222 Chapter 7 In order to explore challenges in processing the evidence for tests and testing strategies and suggest solutions, we conducted systematic reviews of all elements of a test-management pathway of an illustrative example using GRADE. Therefore, we analysed the evidence for the clinical question: what is the value of specific immunoglobulin E (sIgE) blood testing as an add-on test to history taking (I) compared to history taking alone (C) in patients suspected of having allergic rhinitis (P), with a relief of nasal or ocular symptoms as critical outcomes, and concentration, sleep problems, work/school absence, and quality of life as important outcomes (O). This study identified challenges and suggested solutions. One major challenge was the lack of high quality evidence in all elements of the test-management pathway, including test burden, natural course of the condition of interest, and the link between test results and people-important outcomes. It is therefore not possible to draw any firm conclusions. Conducting more relevant studies while using the GRADE downgrading factors, such as risk of bias and imprecision as a guidance, is a potential long-term solution in a broader perspective. In the context of guideline development, a broadening of the scope can be a solution, for example, by shifting the focus of test burden from specific to more general. Input from patient advocates could be considered, particularly regarding experiences with test burden. However, it is important to note that this input can not be used to increase the certainty of the evidence. Furthermore, the description of the natural course of the disease of interest lacked transparency, for which we suggest downgrading for indirectness. There was also no evidence found about linking test results to subsequent management. To address this, we suggest concentrating on disease-specific details, such as treatment adherence and difficulties, and discussing these with the guideline panel. Additionally, qualitative evidence could be included. The lack of evidence led to the inability to determine the overall certainty of evidence, as some elements of the test-management pathway were missing. To determine the overall certainty of the evidence, we recommend considering the critical elements for decision making, as suggested by the guideline panel. Finally, the critical appraisal of all elements of the test-management pathway is substantially more time consuming than merely evaluating test accuracy. We propose to focus the discussion on those elements of the test-management pathway that are critical for the decision of whether or not to recommend a test, and to conduct systematic reviews for those elements. In light of these challenges, we aimed to evaluate the evidence-base of current guidelines about healthcare related testing. We therefore conducted a systematic document analysis of published guidelines for three test questions that diverged in terms of invasiveness, purpose, disease of interest, and costs: C-reactive protein
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