42 Chapter 2 solutions to cope with these challenges. A next step is to study whether these solutions are effective and feasible in the context of a CPG panel. Conclusion This study identified challenges by applying the GRADE approach for diagnostic tests and test strategies to assess the certainty in the evidence in all steps of the testtreatment strategy. Important challenges were identifying evidence, drawing conclusions in the absence of high-quality evidence and investing time. An important solution is to discuss the main elements of a test-treatment strategy that drive the decision within guideline panels and to identify for which elements a systematic review is relevant and for which elements the panel can rely on other sources of information, like expert opinion. Acknowledgement The authors thank Martijn Sijbom PhD, Leiden University Medical Center, for his cooperation in the determination of patient-important outcome measures, and Rikie Deurenberg, SIROSS, for the literature searches.
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