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The prevalence of patients with multimorbidity, defined by two chronic conditions is rapidly increasing. Defining multimorbidity remains challenging, with varying criteria in research. A recent study by MacRae et al. examined the impact of the number and selection of conditions on estimated multimorbidity prevalence, revealing significant variations from 4.6% to 40.5%. To standardize the definition for research, MacRae et al. recommend using three measurement instruments (Ho always + usually, Barnett, or Fortin condition-lists) to consistently measure prevalence over time. Multimorbidity's complexity is not adequately captured by dichotomous definitions, as this depends on context and purpose. Chronic diseases profoundly affect daily life, leading to reduced physical function and adverse psychosocial outcomes. Patients often experience increased stress, anxiety, and depression, which can further exacerbate somatic conditions. To assess multimorbidity from a patient perspective, considering experienced health and quality of life indicators like ADL functioning, mobility, mood, memory, and social factors is crucial. Effectively managing multimorbidity requires a holistic, tailored approach, including identifying and prioritizing key health issues, promoting self-management, proactive care planning, and coordinating treatments. Understanding the potential for differential treatment effects and considering individual life expectancy is vital. Multimorbidity also places a significant burden on healthcare systems, leading to fragmented care, communication gaps, and increased costs. Identifying complex disease clusters with high mortality and resource utilization can guide integrated care efforts. In less complex cases, primary care physicians can collaborate to provide comprehensive care. Multimorbidity remains a priority in healthcare, necessitating appropriate measurement and tailored interventions for diverse populations.

Clinical practice guidelines are fundamental to support knowledge and decision making of healthcare professionals in many disciplines. They can contribute to reducing undesirable practice variation, educating patients, and monitoring care. However, the burden increases if the number and size of guidelines continues to increase and as more side effects occur due to injudicious use, both in the professional and policy setting. Restricting the scope and finding the right balance between completeness and conciseness are major challenges for guideline developers and stakeholders. Ongoing innovation projects are working on improving accessibility, updating, and applicability in multimorbidity through optimal use of digital technologies. As long as healthcare professionals are in the lead in guideline development and involved in policy making, doctors can continue to rely on guidelines, if used correctly for the right care.

Objective: To gain insight in medical specialists' and nurse practitioners' opinions on multimorbidity and coordination and tailoring of hospital care., Design: Exploratory mixed-method design., Method: From August 2018 until January 2019, 35 Dutch medical associations were asked to forward a digital survey with open- and close-ended questions to their members. We used qualitative and quantitative methods to analyze the data. The main themes were identified with inductive, thematic analysis., Results: There were 554 respondents from 22 associations, 43% of the medical specialist respondents were internist (n=221). The qualitative analysis of the answers regarding what is required in hospital care for patients with multimorbidity resulted in eight themes at the patient's, professional's and hospital organization's level. To the open question about who should take the lead, respondents most often answered the geriatrician or internist, followed by the general practitioner, 'the care professional who is treating the main problem', a nurse practitioner/physician assistant and the 'attending physician of the primary team'. All geriatricians and almost all internists felt they possessed the competencies to take the lead in hospital care for patients with multimorbidity., Conclusion: Medical specialists' and nurse practitioners' diverse ideas about who should take the lead in hospital care for patients with multimorbidity were a noteworthy finding. It is important to start local conversations about how to divide roles and responsibilities regarding the coordination and tailoring of hospital care for patients with multimorbidity.

Discrimination based on ethnic background and the use of terminology like 'Negro Race' in clinical practice guidelines have been criticized, also in this journal. Typical Dutch words 'allochtonen', 'non-western', 'Creools' and 'Hindostan' are unspecific or could also offend people. Nevertheless, there are health risks related to ethnic background. Healthcare improves when health professionals would consider these, contributing to person centred cultural sensitive care. Therefore, we aimed to start a discussion about which acceptable terminologies should be used to describe ethnic differences in guidelines and research. We suggest that terminologies use to describe ethnic minority groups should be as precise as possible and should not be offensive, for instance 'migration background' instead of allochtoon, and 'African-Surinamese' instead of Creool. We invite guideline developers, researchers and people of different ethnic background, to join this discussion.

This study is based on a large international survey, which collected the views of general practitioners (GPs) in 11 different countries on their respective healthcare systems in 2019. Findings show that Dutch GPs are positive about the quality of GP care and that they are satisfied with their profession. However, findings also show that there is room for improvement. (i) Work pressure and work-related stress among GPs is high in the Netherlands, which may be due to moves to substitute primary care for some hospital care. (ii) Dutch GPs are behind other high-income countries in their uptake of some digital applications (e.g. video consultations). (iii) According to Dutch GPs, pressure from patients, lack of time, and fear of complaints contributes to provision of low-value care. The COVID-19 epidemic has created opportunities to improve Dutch GP care further, for example through wider uptake of digital health applications.

The revised Dutch College of General Practitioners (Nederlands Huisartsen Genootschap [NHG]) guideline 'Deep-vein thrombosis and pulmonary embolus' includes recommendations for the treatment of patients with deep-vein thrombosis (DVT) and thrombophlebitis, and for the exclusion of pulmonary embolism (PE). The general practitioner (GP) can exclude the presence of DVT or PE in some patients by using a decision rule and a D-dimer test. When using D-dimer test as a point-of-care test, meticulous care is essential during the test procedure and storage of blood. The GP can treat many patients with DVT; the NHG guideline does not advise use of direct oral anticoagulants. In the case of an isolated DVT in the calf, treatment with anticoagulants or ultrasound follow-up can be chosen in consultation with the patient or on the basis of regional agreements. In the case of patients with superficial thrombophlebitis, a wait-and-see approach is usually sufficient.

The Dutch College of General Practitioners' practice guideline "Problem drinking" contains recommendations for the (early) recognition, diagnosis and treatment of problem drinking and includes recommendations for young people and the management of acute alcohol intoxication. In daily practice problems with alcohol manifest themselves mainly as indirect signals and aspecific symptoms. The practice guideline recommends asking about alcohol use in every case where symptoms cannot be directly explained. General practitioners are usually able treat patients with a drinking problem themselves. Short-term interventions by the general practitioner and practice nurse are effective in the reduction of alcohol use. 'E-mental health' is an aid that can be used in the diagnosis and treatment of problem alcohol use.

The diagnosis of ADHD may be considered if a child is hyperactive, impulsive or inattentive, and if this behaviour results in evidently impaired functioning in multiple settings. Children with behavioural problems and slightly impaired functioning may benefit from patient information, education and parenting advice. From the age of 6 years, children can be offered diagnostic testing and professional support within the primary care setting, provided sufficient knowledge and expertise is available and there is collaboration with other health care providers. Management of a child with ADHD but no comorbid psychiatric disorder, consists of a step-by-step plan including education, parent and teacher guidance and, optionally, behavioural therapy for the child. In consultation with parents, child and other therapists, methylphenidate can be prescribed if behavioural interventions are not sufficiently effective. Children taking medication for ADHD should be monitored periodically, including assessment of the effectiveness and side effects.

The revised Dutch College of General Practitioners' practice guideline on 'Vaginal bleeding' provides recommendations for abnormal bleeding in women in the reproduction phase of life and for post-menopausal bleeding. This guideline is closely attuned to the guideline on 'Heavy menstrual bleeding' of the Dutch Society of Obstetrics and Gynaecology. Transvaginal sonography is not reliable for excluding endometrial carcinoma in women with abnormal vaginal bleeding treated with tamoxifen. The choice of medical treatment is determined in consultation with the patient. The following factors are assessed: severity and bother, long-term need for contraception, preference for cycle control, desire to have a child, pain during menstruation, comorbidity and use of medication. Treatment options are nonhormonal (NSAIDs, or tranexamic acid) or hormonal (a levonorgestrel-releasing intrauterine system, or combined oral contraceptive). In women of reproductive age, referral is indicated if medical treatment is not effective. Other indications are intracavitary abnormalities diagnosed by transvaginal sonography, tamoxifen use, persistent contact bleeding, and suspicion of coagulation disorders. Indications for referral for post-menopausal bleeding include: sonographic endometrial thickness > 4 mm, abnormal cervical cytology, tamoxifen use, irregular bleeding during use of hormone therapy for vasomotor symptoms and persistent or recurrent bleeding, regardless of endometrial thickness.

The Dutch College of General Practitioners (NHG) recently published the practice guideline 'Lumbosacral radicular syndrome'. This guideline provides general practitioners with guidance for the diagnostic workup and treatment of patients with lumbosacral radicular syndrome. In this article we discuss the most important changes and modifications to this guideline point by point. The most important recommendations for management are summarized in a flowchart.

This article discusses recent criticism of evidence-based medicine (EBM), which has tended to place unilateral emphasis on evidence originating from randomised trials into effectiveness. The goal of the pioneers of EBM, however, was actually the application of scientific evidence to the individual patient, including the doctor's experience ('practice-based') and the patient's preference ('preference-based') in decision making. Guidelines can support this process by systematically paying attention to patients' preferences and by presenting the advantages and disadvantages of different management options. The application of guidelines should not involve pursuit of 'standard care' but, primarily, the pursuit of shared decision making. This could lead to 'real EBM', in which medical knowledge is translated to practical choice options from different perspectives.

The guideline 'The STD consultation' of the Dutch College of General Practitioners provides guidelines for the diagnosis and management of patients with symptoms of a sexually transmitted disease (STD), patients at high risk of being infected with a STD (risk groups), and patients with questions or concerns about STDs. The test policy depends on the patient's symptoms and risks and is extensively described in the guideline. Men who have sex with men (MSM), prostitutes, people who visit prostitutes, people from countries in which STDs are endemic, people with multiple sexual partners, and people with a partner from one of these groups are at increased risk of contracting one of the five major STDs (chlamydia, gonorrhoea, syphilis, hepatitis B, and HIV). Patients originating from HIV-endemic regions or MSM can be offered HIV and, if appropriate, hepatitis B testing. Young men and women (< 25 years) can be offered chlamydia testing.- Treatment is dependent on the causative agent.

The Dutch College of General Practitioners (NHG) guideline 'Stroke' covers the diagnosis, management and long-term care of stroke in general practice. Patients with neurological symptoms suspected to be due to cerebral infarction or haemorrhage should be transferred directly to a stroke unit. The specialized care provided by these units, including emergency interventions (e.g. intravenous thrombolysis) and early mobilization help improve outcomes. If neurological symptoms have resolved completely, the patient should be referred to a TIA service as soon as possible, preferably within 1 day. Stroke often leads to permanent disability and neuropsychological impairments. The general practitioner (GP) should provide patients and caregivers with information and support, and should be alert to the psychological consequences of stroke, both in patients and caregivers. Secondary prevention measures are started as soon as the diagnosis of stroke is confirmed. GPs should regularly evaluate and monitor risk factors and compliance.

The revised guideline on 'Acute diarrhoea' from the Dutch College of General Practitioners covers the diagnosis and management of suspected acute infectious diarrhoea. Acute diarrhoea resulting from infectious gastroenteritis is often caused by a virus and is usually self-limiting; stool testing is rarely indicated. The main complication of acute diarrhoea is dehydration, although this is rare in the Netherlands. Children under 2 years old and patients over 70 are at an increased risk of dehydration. Dehydration is a clinical diagnosis based on a combination of patient history and physical examination. DNA diagnostic methods such as polymerase chain reaction (PCR) are now available for stool testing, in addition to stool culture and the triple faeces test (TFT). PCR is preferred for its better test properties. Treatment with oral rehydration salts (ORS) is indicated for patients with dehydration and may also be useful in patients at an increased risk of this event. Acute diarrhoea after hospitalisation or after visiting the tropics or subtropics merits special attention on account of the risk of infection with unusual pathogens and the consequences with regard to management.

The revised practice guideline 'Delirium' of the Dutch College of General Practitioners (NHG) provides recommendations about the prevention, early detection, diagnosis and treatment of delirium in elderly patients in general practice. The guideline now also offers tools for the treatment of delirium in terminally-ill patients. A patient with delirium can only be cared for at home if a safe environment and the continuous presence of carers can be guaranteed. This requires close cooperation between the care services and the home carers involved and good coordination with the general practice health centre. The discharge from hospital of patients with persistent symptoms of delirium to their homes requires optimal transfer from the specialist/nursing staff to the general practitioner and home carers involved. The NHG guideline therefore pays considerable attention to collaboration and transfer in the care of patients with delirium. The revised version of this guideline was developed in close collaboration with the revision of the multidisciplinary guideline on delirium produced by the Dutch Order of Medical Specialists.

The Dutch College of General Practitioners practice guideline 'Eczema' provides recommendations for the diagnosis and treatment of common types of eczema: atopic dermatitis, contact dermatitis, acro-vesicular eczema, nummular eczema, hypostatic eczema, and asteatotic eczema. Age is an important factor when determining the type of eczema. According to the guideline, patient history and physical examination are sufficient in the diagnosis of eczema; additional investigations are rarely indicated. Moisturizing the skin with neutral emollients is the cornerstone of treatment for patients with eczema. If treatment with glucocorticoids is indicated, it is recommended that patients should start with short-term twice daily application, decreasing to once daily application. The guideline advises not to treat eczema patients with tar preparations. General practitioners are also advised not to prescribe calcineurin inhibitors. How work may affect eczema, or how eczema may affect work, should be considered in adult patients.

In general practice, lower urinary tract symptoms (LUTS) in men are usually not attributable to specific disorders. Prostate cancer is rarely the cause of LUTS. Education, counselling, and non-pharmaceutical advice form the basis for treatment of LUTS. Only when these measures do not relieve the patient's symptoms sufficiently, drug therapy could be considered. Alpha-blockers are the drugs of first choice and are also recommended when transurethral catheterization is needed for acute urinary retention. The effect of medication on LUTS is limited and largely based on placebo effect. The effectiveness of prostate cancer screening is a subject of debate; therefore patients asking for a PSA test should be informed about the benefits and harms of measuring PSA before having a test. A PSA value > 4 ng/ml, or abnormal results on digital rectal examination should prompt further diagnostic evaluation.

The practice guideline 'Acute coronary syndrome' gives the general practitioner (GP) guidance on the diagnosis, treatment and long-term management of adults with (experienced) acute coronary syndrome (ACS). Not every patient with ACS presents with chest pain as the main symptom. The GP should evaluate every sign and symptom that may indicate ACS in the same way in both men and women. In patients with ACS the GP should immediately call an ambulance and the patient should be given oral salicylic acid 160-320 mg. If there is chest pain, sublingual nitroglycerine spray is indicated, if necessary followed by intravenous morphine or fentanyl. A normal ECG does not exclude ACS. Patients who have had symptoms indicative of ACS for less than 12 hours, and whose ECG shows abnormalities consistent with myocardial infarction with ST elevation should be referred to a cardiological intervention centre for percutaneous coronary intervention without delay whatever age they are. Patients who have symptoms indicative of ACS but who do not fulfil the above criteria may be given an emergency referral to a general hospital.

The guideline 'Gastric symptoms' covers the diagnosis and management of adults with dyspepsia in general practice, the prevention of unnecessary proton pump inhibitor use, and gastric protection during treatment with non-steroidal anti-inflammatory drugs (NSAIDs), including low-dose acetylsalicylic acid derivatives. During an initial episode of dyspepsia no distinction is made between reflux and ulcus symptoms because management is the same: start by prescribing an antacid and, if these provide insufficient effect, progress to a H₂-receptor antagonist and subsequently to a proton pump inhibitor (PPI). Testing for Helicobacter pylori should be performed in all patients with persistent or recurrent symptoms, preferably by using the monoclonal stool test. Gastroscopy should be performed with restraint in an H. pylori negative patient < 50 years with persistent or recurrent symptoms but no acute symptoms as there is only a very slight risk of malignancy. - Chronic PPI use is seen in 7% of the population and is associated with infections and osteoporosis. Phasing out of PPI use without good indication seems to be possible in 70% of patients.

The 'Thyroid disorders' guideline of the Dutch College of General Practitioners (NHG) provides recommendations for the diagnosis and management of hypothyroidism, hyperthyroidism and changes in the size of the thyroid gland, such as goitre and thyroid nodules. Hypothyroid patients younger than 60 years and without cardiac comorbidity should receive the full substitution dose of levothyroxine at treatment onset. In case of hypothyroidism in pregnancy, the levothyroxine dose should be immediately increased by 25%. All pregnant patients with (a history of) thyroid diseases should be tested for TSH-receptor antibodies at the start of the pregnancy. Management of subclinical hypo- and hyperthyroidism consists of monitoring laboratory values due to the great likelihood of normalization of the TSH value. All patients with a solitary nodule or a dominant nodule in a multinodular goitre should be referred to an endocrinologist for further investigation.

This guideline gives recommendations for the management of depression and depressive symptoms. The diagnosis of suspected depression requires a broad exploration of symptoms, sometimes over several visits. The guideline promotes self-management and patient empowerment during the healing process. The initial step in the treatment of depressive symptoms is patient education; patients with depression are supported with activity scheduling and are offered a short course of psychological treatment. If the initial treatment in patients with depression is not effective or if the depression is associated with severe suffering, severe social dysfunctioning or severe psychiatric comorbidity, psychotherapy or an antidepressant is recommended.

The choice of a method of contraception is individual, based on factors including good advice from the general practitioner. There are various reliable forms of contraception available, such as the contraceptive pill, the copper or hormone-containing coil (intrauterine device), the vaginal ring, the contraceptive patch, the contraceptive injection, contraceptive implants, and male sterilization (vasectomy) or female sterilization. When choosing for a combined hormonal preparation the preference is for a pill containing levonorgestrel and ethinylestradiol 30 μg. Women aged ≥ 35 years who smoke and are not prepared to stop are advised against taking combined preparations. Only liver-enzyme inducing drugs have been proven to have relevant interaction with hormonal contraceptives; this has not been proven in the case of antibiotics. A transvaginal ultrasound is not necessary following an uncomplicated insertion of an intrauterine device.

Anxiety and anxiety disorders are addressed in the practice guideline of the Dutch College of General Practitioners (NHG). It is important to distinguish anxiety and anxiety disorders because of differences in prognosis and treatment. Several visits may be needed before the diagnosis is established. Treatment is based on a stepped-care model. For anxiety, psychoeducation and follow-up visits are often sufficient. For anxiety disorders with relatively low levels of distress or social dysfunctioning, self-help with supervision in addition to psychoeducation is helpful. If this is not effective or if there is severe distress or social dysfunctioning, cognitive behavioural therapy is the first choice treatment. An antidepressant could be started after or in addition to cognitive behavioural therapy. If an antidepressant is prescribed, SSRIs are preferred above tricyclic antidepressants because of the lesser risk of severe adverse effects.

Dementia is a clinical diagnosis which a general practitioner can either make him/herself or by specific referral. If no abnormalities are found on further clinical investigations by the GP, the risk of missing a treatable cause of dementia is very small; therefore routine imaging examinations are not necessary. GPs are not recommended to prescribe cholinesterase inhibitors or memantine. The implementation of various psycho-social interventions has a positive effect on patients and their home carers and can postpone admission to a nursing home. Dementia care requires working agreements and collaboration amongst local care providers.

The Dutch College of General Practitioners' (NHG) practice guideline 'The menopausal transition' provides general practitioners with guidelines for the management of menopausal symptoms in women from the age of 40 years. Patient history is vital in determining and assessing menopausal symptoms. Patient education is often sufficient to help women cope with their menopausal symptoms; medication is seldom required. Most systemic hormonal preparations increase the risk of venous thromboembolism, cardiovascular disease and breast cancer; these are therefore only indicated if vasomotor symptoms lead to serious limitations in daily life. Before the patient is given hormonal therapy, the cardiovascular risk profile and risk of venous thromboembolism and breast cancer should be assessed. Local hormonal treatment can be indicated for vaginal symptoms.

Research in primary care showed that providers did not routinely respond to abnormal values of haemoglobin A1c, blood pressure or LDL cholesterol in patients with type 2 diabetes mellitus as defined in clinical practice guidelines. This problem is characterised as 'therapeutic inertia'. Providers may be reluctant to achieve the goals of therapy for several reasons. Firstly, target values have been lowered over time, partly due to influences from the pharmaceutical industry. Secondly, the applicability of clinical trial results to patients seen in primary care settings is limited. Thirdly, some patients prefer improvement of life style above drug therapy. Indicators for therapy intensification could be valid and useful for quality improvement if common reasons for non-adherence to guidelines are registered in electronic health records.