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OBJECTIVE: To determine the association between the quality of guidelines for diagnostic tests (both the quality and reporting and the quality of the evidence underpinning recommendations) and non-adherence. STUDY DESIGN AND SETTING: We conducted a meta-epidemiological study. We previously published a systematic review that quantified the percentage of test use that was non-adherent with guidelines. For the current study, we assessed these guidelines using the Appraisal of Guidelines for Research & Evaluation (AGREE) II tool. We then assessed the quality of evidence underpinning recommendations within these guidelines using Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Linear models were then constructed to determine the association between guideline non-adherence and (a) AGREE II score and (b) GRADE score. RESULTS: There was no significant association between AGREE II score and non-adherent testing (p = 0.09). There was a significant association between GRADE score and non-adherence: recommendations based on low and very low-quality evidence had 38% (p <0.01) and 24% (p = 0.02) more non-adherent testing, compared with recommendations based on high quality evidence. CONCLUSION: Diagnostic test guideline recommendations based on high-quality evidence are adhered to more frequently.

Original publication




Journal article


J clin epidemiol

Publication Date



AGREE II, GRADE, and meta-research, diagnostic tests, guidelines, primary care