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Background: Low-value care provides minimal or no benefit for the patient, wastes resources, and can cause harm. Explicit do-not-do recommendations in clinical guidelines are a first step in reducing low-value care. The aim of this study was to identify and prioritize do-not-do recommendations in general practice guidelines with priority for implementation. Methods: We used a mixed method design in Dutch primary care. First, we identified do-not-do recommendations through a systematic assessment of 92 Dutch guidelines for general practitioners (GPs), resulting in 385 do-not-do recommendations. Second, we selected 146 recommendations addressing high prevalent conditions. Third, a random sample of 5000 Dutch GPs was invited for an online survey to prioritize recommendations based on the prevalence of the condition and low-value care practice, potential harm, and potential cost reduction on a scale from 1 to 5/6. Total scores could range from 4 to 22. Recommendations with a median score > 12 were included. In total, 440 GPs completed the survey. Results: The selection process led to 30 prioritised recommendations. These covered drug treatments (n = 12), diagnostics (n = 10), referral to other healthcare professions (n = 5), and non-drug treatment (n = 3). Conclusion: Dutch clinical guidelines include many do-not-do recommendations that are perceived as highly relevant by the GPs. The list of 30 high-priority do-not-do recommendations can be used to raise awareness of low-value care among GPs. As the recommendations are supported with the latest evidence from international studies, primary healthcare professionals and policy makers worldwide can use the list for further validating the list in their local context and designing strategies to reduce low-value care. [ABSTRACT FROM AUTHOR]

Objective: To develop and internally validate prediction models for future hospital care utilization in patients with multiple chronic conditions. Design: Retrospective cohort study. Setting: A teaching hospital in the Netherlands (542 beds) Participants: All adult patients (n = 18.180) who received care at the outpatient clinic in 2017 for two chronic diagnoses or more (including oncological diagnoses) and who returned for hospital care or outpatient clinical care in 2018. Development and validation using a stratified random split-sample (n = 12.120 for development, n = 6.060 for internal validation). Outcomes: ≥2 emergency department visits in 2018, ≥1 hospitalization in 2018 and ≥12 outpatient visits in 2018. Statistical analysis: Multivariable logistic regression with forward selection. Results: Evaluation of the models' performance showed c-statistics of 0.70 (95% CI 0.69–0.72) for the hospitalization model, 0.72 (95% CI 0.70–0.74) for the ED visits model and 0.76 (95% 0.74–0.77) for the outpatient visits model. With regard to calibration, there was agreement between lower predicted and observed probability for all models, but the models overestimated the probability for patients with higher predicted probabilities. Conclusions: These models showed promising results for further development of prediction models for future healthcare utilization using data from local electronic health records. This could be the first step in developing automated alert systems in electronic health records for identifying patients with multimorbidity with higher risk for high healthcare utilization, who might benefit from a more integrated care approach. [ABSTRACT FROM AUTHOR]

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Abstract: Background: To meet the challenge of multimorbidity in decision making, a switch from a disease‐oriented to a goal‐oriented approach could be beneficial for patients and clinicians. More insight about the concept and the implementation of this approach in clinical practice is needed. Objective: This study aimed to develop conceptual descriptions of goal‐oriented care by examining the perspectives of general practitioners (GPs) and clinical geriatricians (CGs), and how the concept relates to collaborative communication and shared decision making with elderly patients with multimorbidity. Method: Qualitative interviews with GPs and CGs were conducted and analyzed using thematic analysis. Results: Clinicians distinguished disease‐ or symptom‐specific goals, functional goals and a new type of goals, which we labelled as fundamental goals. “Fundamental goals” are goals specifying patient's priorities in life, related to their values and core relationships. These fundamental goals can be considered implicitly or explicitly in decision making or can be ignored. Reasons to explicate goals are the potential mismatch between medical standards and patient preferences and the need to know individual patient values in case of multimorbidity, including the management in acute situations. Conclusion: Based on the perspectives of clinicians, we expanded the concept of goal‐oriented care by identifying a three‐level goal hierarchy. This model could facilitate collaborative goal‐setting for patients with multiple long‐term conditions in clinical practice. Future research is needed to refine and validate this model and to provide specific guidance for medical training and practice. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Interventions aimed at improving guideline adherence should take into account the specific features of the target users; however, it is unclear how general practitioners ( GPs) evaluate the different types of interventions. The aim of this paper was to identify GPs' preferences for interventions to improve guideline adherence in practice and whether these differ across key guideline recommendations. Method An electronic survey was conducted among 703 GPs working in the south-western part of the Netherlands. Each survey focused on two of four guidelines: cerebrovascular accident, eye inflammation, thyroid disorders and urinary tract infection. GPs were asked to rate potential interventions in terms of their usefulness in improving guideline adherence in general and for specific key guideline recommendations. Results 264 GPs (38%) completed the questionnaire. In general, GPs preferred interactive small group meetings (84% rated this as much or very much encouraging), audit and feedback (53%), organizational interventions (50%) and the use of local opinion leaders (50%) as methods for improving guideline adherence. Financial interventions (24%), distribution of educational materials (22%) and big group educational meetings (21%) were of least interest. Some interventions were preferred by GPs irrespective of the specific key recommendations (e.g. audit and feedback), while ratings for other interventions differed across key recommendations (reminders/computer support). Conclusions To implement guidelines, interventions need to be identified that are acceptable and appealing to the target group. GPs seem to have general and recommendation-specific preferences regarding interventions, these should be taken into account when developing plans for guideline implementation to encourage the uptake of guidelines in practice. [ABSTRACT FROM AUTHOR]

Purpose. Although in the last decades primary care research has evolved with great success, there is a growing need to prioritize the topics given the limited resources available. Therefore, we constructed a nationwide database of ongoing primary care research projects in the Netherlands, and we assessed if the distribution of research topics matched with primary care practice. Methods. We conducted a survey among the main primary care research centres in the Netherlands and gathered details of all ongoing primary care research projects. We classified the projects according to research topic, relation to professional guidelines and knowledge deficits, collaborative partners and funding source. Subsequently, we compared the frequency distribution of clinical topics of research projects to the prevalence of problems in primary care practice. Results. We identified 296 ongoing primary care research projects from 11 research centres. Most projects were designed as randomized controlled trial (35%) or observational cohort (34%), and government funded mostly (60%). Thematically, most research projects addressed chronic diseases, mainly cardiovascular risk management (8%), depressive disorders (8%) and diabetes mellitus (7%). One-fifth of the projects was related to defined knowledge deficits in primary care guidelines. From a clinical primary care perspective, research projects on dermatological problems were significantly underrepresented (P = 0.01). Conclusions. This survey of ongoing projects demonstrates that primary care research has a firm basis in the Netherlands, with a strong focus on chronic disease. The fit with primary care practice can improve, and future research should address knowledge deficits in professional guidelines more. [ABSTRACT FROM PUBLISHER]

Background To explore how clinical practice guidelines can be adapted to facilitate shared decision making. Methods This was a qualitative key-informant study with group discussions and semi-structured interviews. First, 75 experts in guideline development or shared decision making participated in group discussions at two international conferences. Next, health professionals known as experts in depression or breast cancer, experts on clinical practice guidelines and/or shared decision making, and patient representatives were interviewed (N=20). Using illustrative treatment decisions on depression or breast cancer, we asked the interviewees to indicate as specifically as they could how guidelines could be used to facilitate shared decision making. Results Interviewees suggested some generic strategies, namely to include a separate chapter on the importance of shared decision making, to use language that encourages patient involvement, and to develop patient versions of guidelines. Recommendation-specific strategies, related to specific decision points in the guideline, were also suggested: These include structuring the presentation of healthcare options to increase professionals' option awareness; structuring the deliberation process between professionals and patients; and providing relevant patient support tools embedded at important decision points in the guideline. Conclusions This study resulted in an overview of strategies to adapt clinical practice guidelines to facilitate shared decision making. Some strategies seemed more contentious than others. Future research should assess the feasibility and impact of these strategies to make clinical practice guidelines more conducive to facilitate shared decision making. [ABSTRACT FROM AUTHOR]

Background: Clinical guidelines are considered important instruments to improve quality in health care. Since 1998 the Royal Dutch Society for Physical Therapy (KNGF) produced evidence-based clinical guidelines, based on a standardized program. New developments in the field of guideline research raised the need to evaluate and update the KNGF guideline program. Purpose of this study is to compare different guideline development programs and review the KNGF guideline program for physical therapy in the Netherlands, in order to update the program. Method: Six international guideline development programs were selected, and the 23 criteria of the AGREE Instrument were used to evaluate the guideline programs. Information about the programs was retrieved from published handbooks of the organizations. Also, the Dutch program for guideline development in physical therapy was evaluated using the AGREE criteria. Further comparison the six guideline programs was carried out using the following elements of the guideline development processes: Structure and organization; Preparation and initiation; Development; Validation; Dissemination and implementation; Evaluation and update. Results: Compliance with the AGREE criteria of the guideline programs was high. Four programs addressed 22 AGREE criteria, and two programs addressed 20 AGREE criteria. The previous Dutch program for guideline development in physical therapy lacked in compliance with the AGREE criteria, meeting only 13 criteria. Further comparison showed that all guideline programs perform systematic literature searches to identify the available evidence. Recommendations are formulated and graded, based on evidence and other relevant factors. It is not clear how decisions in the development process are made. In particular, the process of translating evidence into practice recommendations can be improved. Conclusion: As a result of international developments and consensus, the described processes for developing clinical practice guidelines have much in common. The AGREE criteria are common basis for the development of guidelines, although it is not clear how final decisions are made. Detailed comparison of the different guideline programs was used for updating the Dutch program. As a result the updated KNGF program complied with 22 AGREE criteria. International discussion is continuing and will be used for further improvement of the program. [ABSTRACT FROM AUTHOR]

Background: Deprescribing of medication for cardiovascular risk factors and diabetes has been incorporated in clinical guidelines but proves to be difficult to implement in primary care. Training of healthcare providers is needed to enhance deprescribing in eligible patients. This study will examine the effects of a blended training program aimed at initiating and conducting constructive deprescribing consultations with patients., Methods: A cluster-randomized trial will be conducted in which local pharmacy-general practice teams in the Netherlands will be randomized to conducting clinical medication reviews with patients as usual (control) or after receiving the CO-DEPRESCRIBE training program (intervention). People of 75 years and older using specific cardiometabolic medication (diabetes drugs, antihypertensives, statins) and eligible for a medication review will be included. The CO-DEPRESCRIBE intervention is based on previous work and applies models for patient-centered communication and shared decision making. It consists of 5 training modules with supportive tools. The primary outcome is the percentage of patients with at least 1 cardiometabolic medication deintensified. Secondary outcomes include patient involvement in decision making, healthcare provider communication skills, health/medication-related outcomes, attitudes towards deprescribing, medication regimen complexity and health-related quality of life. Additional safety and cost parameters will be collected. It is estimated that 167 patients per study arm are needed in the final intention-to-treat analysis using a mixed effects model. Taking loss to follow-up into account, 40 teams are asked to recruit 10 patients each. A baseline and 6-months follow-up assessment, a process evaluation, and a cost-effectiveness analysis will be conducted., Discussion: The hypothesis is that the training program will lead to more proactive and patient-centered deprescribing of cardiometabolic medication. By a comprehensive evaluation, an increase in knowledge needed for sustainable implementation of deprescribing in primary care is expected., Trial Registration: The study is registered at ClinicalTrials.gov (identifier: NCT05507177)., (© 2024. The Author(s).)

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.

Background: Several funding organizations using different agendas support research in general practice. Topic selection and prioritization are often not coordinated, which may lead to duplication and research waste., Objectives: To develop systematically a national research agenda for general practice involving general practitioners, researchers, patients and other relevant stakeholders in healthcare., Methods: We reviewed knowledge gaps from 90 Dutch general practice guidelines and formulated research questions based on these gaps. In addition, we asked 96 healthcare stakeholders to add research questions relevant for general practice. All research questions were prioritized by practising general practitioners in an online survey (n = 232) and by participants of an invitational conference including general practitioners (n = 48) and representatives of other stakeholders in healthcare (n = 16), e.g. patient organizations and medical specialists., Results: We identified 787 research questions. These were categorized in two ways: according to the chapters of the International Classification for Primary Care (ICPC) and in 12 themes such as common conditions, person-centred care and patient education, collaboration and organization of care. The prioritizing procedure resulted in top 10 lists of research questions for each ICPC chapter and each theme., Conclusion: The process resulted in a widely supported National Research Agenda for General Practice. We encourage both researchers and funding organizations to use this agenda to focus their research on the most relevant issues in general practice and to generate new evidence for the next generation of guidelines and the future of general practice.

Background: In the last decade, guideline organizations faced a number of problems, including a lack of standardization in guideline development methods and suboptimal guideline implementation. To contribute to the solution of these problems, we produced a toolbox for guideline development, implementation, revision, and evaluation., Methods: All relevant guideline organizations in the Netherlands were approached to prioritize the topics. We sent out a questionnaire and discussed the results at an invitational conference. Based on consensus, twelve topics were selected for the development of new tools. Subsequently, working groups were composed for the development of the tools. After development of the tools, their draft versions were pilot tested in 40 guideline projects. Based on the results of the pilot tests, the tools were refined and their final versions were presented., Results: The vast majority of organizations involved in pilot testing of the tools reported satisfaction with using the tools. Guideline experts involved in pilot testing of the tools proposed a variety of suggestions for the implementation of the tools. The tools are available in Dutch and in English at a web-based platform on guideline development and implementation (http://www.ha-ring.nl)., Conclusions: A collaborative approach was used for the development and evaluation of a toolbox for development, implementation, revision, and evaluation of guidelines. This approach yielded a potentially powerful toolbox for improving the quality and implementation of Dutch clinical guidelines. Collaboration between guideline organizations within this project led to stronger linkages, which is useful for enhancing coordination of guideline development and implementation and preventing duplication of efforts. Use of the toolbox could improve quality standards in the Netherlands, and might facilitate the development of high-quality guidelines in other countries as well.

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.

Background: Patient participation is essential in developing high-quality guidelines but faces practical challenges. Evidence on timing, methods, evaluations, and outcomes of methodologies for patient participation in guideline development is lacking., Objective: To assess the feasibility of a wiki as a participatory tool for patients in the development of a guideline on infertility determined by (1) use of the wiki (number of page views and visitors), (2) benefits of the wiki (ie, number, content, and eligibility of the recommendations to be integrated into the guideline), and (3) patients' facilitators of and barriers to adoption, and the potential challenges to be overcome in improving this wiki., Methods: To obtain initial content for the wiki, we conducted in-depth interviews (n = 12) with infertile patients. Transcripts from the interviews were translated into 90 draft recommendations. These were presented on a wiki. Over 7 months, infertile patients were invited through advertisements or mailings to formulate new or modify existing recommendations. After modifying the recommendations, we asked patients to select their top 5 or top 3 recommendations for each of 5 sections on fertility care. Finally, the guideline development group assessed the eligibility of the final set of recommendations within the scope of the guideline. We used a multimethod evaluation strategy to assess the feasibility of the wiki as a participatory tool for patients in guideline development., Results: The wiki attracted 298 unique visitors, yielding 289 recommendations. We assessed the 21 recommendations ranked as the top 5 or top 3 for their eligibility for being integrated into the clinical practice guideline. The evaluation identified some challenges needed to be met to improve the wiki tool, concerning its ease of use, website content and layout, and characteristics of the wiki tool., Conclusions: The wiki is a promising and feasible participatory tool for patients in guideline development. A modified version of this tool including new modalities (eg, automatically limiting the number and length of recommendations, using a fixed format for recommendations, including a motivation page, and adding a continuous prioritization system) should be developed and evaluated in a patient-centered design.

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.

Background: Despite considerable efforts to promote and support guideline use, adherence is often suboptimal. Barriers to adherence vary not only across guidelines but also across recommendations within guidelines. The aim of this study was to assess the perceived barriers to guideline adherence among GPs by focusing on key recommendations within guidelines., Methods: We conducted a cross-sectional electronic survey among 703 GPs in the Netherlands. Sixteen key recommendations were derived from four national guidelines. Six statements were included to address the attitudes towards guidelines in general. In addition, GPs were asked to rate their perceived adherence (one statement) and the perceived barriers (fourteen statements) for each of the key recommendations, based on an existing framework., Results: 264 GPs (38%) completed the questionnaire. Although 35% of the GPs reported difficulties in changing routines and habits to follow guidelines, 89% believed that following guidelines leads to improved patient care. Perceived adherence varied between 52 and 95% across recommendations (mean: 77%). The most perceived barriers were related to external factors, in particular patient ability and behaviour (mean: 30%) and patient preferences (mean: 23%). Lack of applicability of recommendations in general (mean: 22%) and more specifically to individual patients (mean: 25%) were also frequently perceived as barriers. The scores on perceived barriers differed largely between recommendations [minimum range 14%; maximum range 67%]., Conclusions: Dutch GPs have a positive attitude towards the NHG guidelines, report high adherence rates and low levels of perceived barriers. However, the perceived adherence and perceived barriers varied largely across recommendations. The most perceived barriers across recommendations are patient related, suggesting that current guidelines do not always adequately incorporate patient preferences, needs and abilities. It may be useful to provide tools such as decision aids, supporting the flexible use of guidelines to individual patients in practice.

Background: Urinary tract infections (UTI) are among the most common health problems seen in general practice. Evidence-based guidelines on UTI are available, but adherence to these guidelines varies widely among practitioners for reasons not well understood. The aim of this study was to identify the barriers to the implementation of a guideline on UTI perceived by Dutch general practitioners (GPs) and to explore interventions to overcome these barriers., Methods: A focus group study, including 13 GPs working in general practices in the Netherlands, was conducted. Key recommendations on diagnosis and treatment of uncomplicated UTI were selected from the guideline. Barriers to guideline adherence and possible interventions to address these barriers were discussed. The focus group session was audio-taped and transcribed verbatim. Barriers were classified according to an existing framework., Results: Lack of agreement with the recommendations, unavailable and inconvenient materials (i.e. dipslides), and organisational constraints were perceived as barriers for the diagnostic recommendations. Barriers to implementing the treatment recommendations were lack of applicability and organisational constraints related to the availability of drugs in pharmacies. Suggested interventions were to provide small group education to GPs and practice staff members, to improve organisation and coordination of care in out of hour services, to improve the availability of preferred dosages of drugs, and to pilot-test guidelines regionally., Conclusions: Despite sufficient knowledge of the recommendations on UTI, attitudinal and external barriers made it difficult to follow them in practice. The care concerning UTI could be optimized if these barriers are adequately addressed in implementation strategies. The feasibility and success of these strategies could be improved by involving the target group of the guideline in selecting useful interventions to address the barriers to implementation.

Objective: Patient involvement in medical decision making has been suggested to contribute to patients' satisfaction and better patient outcomes. Decision aids are particularly useful for preference-sensitive decisions. Ideally, these should be based on up-to-date evidence-based guidelines. The objective of this project was to develop a generic format for development and maintenance of decision aids based on evidence-based guidelines., Methods: Decision aids, evidence-based guidelines and IPDAS standards were used for development of a generic format for decision aids. Patient focus groups were used to assess patients' information needs, expectations, personal values and preferences for presentation of information., Results: We developed a generic format for decision aids and six specific decision aids derived from evidence-based guidelines. The decision aids were published on the Dutch national health care portal. Furthermore, we reached formal agreement on ownership and maintenance of the decision aids with all stakeholders. We achieved these results within 12 months., Conclusion: Our generic format facilitated the efficient production of specific decision aids based on evidence-based guidelines., Practice Implications: If guidelines and decision aids are developed in parallel, high-quality patient information can be produced within a short time frame. The process of development should include adequate patient involvement and a strategy for maintenance.

Background: Clinical guidelines are considered important instruments to improve quality in health care. Since 1998 the Royal Dutch Society for Physical Therapy (KNGF) produced evidence-based clinical guidelines, based on a standardized program. New developments in the field of guideline research raised the need to evaluate and update the KNGF guideline program. Purpose of this study is to compare different guideline development programs and review the KNGF guideline program for physical therapy in the Netherlands, in order to update the program., Method: Six international guideline development programs were selected, and the 23 criteria of the AGREE Instrument were used to evaluate the guideline programs. Information about the programs was retrieved from published handbooks of the organizations. Also, the Dutch program for guideline development in physical therapy was evaluated using the AGREE criteria. Further comparison the six guideline programs was carried out using the following elements of the guideline development processes: Structure and organization; Preparation and initiation; Development; Validation; Dissemination and implementation; Evaluation and update., Results: Compliance with the AGREE criteria of the guideline programs was high. Four programs addressed 22 AGREE criteria, and two programs addressed 20 AGREE criteria. The previous Dutch program for guideline development in physical therapy lacked in compliance with the AGREE criteria, meeting only 13 criteria. Further comparison showed that all guideline programs perform systematic literature searches to identify the available evidence. Recommendations are formulated and graded, based on evidence and other relevant factors. It is not clear how decisions in the development process are made. In particular, the process of translating evidence into practice recommendations can be improved., Conclusion: As a result of international developments and consensus, the described processes for developing clinical practice guidelines have much in common. The AGREE criteria are common basis for the development of guidelines, although it is not clear how final decisions are made. Detailed comparison of the different guideline programs was used for updating the Dutch program. As a result the updated KNGF program complied with 22 AGREE criteria. International discussion is continuing and will be used for further improvement of the program.

Background: Clinical practice guidelines should be based on the best available evidence. However, this evidence is often incomplete, controversial, or lacking. Other considerations beyond the evidence are therefore needed to be able to formulate specific and applicable recommendations for clinical practice., Objective: The aim of this study is to obtain consensus among experts about a set of domains and items covering the most relevant 'other considerations' to formulate recommendations in evidence-based guideline development., Methods: An initial list of 10 domains and 49 items for a systematic and considered judgement of scientific evidence was generated from the literature. A panel of Dutch experts in guideline development tested this list using a two-round Delphi consensus technique. Each expert was asked to independently score the relevance of the items on a 4-point Likert scale, ranging from 'very important' to 'not important'. The final list consisted of items that were included by at least 60% consensus., Results: Twenty-eight experts participated in the first Delphi round and 21 of them in the second round. High scoring domains were 'clinical relevance', 'safety', and 'availability of resources'. There was consensus about the relevance of 37 items. The domain 'conflicts of interest by industry' was excluded because of lack of consensus., Conclusion: This is the first formal consensus approach towards structuring the considered judgement process in formulating recommendations in clinical guidelines. The final list of items can be used to facilitate the process of guideline development. The next step is to test the practical usefulness and applicability of this list in guideline development.