142 6 CHAPTER 6 14 | GOODARZI et al. 4 | DISCUSSION This study provides insight into variation in local hospital protocols for neonatal referral to the pediatrician in the Netherlands as a possible determinant contributing to unwarranted practice variation.5,12,13 Analysis of the protocols for LGA, SGA, MSAF, VE, FE, and CB showed interhospital, interdepartmental, and intradepartmental variation in recommendations for type of neonatal referral, admission, screening/diagnostic tests, treatment, and discharge. Furthermore, we found lower referral thresholds in neonatal departments compared with obstetric departments, and a higher referral threshold in the eastern region compared with the weighted referral threshold of all regions. 4.1 | Explaining unwarranted variation: the role of evidence-based guidelines, health care resources, and providers' beliefs and interests In this study, we did not examine the association between variation in local hospital protocols and care outcomes. Further study is needed to determine whether the variation in local hospital protocols for neonatal referral to the pediatrician results in unwarranted variation in neonatal care outcomes. The protocols analyzed in this study did not contain descriptions of local population characteristics as explanations for specific recommendations. Reflecting on the study findings using definitions of warranted and unwarranted variation suggests that the variation in hospital Discharge Type of department O P n, % n, % MSAF Totala 33 37 Neonatal condition 2 2 After ≥8 h postpartum 17 22 After 9–12h postpartum 5 0 After 13–48h postpartum 1 1 Referred to a different document 6 2 Not mentioned 2 10 VE Totala 26 31 Neonatal condition 0 1 After ≥8 h postpartum 4 5 After 9–12h postpartum 5 6 After 13–48h postpartum 3 2 Not mentioned 14 17 FE Totala 22 29 Neonatal condition 0 1 After ≥8 h postpartum 2 3 After 9–12h postpartum 5 6 After 13–28h postpartum 1 2 Not mentioned 14 17 CB Totala 39 42 Food intake 0 1 After ≥12h postpartum 1 2 After 13–24h postpartum 3 9 Not mentioned 35 30 Abbreviations: CB, cesarean birth; FE, forceps extraction; LGA, large for gestational age/macrosomia; MSAF, meconium stained amniotic fluid; N, neonatal department; O, obstetric department; SGA, small for gestational age/fetal growth restriction; VE, vacuum extraction. aExcluding the categories “referral not indicated” and “unclear if referral is indicated” (Table 4). bNumbers obtained from the results shown in Supplement 2. TABLE 5 (Continued) 1523536x, 0, Downloaded from by Vrije Universiteit Amsterdam, Wiley Online Library on [14/11/2022]. See the Terms and Conditions ( on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License