164 Chapter 7 National guidelines and regional protocols Several sources of unwarranted practice variation have been described in the literature. One of the most important sources of unwarranted variation appears to be misinterpretation or misapplication of relevant clinical evidence (24). One strategy to minimize this type of unwarranted variation is the development of national guidelines (12,25). National guideline development provides an opportunity to ensure that sufficient knowledge and resources are available. Guideline development is a specialized task that requires experts who have the time to conduct a systematic analysis of the literature and formulate evidence-based recommendations (26). According to our study, national guidelines do not always seem to reflect current professional practice. Several national guidelines were out of date and do not support healthcare providers with the latest evidence and current issues. Regional protocols do not appear to adequately compensate for these shortcomings. Therefore, national associations need to ensure that guidelines are regularly reviewed to determine whether they are still up-to-date or need to be revised (12). In this way, guidelines can truly be the evidence base for clinical decision-making. Our analysis confirms previous research that there is great variation between regional protocols (15,17). We found that evidence from national guidelines is not always incorporated into regional protocols, and some MCNs redo the guideline development process to develop a regional protocol. Considering this, there is a need for clarity in Dutch maternity care about the relationship between national guidelines and regional protocols, and about the content of regional protocols. Ultimately, a national guideline is the leading document that provides the systematic literature analysis and evidencebased recommendations on when certain care is needed. Guidelines should also describe where the evidence is less strong and where there is room for women’s preferences. As a result, guidelines give direction to regional protocols, leaving only context-specific factors such as ‘who’ and ‘how ‘ to be specified (26). This can avoid random use of evidence in regional protocols and allows for women’s preferences, potentially reducing regional practice variation between MCNs. If recommendations in regional protocols do differ from those in the national guideline or, for example, if different cut-off values are used, this should be justified in the protocol. The risk of over-standardization Regional protocols provide an opportunity for a concrete description of medical practice provided in a particular region. This standardization in protocols can help to reduce healthcare provider subjectivity, bias, and uncertainty, thereby reducing unwarranted practice variation (26,27). However, while protocols should facilitate evidence-based practice, they should not promote undesirable standardization of care. Evidence-based practice combines knowledge of the patient’s clinical condition, with the scientific literature, and the patient’s individual preferences. The risk of undesirable standardization is that these factors are not sufficiently taken into account (27). National guidelines can provide the scientific literature for regional protocols,
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