200 Chapter 6 patients might present, when they would be considered for testing and the role of the test [18]. Limitations of this study The first user testing was done with participants experienced in test research and/or guideline development. Most participants in these sessions had prior knowledge about evaluation of tests and development of guideline recommendations about tests. It is therefore questionable whether the results of these user testing phases are applicable to guideline panels with less methodological expertise and experience. It is known that guideline panels are quite familiar with treatment guidelines and have limited initial understanding of the link between testing, downstream management, and peopleimportant outcomes [19]. Thus, more guidance might be needed. We therefore also user tested the step-by-step guide with guideline panel members. We tested the step-by-step guide in a limited number of persons and panels. They were recruited as a purposeful sample of experienced and less experienced guideline developers and reviewers with varying expertise and experience in test research. During user testing with guideline panel members, we observed that participants considered reformulating their initial test question after using the step-by-step guide. The instructions on creating questions for a guideline reflect a natural situation, as the development of guideline questions typically involves a group process led by a guideline methodologist. Some data were collected almost a decade ago. Therefore, we adjusted the step-by step guide using terminology that is inclusive and more widely accepted by today’s standards. We believe that our findings are still relevant after adjustment and by adding a test-management pathway visualization and instructions for use. The primary focus for our step-by-step guide is to raise awareness on people-important outcomes. Recommendations on tests can be focused on other aims as well, such as simplifying or streamlining the healthcare process, to reduce costs, to increase efficiency, or to reduce painful procedures. We agree that these considerations matter but in all cases the people-important outcomes should also be considered. Implications for practice The step-by-step guide is meant to be used in a flexible manner. During the user testing sessions, there was some debate about where to start in the process: with the ‘P’ for people or population, or with the ‘I’ for index test. We think this may depend on the overall question to be answered. For example, if an index test is central in the question, such as ‘Should we use this test in these patients?’, then starting with the ‘I’ seems to
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