Tuut Mk1, Burgers Js2, Langendam Mw3. 1. School CAPHRI, Department of Family Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands; PROVA, Varsseveld, The Netherlands. Electronic address: mariska.tuut@maastrichtuniversity.nl. 2. School CAPHRI, Department of Family Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands; Dutch College of General Practitioners, Utrecht, The Netherlands. 3. Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health institute, Amsterdam, The Netherlands.
Abstract
OBJECTIVE: To identify challenges in the application of GRADE for diagnosis when assessing the certainty of evidence in the test-treatment strategy (diagnostic accuracy, test burden, management effectiveness, natural course, linked evidence) in an illustrative example and to propose solutions to these challenges. STUDY DESIGN: A case study in applying GRADE for diagnosis that looked at the added value of IgE for diagnosing allergic rhinitis. RESULTS: Evaluation of the full test-treatment strategy showed a lack of (high-quality) evidence for all elements. In our example, we found a lack of evidence for test burden, natural course and link between test result and clinical management. Overall, systematically reviewing the evidence for all elements of a test-treatment strategy is more time-consuming than only considering test accuracy results and management effectiveness. To increase efficiency, the guideline panel could determine critical elements of the test-treatment strategy that need a systematic review of the evidence. For less critical elements, a guideline panel can rely on grey literature and professional expertise. CONCLUSION: A lack of high-quality evidence and time investment if the full test-treatment strategy is assessed create challenges in applying GRADE for diagnosis. Discussion within guideline panels about critical elements that need to be reviewed might help.
OBJECTIVE: To identify challenges in the application of GRADE for diagnosis when assessing the certainty of evidence in the test-treatment strategy (diagnostic accuracy, test burden, management effectiveness, natural course, linked evidence) in an illustrative example and to propose solutions to these challenges. STUDY DESIGN: A case study in applying GRADE for diagnosis that looked at the added value of IgE for diagnosing allergic rhinitis. RESULTS: Evaluation of the full test-treatment strategy showed a lack of (high-quality) evidence for all elements. In our example, we found a lack of evidence for test burden, natural course and link between test result and clinical management. Overall, systematically reviewing the evidence for all elements of a test-treatment strategy is more time-consuming than only considering test accuracy results and management effectiveness. To increase efficiency, the guideline panel could determine critical elements of the test-treatment strategy that need a systematic review of the evidence. For less critical elements, a guideline panel can rely on grey literature and professional expertise. CONCLUSION: A lack of high-quality evidence and time investment if the full test-treatment strategy is assessed create challenges in applying GRADE for diagnosis. Discussion within guideline panels about critical elements that need to be reviewed might help.