Applying GRADE for diagnosis 41 2 However, the authors did not go beyond diagnostic accuracy to the downstream consequences. A similar case study was reported by Hsu and colleagues, who applied the GRADE approach to make evidence-based recommendations within a CPG panel about the diagnosis of cow milk allergy [11]. This study showed that explicitly defining patientimportant outcomes as true positives and false positives beyond sensitivity and specificity was helpful to panel members with limited experience in clinical epidemiology. However, Hsu et al. did not explicitly consider downstream consequences like test burden and management effectiveness. Our study fills this gap in the knowledge. Strengths and limitations of this study This study evaluated the feasibility of a systematic evaluation of a test-treatment strategy in the context of guideline development. Such an evaluation has the potential to deliver an in-depth assessment of the clinical value of diagnostic test results. We performed this critical exercise by applying GRADE from the perspective of the methodologist, apart from the dynamics of a real-time CPG panel. Consulting panel members (e.g. in determining outcome measures) and discussing for which elements of the test-treatment strategy a systematic review of the literature is required would probably improve the efficiency of the in-depth assessment. The diagnostic test discussed in this case study may have some limitations for generalisability of the study findings. Although allergic rhinitis is a very common condition, the evidence-base for the sIgE-test was limited. Applying the GRADE for diagnosis approach to conditions and tests for which more research is available might reveal other challenges. However, a limited evidence-base occurs frequently in CPG development. Implications for practice We suggest that CPG developers prioritise the elements of a test-treatment strategy for which a systematic review of the literature is needed. This prioritisation should take place in the planning phase of a guideline development process, in collaboration with clinical professionals and patient representatives. The outcome of this process might have consequences for the resources that are needed to develop the guideline. Implications for research This study unveiled methodological and planning challenges in the process of evaluating the added value of a diagnostic test in a CPG setting, and proposed
RkJQdWJsaXNoZXIy MTk4NDMw