For example, the committee might have set a threshold of 90% as an acceptable level to recommend a test. The evidence was downgraded by 1 increment if the individual studies varied across 2 areas [(for example, 50 90% and 90 100%)] and by 2 increments if the individual studies varied across 3 areas [(for example, 0 50%, 50 90% and 90 100%)]. The judgement of precision was based on visual inspection of the confidence region around the summary sensitivity and specificity point from the diagnostic meta-analysis, if a diagnostic meta- analysis was conducted. Where a diagnostic meta-analysis was not conducted, imprecision was assessed according to the range of point estimates or, if only one study contributed to the evidence, Chronic Heart Failure Methods NICE 2018. All rights reserved. Subject to Notice of rights. ISBN: 978-1-4731-3093-7 the 95% CI around the single study. As a general rule (after discussion with the committee) a variation of 0 20% was considered precise, 20 40% serious imprecision, and >40% very serious imprecision. Imprecision was assessed on the primary outcome measure for decision-making. 4.3.4.3.3 Overall grading Quality rating started at High for prospective and retrospective cross-sectional studies, and each major limitation (risk of bias, indirectness, inconsistency and imprecision) brought the rating down by 1 increment to a minimum grade of Very Low, as explained for intervention reviews. 4.3.4.4 Qualitative reviews Review findings from the included qualitative studies were evaluated and presented using the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) Approach developed by the GRADE-CERQual Project Group, a subgroup of the GRADE Working Group. The CERQual Approach assesses the extent to which a review finding is a reasonable representation of the phenomenon of interest (the focus of the review question). 