Testing can be a substantial driver of health care costs. Increase in test use over recent decades has occurred despite disappointing results from test accuracy evaluations. Poor quality and reporting of primary test accuracy studies and difficulties with understanding and application of test accuracy information are purported to be important contributors to this observed evidence ‘gap’. \ud \ud The objectives of this thesis were to:\ud * Systematically review evidence concerning the understanding and application of test accuracy metrics.\ud * Undertake primary research building on the review of understanding and application.\ud * Assess whether the contribution of test accuracy reviews to the test accuracy evidence base is compromised by deficiencies in their contextual fit, or of included primary studies.\ud \ud Existing research concerned with understanding and application of test accuracy information is not driven by the needs of decision makers. Contrary to the prevailing view in the literature, findings of original research from this thesis demonstrate that probability revision is not a feature of diagnostic decision making. Choice of test accuracy metric however was shown to have a profound influence on diagnostic decision making. Deficiencies in question formulation and contextualisation of test accuracy reviews are undermining their contribution to the test accuracy evidence base.\u
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