Applying GRADE for diagnosis 39 2 Clinical management The literature search yielded multiple systematic reviews. We decided to select the most recent systematic review with at least moderate-quality evidence about a specific intervention (avoidance measures, antihistamines, corticosteroids). Relying on published systematic reviews resulted in (very) low-quality evidence for a limited number of selected outcome measures. De novo development of systematic reviews might help in retrieving evidence that fits more precisely with the PICO. Natural course We were interested in the follow-up of untreated AR patients. Treatment was often not specified in the selected studies. However, it is unlikely that cohorts of people did not receive any treatment over the years. We decided to downgrade for indirectness. Link between test result and management It was challenging to perform a literature search to identify evidence for the link between test result and clinical management. We decided to focus on treatment adherence and treatment difficulties. Another suggestion would be to rely on expert opinion in a CPG panel (including patient representatives) to formulate good practice statements. Overall quality Overall quality is defined as the weakest link in the chain of evidence [7]. However, not all elements of that chain could be explicitly assessed. We suggest determining the overall certainty of evidence by considering those elements that are critical to decision-making according to a CPG panel. Time investment and expertise of the research team Critically and systematically appraising the evidence of the full test-treatment strategy took substantially more time than only evaluating diagnostic test accuracy, since seven PICOs had to be answered instead of only one. We propose discussing within the CPG panel the elements of the evidence chain for which a systematic review of the literature has added value. Relying on other published guidelines (e.g. treatment guidelines) may also save time. For this study we ensured that our author team included expertise in conducting systematic reviews (including DTA), applying GRADE, guideline development and clinical management of allergic rhinitis. Including different types of expertise is needed to efficiently collect, assess, summarize and interpret the different types of evidence. We strongly recommend involvement of experienced methodologists for the development of guidelines, in particular for diagnostic recommendations.
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