143 6 (UN)WARRANTED VARIATION IN HOSPITAL PROTOCOLS FOR NEONATAL REFERRAL TO THE PEDIATRICIAN | 15 GOODARZI et al. protocols found in this study might may be explained by: (1) variation in existing guidelines, (2) availability of health care resources, and/or (3) care based on providers' beliefs and interests.1–3 International guidelines are the foundation for national guidelines, providing professionals with evidence- based guidance in care. National guidelines form the basis for local protocols, describing the procedures of care.19 Protocols can deviate from guidelines and differ because of population characteristics or local organization of care. Unexplained differences between protocols in recommendations for care may result from gaps in guidelines because of unaddressed questions and/or lack of evidence. Indeed, for SGA and LGA, international evidence-based guidelines contain varying glucose and birth weight p-value cutoff points, which is consistent with our findings.20–24 According to Thornton and Adamkin (2016), this variation is unsurprising, considering the paucity of evidence about clinically significant levels of neonatal hypoglycemia and the lack of consensus about a specific level or range to define hypoglycemia.22 Recently, the Dutch association of pediatricians developed a national multidisciplinary guideline on hypoglycemia. This guideline was consensus-based because of incomplete and inconclusive evidence.23 Another explanation for the variation in protocols found in this study may be professionals' lack of adherence to national or international guidelines because they are unaware of them or do not agree with them.25–28 Indeed, in contrast with the majority of the MSAF, VE, FE, and CB protocols TABLE 6 The referral thresholda specified for type of department and region (n, %) Threshold for referral Total Low Average High n % n % n % n % Type of department Obstetric 152 100 120 79 19 13 13 9 Neonatal 190 100 126 66 28 15 36 19 Region North 65 100 50 77 9 14 6 9 East 25 100 17 68 1 4 7 28 South 79 100 60 76 9 11 10 13 Southwest 88 100 65 74 14 16 9 10 Northwest 85 100 54 63 14 17 17 20 aLow threshold = indications that led to the most pediatric consultations or neonatal admissions; High threshold = indications led to the least pediatric consultations or neonatal admissions. TABLE 7 Association between referral threshold, type of department and region (OR, aOR) Referral threshold Low Average High OR [95% CI] aOR [95% CI]a OR [95% CI] aOR [95% CI]a OR [95% CI] aOR [95% CI]a Type of department Obstetric (reference category) 1.0 1.0 1.0 1.0 1.0 1.0 Neonatal 0.53 [0.32–0.86]* 0.56 [0.34–0.93]* 1.21 [0.65–2.26] 1.18 [0.63–2.35] 2.50 [1.27–4.91]* 2.31 [1.16–4.60]* Regionb North 1.28 [0.77–2.14] 1.24 [0.74–2.09] 1.06 [0.56–2.02] 1.07 [0.56–2.65] 0.65 [0.31–1.35] 0.68 [0.32–1.42] East 0.82 [0.36–1.84] 0.82 [0.36–1.86] 0.27 [0.04–1.79] 0.27 [0.42–1.66] 2.48 [1.04–5.91]* 2.52 [1.05–6.09]* South 1.22 [0.78–1.90] 1.19 [0.76–1.87] 0.85 [0.46–1.55] 1.85 [0.04–2.10] 0.92 [0.52–1.65] 0.95 [0.53–1.71] Southwest 1.09 [0.72–1.64] 1.05 [0.69–1.58] 1.25 [0.74–2.09] 1.26 [0.47–2.90] 0.73 [0.41–1.29] 0.76 [0.43–1.36] Northwest 0.67 [0.45–0.99]* 0.73 [0.49–1.08] 1.29 [0.77–2.19] 1.27 [0.75–2.94] 1.59 [0.97–2.61] 1.43 [0.86–2.34] Abbreviations: N, neonatal department; O, obstetric department. aThe model for type of department was adjusted for region and the model for region was adjusted for type of department potential confounders. bThe reference category (OR of 1.0) is the weighted referral threshold of all regions. *p value <0.05. 1523536x, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/birt.12690 by Vrije Universiteit Amsterdam, Wiley Online Library on [14/11/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
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