Step-by-step guide 201 6 result in a more focused process. On the other hand, if the question is about whether a test should be recommended in a particular setting, then first describing the ‘P’ and setting may be more helpful. We suggest to utilize the step-by-step guide in the guideline panel process during the stage of (PICO) question generation [25, 26]. Drafting a test-management pathway will often be an iterative process. Further modifications of the pathway during guideline development may be needed. Our step-by-step guide can help in this process. Although using the step-by-step guide in the guideline development process may require some time, it is anticipated that this will facilitate the specification of more focused questions. We expect that this might reduce the time required at a later stage in the guideline development process and will enable the development of targeted and more balanced recommendations. Though our focus was on guideline development, we have experienced that the user guide can also be useful in other areas of decision making. As authors, we have used it in developing recommendations about coverage in a healthcare benefits package. We have also used it when designing clinical trials and deciding on the proper performance measures. Within the recently introduced European Union In Vitro Diagnostics Regulation, clinical performance should be informative about the clinical utility of the test, reflecting the purpose of testing in the intended use setting and population. Users expressed that a digital tool that is both intuitive and flexible would be helpful for drawing test-management pathways, and to document the iterations it goes through. We suggest developing an online tool, for example as a feature in software such as RevMan and/or GRADEpro. Implications for research In developing a test-management pathway we encourage further evaluations of the step-by-step guide in guideline panels. This could result in additional tools and instruments to facilitate the development of recommendations about tests and testing. Once the pathway is defined, research evidence to support assumptions made in the pathway can be sought. One could also use the test-management pathway to decide on minimally acceptable performance of the tests, and to evaluate limitations in the applicability of research findings. Conclusion We have developed a step-by-step guide, for guideline developers, to create a testmanagement pathway, which can be helpful in formulating focused questions
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