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How GPs value guidelines applied to patients with multimorbidity: a qualitative study
  1. Hilde Luijks1,
  2. Peter Lucassen1,
  3. Chris van Weel1,2,
  4. Maartje Loeffen1,
  5. Antoine Lagro-Janssen1,
  6. Tjard Schermer1
  1. 1Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
  2. 2Department of Primary Health Care Research, Australian National University, Canberra, New South Wales, Australia
  1. Correspondence to Dr Hilde Luijks; Hilde.Luijks{at}


Objectives To explore and describe the value general practitioner (GPs) attribute to medical guidelines when they are applied to patients with multimorbidity, and to describe which benefits GPs experience from guideline adherence in these patients. Also, we aimed to identify limitations from guideline adherence in patients with multimorbidity, as perceived by GPs, and to describe their empirical solutions to manage these obstacles.

Design Focus group study with purposive sampling of participants. Focus groups were guided by an experienced moderator who used an interview guide. Interviews were transcribed verbatim. Data analysis was performed by two researchers using the constant comparison analysis technique and field notes were used in the analysis. Data collection proceeded until saturation was reached.

Setting Primary care, eastern part of The Netherlands.

Participants Dutch GPs, heterogeneous in age, sex and academic involvement.

Results 25 GPs participated in five focus groups. GPs valued the guidance that guidelines provide, but experienced shortcomings when they were applied to patients with multimorbidity. Taking these patients’ personal circumstances into account was regarded as important, but it was impeded by a consistent focus on guideline adherence. Preventative measures were considered less appropriate in (elderly) patients with multimorbidity. Moreover, the applicability of guidelines in patients with multimorbidity was questioned. GPs’ extensive practical experience with managing multimorbidity resulted in several empirical solutions, for example, using their ‘common sense’ to respond to the perceived shortcomings.

Conclusions GPs applying guidelines for patients with multimorbidity integrate patient-specific factors in their medical decisions, aiming for patient-centred solutions. Such integration of clinical experience and best evidence is required to practise evidence-based medicine. More flexibility in pay-for-performance systems is needed to facilitate this integration. Several improvements in guideline reporting are necessary to enhance the applicability of guidelines in patients with multimorbidity.

  • GENERAL MEDICINE (see Internal Medicine)

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