184 Chapter 5 Follow-up testing Follow-up testing may serve various objectives, such as maintaining disease control, detecting potential adverse drug effects, identifying early disease recurrence, or monitoring drug compliance. Examples include questionnaires to detect drug side effects, and mammography in women with a history of breast cancer. We illustrated this with a test-management pathway for the use of spirometry in smokers with COPD (figure 2d) [15]. A positive test result prompts intensifying pharmaceutical treatment, whereas a negative test result may not lead to alterations, except for general smoking cessation advise in all cases. Repeated measurements and identifying possible reasons for suboptimal results (e.g., limited drug adherence) could be useful. Therefore, it is important to carefully consider all potential test consequences, to provide effective healthcare aimed at improving people-important outcomes. The example presented may thus be too narrowly focused, since issues such as feasibility of spirometry in a frail population, lifestyle measures, and drug adherence may also be important. Conclusion Designing test-management pathways can help formulate specific health questions about the use of testing as essential first step in guideline development [17]. These questions should then be answered by systematically reviewing and analysing the consequences of the different test results (TP, FP, TN, FN, inconclusive) on peopleimportant outcomes, and considering other aspects, such as patient values, costs, and feasibility [18-20]. To illustrate, in the context of breast cancer, the question is not merely whether MRI-testing is more accurate than mammography in detecting breast cancer. Rather, the question is what is the net benefit of MRI-testing in comparison to traditional mammography in terms of people-important outcomes such as diseasefree survival, taking into account all aspects, including patient burden, overdiagnosis and costs. This can be determined by formal modelling, in which evidence for the various steps of the test-management pathway is integrated into a decision analysis. An alternative is informal modelling, in which assumptions are made about the effects of different test results on people-important outcomes. In addition, further considerations are required to move from evidence to recommendations. These include certainty of the evidence, values, balance between the desirable and undesirable effects, resource use, equity, acceptability, and feasibility [19]. The elaborated test-management pathways in this paper serve as examples that can be used to explain the concept of test-management pathways.
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