General introduction 21 1 Challenges in guideline development about testing Guideline panel members face challenges when interpreting test accuracy measures, such as sensitivity and specificity. Recalculating these measures to determine the number of true positives, true negatives, false positives and false negatives per 1000 people tested provides greater clarity, which is easier to understand [55]. Formulating key questions about testing that include people-important outcomes can be challenging as well. Moreover, there are barriers in searching and synthesizing the evidence, such as a lack of valid search filters, complex meta-analysis methods and the inclusion of outcomes beyond diagnostic accuracy. Interpreting and applying GRADE criteria for the evaluation of the clinical performance of a test can be difficult because the assessment of inconsistency and imprecision differs from the evaluation of intervention studies on clinical performance of a treatment [56]. Formulating recommendations about testing is challenging due to a lack of evidence, conflicting expert opinions, and insufficient knowledge and competencies [57]. Given the numerous challenges, it is suspected that consequences of testing on peopleimportant outcomes are hardly considered when developing recommendations on healthcare related testing. Aim and research questions Developing guidelines comes with various issues, particularly when focusing on developing recommendations about testing, as described in the previous sections. There are indications from evidence and experience from guideline methodologists that the process of guideline development related to testing is suboptimal, which may lead to inaccurate consideration of the benefits and harms of testing. It is not yet known which knowledge or tools are necessary and/or helpful in appropriately developing guideline recommendations about testing. Therefore, this thesis focuses on barriers and solutions in the development of guideline recommendations about testing, with specific attention to the required expertise for developing these recommendations and tools to facilitate this process. The aim of this thesis is to facilitate and improve guideline development concerning healthcare related testing. The first objective is to identify problems by exploring current practice and challenges in developing guidelines for healthcare related testing. The second objective is to improve this process by identifying the knowledge needed to develop testing recommendations in guidelines. The third objective is to facilitate the guideline development process by developing and testing a tool to support the formulation of appropriate guideline questions on healthcare related testing.
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