145 6 (UN)WARRANTED VARIATION IN HOSPITAL PROTOCOLS FOR NEONATAL REFERRAL TO THE PEDIATRICIAN | 17 GOODARZI et al. diagnostic tests, treatment, and discharge. Furthermore, the results showed lower referral thresholds in neonatal departments compared with obstetric departments, and higher referral thresholds in the eastern region compared with the weighted referral thresholds of all regions. These results suggest unwarranted variation in hospitals protocols, whichmay contribute to unwarranted variation in care. The recommendations in local protocols were not always consistent with existing evidence-based guidelines. This may be explained by variation and gaps in guidelines and/or a lack of adherence to guidelines, leaving room for provider preference and resource-driven recommendations. To reduce unwarranted variation in local protocols, we recommend the development of evidence-based, multidisciplinary guidelines to support local protocols. Only where evidence is lacking or inconclusive should agreements be based on multidisciplinary consensus. Moreover, attention should be paid to the implementation of evidence. If local protocols deviate from evidence-based guidance because of specific local circumstances, this should be well described. Uniformity in guidance will offer clear standards for care evaluation, including opportunities to reduce inappropriate care. AUTHOR CONTRIBUTIONS BG is the main author of the manuscript, organizing all aspects of the article including data collection, data extraction, data analyses, and drafting of the initial manuscript. ASS, DC, HL, TA, AK, and AJ provided guidance and critically reviewed the manuscript. ASS checked the syntax for the analyses. All authors contributed to the manuscript revisions, and read and approved the submitted version. AJ supervised the study. ACKNOWLEDGMENT We thank Kenza Gamoudi and Laurine van der Mol- Otterloo for the support and input during the first phase of this study. FUNDING INFORMATION The authors received no funding for this work. CONFLICT OF INTEREST The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. DATA AVAILABILITY STATEMENT The protocols collected for this study are not readily available because of respondent's privacy. The data set developed for this study is accessible. Requests to access the data sets should be directed to corresponding author. ETHICS STATEMENT Ethical approval was requested from the Medical Ethics Review Committee of VU University Medical Centre. The committee confirmed that ethical approval was not required because the Medical Research involving Human Subjects Act did not apply to this study (nr. 2019.549). 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