety of experience. Age: range 39-65 Severity: moderate to severe with at least one hospitalisation. Explore how middle- aged people with moderate-severe HF experience and understand formal care. Setting: HF clinic in Sweden Qualitative study nested in a larger project. Semi- structured interviews with N= 33 HCP, including GPs (7), HF nurses and geriatricians (8), Explore views of HCP on managing heart failure pt. Part of bigger project around communication in Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 Study Design Population Research aim Comments HCP. Coded according to themes, subsequently explored in relation to the literature, using a variation of the constant comparison method. from ten sites, chosen for variety. HF (unpublished). Setting: UK, in multiple sites in North of England Qualitative, using Complex Adaptive System (CAS) theory. Interviews with pt to identify all other people involved in their care, followed by attempts to interview all in these networks. A constant comparison method to improve interview. Used constructivist grounded theory to build an explanatory theory. N= 50 pt networks, including specialist HF services and at least two of the pts carers. Carers included family/informal care, caring professionals and healthcare professionals from both specialist and general services. Some HCP appeared in more than one pt network). Sampled to enrich applicability to palliative care. Age (pt): Not stated Severity: NYHA III-IV Better understand the behaviour of the teams providing heart failure care to those with advanced HF in order to plan how best palliative care services can integrate into these teams. Setting: Five Canadian cities in three provinces. Abbreviations: Pt = people with chronic heart failure, HCP = healthcare professional 9.3.3.4 Qualitative evidence synthesis 9.3.3.4.1 Narrative review findings The review findings were grouped within five overarching findings, as follows: 4. Contact and Access 5. Role of specialist heart failure services Within most findings there were sub-findings relating to (a) challenges/problems, (b) ideas for improvement, and (c) complex transition issues. The sub-findings are presented, along with an evaluation of the quality, including an explanation for the CerQual grading that appears with each sub-finding in the summary tables in 9.3.3.5. Relevancy was judged with respect to making recommendations on this particular issue for current NHS specialist and general services, taking into account that some evidence came from studies were conducted in other countries (studies from US and outside the OECD were excluded) and before major NHS configuration changes. Review sub-finding 1a: Lack of continuity in HF care Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 Both people with heart failure and health professionals felt that heart failure care was fragmented, leading to a lack of continuity. This was contrasted in one study with the more seamless care offered to people with cancer. Patients who experienced lack of continuity found it made it more difficult to form therapeutic relationships, which undermined their confidence in their management plans. Patients aged 65 and under mentioned that lack of continuity sometimes led to encounters with professionals appearing anonymous and meaningless. This sub-finding was based on four studies 126, 144, 207, 225 . Methodological limitations were rated moderate concerns overall. Two papers were rated serious limitations as they were secondary analyses with insufficient information about the original interviews. One paper was rated as moderate limitations due to lack of context and data richness. One paper was rated as minor limitations. 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. The only findings that tend the other way are regarding the positive influence of GPs in continuity, and this is not inconsistent. Relevance was rated minor concerns overall. The relevance of the sub-finding to the focus of the review was high. Concerns stemmed from two papers being from outside the UK and in a sub-set of CHF, and the data collection in a UK paper dating back to 2010. However, the finding was found in various settings, and likely to generalise well. Adequacy was rated as no or very minor concerns. The sub-finding was general, and although explicitly supported by a limited number of studies, other studies found similar findings. The sub- finding was descriptive and the richness of data was sufficient for this. The overall assessment of confidence was moderate, having been downgraded by one increment due to the combination of concerns in methodology and relevance. Review sub-finding 1b: Primary care People with heart failure and professionals working in heart failure care both recognised that primary care, and general practitioners in particular, could provide individualised care with continuity. It was acknowledged that such continuity is important to patients, and there was concern that where HF services take over a patient, this could cause patients to lose touch with primary care, with a consequent loss of continuity. In one study GPs spoke of how they wished for a consultant model where specialists answered questions and made recommendations, but did not take over care of the patient. In an assessment of a new heart failure service, it was emphasised by GPs that new services should integrate into the existing primary care/community multidisciplinary team, partly for this reason Methodological limitations were rated minor overall. One paper was rated serious limitations due to the lack of explanation of methods and lack of depth of data collection. One paper was rated as moderate limitations due to the participants not being well described. Two papers were rated as minor limitations. Coherence was rated minor concerns overall. Agreement between papers was good, showing that both patients and other health professionals value the continuity provided by GPs, and believe there is danger of that being disrupted. However, there is other data that challenges the primacy of continuity over other important factors in HF care, for instance the in-depth knowledge of the cardiologist, or the easy access to the HF nurse. Relevance was rated minor concerns overall. The relevance of the subfinding to the focus of the review was high. Both studies that included patients were from outside the UK. A third study (of HCP) Chronic Heart Failure Referral and approach to care NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 was from the Highlands of Scotland, which has rather specific challenges of geography that may affect the importance of primary care. The remaining study however, was conducted with HCP in three different trusts, offering results that seem to generalise well over settings. Adequacy was rated as no or very minor concerns. The subfinding was fairly general, was expected, and is supported by numbers of studies. The finding was descriptive and supported adequately by the richness of data. The overall assessment of confidence was moderate, having been downgraded by one increment due to the combined minor concerns about methodology, coherence and relevance. Review sub-finding 1c: Discharge from HF clinic One study that interviewed people discharged from HF clinics to primary care found that they reported having gone from a situation where they received appointments for follow-up, to one where they were no longer called for review. For some, this felt like they were no longer ill enough to qualify for help. When asked, they expressed a wish to be called to see the GP or nurse once in a while. One patient said: I feel a bit left out, I m not part of the health-care system anymore p291 A different study speaking to HF nurses echoed this, saying that they were aware that people liked being patients in the HF clinic, and that this led to some unhappiness when it came to discharging patients. Regarding HF clinics, one says: I see quite a lot of patients who get discharged, and they hate that. They feel safe someone s interested and they re keeping an eye on me They don t like to lose that. They hate to lose that. P301 294 It is notable that the focussed qualitative review on continuity in CG138 found the finding of Feelings of abandonment (when treatment ends or support not available) , which seems to echo in this specific finding on discharge from HF clinic to primary care. This sub-finding was based on 2 studies 14, 294 . Methodological limitations were rated serious overall. Two papers were rated serious limitations the study of patient interviews because of the small number of participants (4), lack of clarity over methods, the researcher s voice is potentially prominent and lack of richness of data; the study of HCP interviews because of limited discussion and reflection on the role of the researcher and their methods. Coherence was rated no or very minor concerns overall. Agreement between papers was good, and while it does not directly align with the sub-finding concerning the primacy of primary care in providing continuity, it fits with the overall theme of this section regarding lack of continuity within the system as a whole. Relevance was rated minor concerns overall. The relevance of the sub-finding to the focus of the review was very high. Concern was due to one study being from outside the UK and the interviews being in Swedish. However the UK study of HCP shows that the issue is likely to extend to NHS services. Adequacy was rated as moderate concerns. The sub-finding was specific, and so sufficiently supported by lower numbers of studies. The issues are well described and explained, but overall the richness of the data falls short. 