166 Chapter 7 Strengths and limitations This study is an exploration of regional protocols based on four topics for IOL in six MCNs. Although this is a relatively small sample, we saw a large variation in regional protocols. It is likely that protocols on other topics show similar variation. At the time of the analysis, some national guidelines had recently been published or were under revision. It is possible that these national guidelines have been partially implemented in the regional protocols, but this could not be traced due to the limited use of references to the evidence base in the regional protocols. As we did not observe the actual implementation of the regional protocols in practice, we cannot conclude to what extent clinical decision-making is in line with the regional protocols. However, the differences in recommendations in the regional protocols and the apparent relationship with high and low percentage of IOL in MCNs makes it plausible that the regional protocols are a contributing factor to practice variation. Several techniques have been used to enhance qualitative rigor, such as the use of a systematic method, peer debriefing, and the use of multiple researchers in the study (investor triangulation). Data triangulation was achieved by searching for documents on websites, online databases, and requests to the MCN (35,36). Conclusion Overall, this study shows that there is variation in regional protocols, which can lead to unwanted standardization and unwarranted practice variation. There is a need for guidance on the development and content of regional protocols. In order to better align regional protocols with national guidelines, while adequately describing contextual factors, and making room for women’s preferences and professional expertise. Healthcare providers should be trained in the use of evidence and in shared decision-making to become evidence-based practitioners. At the national level, there is a need to work on up-to-date guidelines and to communicate the relationship between national guidelines and regional protocols. Furthermore, research is needed into other mechanisms that contribute to practice variation.
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