Developing guideline recommendations about tests: educational examples of test-management pathways

Abstract

Recommendations about healthcare related testing in guidelines are common. Tests can be used for several purposes: screening, surveillance, risk classification, diagnosis, staging, treatment triage, determination of prognosis and monitoring/follow-up.1 The development of testing recommendations in guidelines is challenging, especially because the benefit of a test not only depends on test characteristics, such as sensitivity and specificity, but also on population characteristics and test consequences, such as management.2–4 Furthermore, the role of a new test in comparison to the existing testing scenario should be defined, since this influences the interpretation of the new test’s value. The following roles of new tests have been identified in the literature: triage, replacement, add-on, and parallel/combined.5 As with treatment, testing can have negative consequences, including physical impairment, psychological distress, disease labelling, and costs.6 There is limited evidence on harms of testing, and healthcare professionals often overestimate its benefits while underestimating its harms.7 This is also true for patients' expectations of testing.8 Additionally, testing occasionally yields unexpected and coincidental findings, which may result in additional testing and treatment. There is a lack of transparency in processing the evidence and considerations that support testing recommendations in guidelines.9 To facilitate the development of test recommendations, we determined the minimum required knowledge for guideline panel members involved, supplementing the competency-based framework available for guideline development.10 11 The concept of the test-management pathway (figure 1) appeared key to understand. Figure 1 Test-management pathway concept. During our developmental study, the need for practical examples of test-management pathways became apparent.10 In our subsequent teach-the-teacher workshop at the 2023 Guideline International Network conference,12 participants requested additional elaboration of pathways for different test outcomes (such as false positives and false negatives) being helpful for explaining the test-management pathway concept to guideline …