Introduction

The COVID-19 pandemic disrupted routine healthcare delivery abruptly and reduced access to elective surgeries. This created a unique natural experiment to assess the necessity and effectiveness of standard care. With intensive care units overwhelmed by critically ill patients and operating room capacity repurposed for COVID-related services, hospitals worldwide were forced to postpone or cancel elective procedures [1–6]. Across countries, elective care volumes dropped significantly during the pandemic, although the extent and duration of disruption varied. In Germany, a multicenter study reported a 25.6% decrease in elective benign surgeries, particularly for procedures such as thyroidectomy and hernia repair. Emergency surgeries declined by 18.8% [7]. In the United Kingdom, delays in joint replacement procedures have persisted well beyond the acute phase of the pandemic [8]. In the Netherlands, elective surgery volumes declined sharply during pandemic peaks, while acute care remained relatively stable [9]. These patterns suggest that benign elective care, often considered deferrable, was particularly affected as systems prioritized life-threatening and urgent conditions.

Although these studies have documented substantial declines in elective care, particularly in surgical specialisms, it remains unclear how healthcare systems responded. Some may have substituted invasive surgical procedures with less intensive alternatives, such as outpatient interventions or pharmacologic management. Others may have deferred care without replacement [1,10–14]. Few analyses have examined whether hospitals, under resource constraints, adapted their care delivery by prioritizing certain patients or interventions [10,14–16]. Consequently, it is unclear to what extent the observed reductions reflect temporary service delays or more deliberate changes in care intensity and patient selection. Addressing this gap is crucial for understanding how healthcare systems operate under pressure. These insights are increasingly relevant given the ongoing financial constraints, staff shortages, the need for more sustainable models of care, and the necessity for pandemic preparedness to ensure resilience in future health crises [17–20].

Benign gynecological care is especially relevant in this context. It includes multiple care pathways where surgical procedures have well-established non-surgical alternatives, such as hormonal treatments, intrauterine devices or minimally invasive outpatient interventions. During periods of constrained access to operating theatres, such alternatives may have been used more frequently to manage symptoms or bridge care gaps. This makes benign gynecology an informative domain for studying how care systems triaged patients and whether substitution occurred under pressure. In previous work, we observed that in the Netherlands, both surgical and non-surgical care for benign gynecological conditions decreased markedly during the first wave of the pandemic [21]. Contrary to the hypothesis that surgical procedures might be replaced by non-surgical alternatives, we found little evidence of such substitution. Instead, care appeared to have been scaled down across the board, raising important questions about how care delivery was adapted under pressure.

While these earlier findings highlighted overall reductions in volume, the current study takes a more granular approach and investigates how care delivery was reshaped to meet acute shortages of health care in order to minimize the consequences for patients. We focus on the combination of treatment modality (surgical vs non-surgical), care intensity and care setting (hospital type and region). We hypothesize that under resource constraints, hospitals may have adjusted the mix of health care provided and the selection of patients treated by prioritizing certain patient groups (triage), decentralizing care (hospital type or region) or substituting surgical for non-surgical treatment (particularly through increased use of pharmacologic alternatives).

Therefore, this study adds to existing research by focusing on the efforts made to minimize patient harm, using national-level claims data from 2017 through 2022. We explore this using changes in treatment delivery. This analysis offers insight into how the Dutch health system adapted benign gynecological care under pandemic conditions and informs the broader transition toward more resilient, appropriate, and sustainable care models in gynecology and beyond.

Methods

Results

A total of 323,946 patient records across the four care pathways were included for the years 2017–2022. Table 1 shows baseline characteristics for each pathway during this period.

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Table 1. Characteristics of care pathways per year.

https://doi.org/10.1371/journal.pone.0345619.t001

The care pathway for heavy menstrual bleeding had the largest volume of patients, while uterine fibroids had the smallest. In 2020 the volumes were lowest in all care pathways except first-trimester pregnancy problems. We see no deviation in 2020 from the pre-existing trend of either increasing or decreasing mean age over the years. Besides, the mean number of care activities per patient does not deviate from the trends in any of the pathways in 2020.

Table 2 shows the treatment mix of surgical and, if relevant, non-surgical treatment options within the care pathways. Shown are proportions of the treatment types on the total of all the included treatments combined within a pathway.

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Table 2. Treatment mix per care pathway per year.

https://doi.org/10.1371/journal.pone.0345619.t002

When examining the treatment patterns within the four different care pathways, it becomes apparent that in the pathways heavy menstrual bleeding and uterine fibroids all types of surgical treatment options either do not deviate from existing decreasing trends or are below expected trend levels in 2020. Looking at the non-surgical treatment options, we see a slight increase in proportion in 2020 for both types of hysteroscopy and insertion of IUDs in the heavy menstrual bleeding pathway. In the uterine fibroids pathway, we see an increase in the insertion of IUDs, therapeutic hysteroscopies and uterine artery embolization in 2020. In the years 2021 and 2022 we see an increase in both pathways in the use of hysteroscopic myomectomies and in the heavy menstrual bleeding pathway of diagnostic laparoscopies as well.

In the prolapse pathway we only looked at surgical treatment options. We can see a shift in treatment mix towards more Anterior&Posterior (A&P) colporrhaphy and vaginal vault suspensions in 2020, while the combined A&P colporrhaphy procedures, mid-urethral sling (TVT/TOT) placements and sacro colpopexies remained stable or decreased in proportion. In the following years, the proportions of enterocele repair, sacro colpopexy in combination with A&P colporrhaphy and the A&P colporrhaphy in combination with cervical amputation rose in proportion.

In the first trimester pregnancy complications pathway an increase was seen in the proportion of hysteroscopies and ectopic pregnancy surgeries in 2020. In the years 2021 and 2022 the proportion of uterine curettage increased again. A decreasing trend is seen over the years of surgical abortion.

Additionally, we looked at changes in treatment mix within regions across the Netherlands during the study period (see S1 Tables A – D in S1 File). All three regions in our pathways show roughly the same patterns in treatment use across the years, however there are some differences between the regions within the pathways in 2020. In the pathway heavy menstrual bleeding, we see proportionally more diagnostic hysteroscopies in regions middle and south, while we see more therapeutic hysteroscopies in north, combined with fewer diagnostic laparoscopies. In the uterine fibroids pathway, more diagnostic hysteroscopies and myomectomies are seen in region north. In region south we see more therapeutic hysteroscopies in 2020. In region middle, the proportion of hysteroscopic myomectomies type b is increased. In the prolapse pathway, the proportion of vaginal hysterectomies was lower in region north. Region middle showed a higher proportion in total laparoscopic hysterectomies and region south had higher proportion of vaginal vault suspension, while showing lower proportion of A&P colporrhaphy. The pathway first trimester pregnancy complications only showed a differentiation in the proportion of open surgery for ectopic pregnancy, which was higher in the middle region.

The proportion of medication use per year does not differ significantly from pre-pandemic levels during the COVID-19 pandemic (Fig 1). A small increase in use is observed in 2020 for the uterine fibroids pathway compared to the previous year (2019) and the following year (2021). However, the proportion is still in line with the pre-existing trend.

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Fig 1. Percentage of medication use over all patients in a care pathway per year.

https://doi.org/10.1371/journal.pone.0345619.g001

We see a trend towards more telephone follow-up consultations instead of physical follow-ups over the years (Fig 2). A significant deviation in this shift is seen in the year 2020 in all four pathways. Most increase is seen in the first trimester pregnancy complications pathway (19%) and least in the uterine fibroids pathway (9%) compared to proportions of 2019. This means that telephone consultations became much more prevalent after COVID and that this trend persisted for heavy menstrual bleeding.

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Fig 2. Proportion of telephone and physical follow-up consultations per year across all four care pathways (2017–2022).

The colored area represents the percentage of telephone consultations, and the area below the line represents the percentage of physical consultations.

https://doi.org/10.1371/journal.pone.0345619.g002

When looking at the types of hospitals where patients received care, we see that most care is delivered in both top clinical hospitals and peripheral hospitals in all four care pathways (Fig 3). Besides, we see a slight increase in proportion over the years in all four pathways toward care delivery in ITC’s, compensating for a decrease in care delivery in academic hospitals. No significant changes in proportions of hospital type were observed in any of the four care pathways within the study period.

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Fig 3. Distribution of hospital types providing care, expressed as proportion of total care per year across four benign gynecological pathways (2017–2022).

https://doi.org/10.1371/journal.pone.0345619.g003

Discussion

This nationwide study investigates how benign gynecological care delivery in the Netherlands was reshaped during the COVID-19 pandemic to mitigate patient harm under conditions of acute resource scarcity. We examined how the health system adjusted treatment modalities, care intensity and care settings across four clinical pathways. Treatment mix changed during the COVID-19 pandemic, but not uniformly across the four pathways or years. While some shifts toward less invasive or outpatient alternatives were visible, particularly in the management of heavy menstrual bleeding and uterine fibroids, most surgical procedures followed existing trends or declined. In prolapse care, we observed internal shifts within surgical options. Overall, medication use did not significantly differ from pre-pandemic levels. Telephone consultations increased sharply in 2020, particularly for first trimester pregnancy complications (19%) and this shift persisted for heavy menstrual bleeding. We found no regional differences in treatment mixes. Patterns of care delivery across hospital types remained stable, with most care provided in top-clinical and peripheral hospitals. A modest increase in care delivery within ITCs was seen across pathways, compensating for a slight decrease in care within academic hospitals. We found that while overall care volumes declined, patterns of care delivery were largely stable. These findings suggest that system adaptations were limited and mostly aimed at maintaining continuity rather than transforming care delivery on a broader scale.

Across all pathways, patient age and care intensity (mean number of care activities) remained stable, indicating that hospitals continued to serve a similar patient population, without shifting toward more urgent or complex cases. This stability is important, as it suggests that any observed shifts in treatment delivery reflect changes in system-level response rather than shifts in our patient population itself [33]. Our findings align with previous findings that indicated care avoidance and deferral rather than redistribution during the pandemic [16,18,34,35].

Our analysis of treatment mixes in the different pathways show that only limited shifts occurred during the initial COVID-19 period. While guidelines at the time encouraged the use of less resource-intensive treatments when possible [11,36,37], our findings suggest that such substitutions were not widely implemented. This may reflect the reality that many hospitals redirected capacity almost entirely to acute and COVID-related care, leaving little room for proactive restructuring of benign services [38]. Moreover, Dutch clinical guidelines for benign gynaecology permit considerable clinical discretion, allowing physicians, within reason, to deviate from recommended surgical pathways based on patient-specific factors, preferences, and shared decision-making. Compared to more centrally regulated healthcare systems, the Netherlands affords clinicians relatively high professional autonomy in treatment decisions, which may have further enabled selective rather than systematic substitution during capacity constraints. Even in the post-acute phase of the pandemic, the reorganization of benign gynecological care appears to have progressed only gradually. This limited restructuring likely reflects persistent uncertainty regarding the consequences of deferred or modified care, including potential impacts on waiting times, quality of life, and long-term outcomes. At that time, evidence was lacking to determine whether postponing or substituting procedures could be safely generalized beyond the crisis context. Additionally, it remains unclear to what extent primary care providers, such as general practitioners, were able to absorb deferred patient demand or whether substantial unmet needs persisted. Further investigation into these dynamics is warranted, as they may inform the evolution of care pathways and guideline development in post-pandemic health systems [1].

Notable changes included increased use of telephone consultations, which may have allowed continued clinical engagement despite reduced physical access. It is in line with earlier published articles about the increased use of telehealth [39–41]. This suggests that outpatient visits and follow-up adapted rapidly to pandemic constraints and could provide a model for reducing unnecessary physical visits in the future.

We investigated whether treatment mix changes were geographically patterned, reflecting the variable impact of COVID-19 across Dutch regions. Regional differences in infection rates and ICU occupancy during the pandemic have been well documented [42–44]. It is likely that hospitals in regions with higher COVID-19 burdens were forced to defer or redirect more elective care, such as benign gynecological care. For instance, the southern provinces, including Noord-Brabant and Limburg, experienced high ICU pressure during early pandemic waves, which may have prompted more aggressive triage and substitution compared to less affected regions. However, we did not observe substantial regional variation in treatment mix. This may reflect the uniformly applied deferral policy and the equal distribution of COVID-19 hospitalized patients nationwide [43–45].

We also assessed the hospital type – academic medical centers, top-clinical hospitals, general hospitals and ITCs – on the extent of care modification. Academic hospitals played a central role in pandemic response. They were likely to reallocate operating rooms, anesthesia personnel, and ward capacity to COVID-related care, thereby reducing availability for elective gynecological procedures [4,46]. In contrast, ITCs, which typically do not have emergency or ICU capacity and are focused on elective procedures, may have been less disrupted. Indeed, Dutch health authorities encouraged the use of ITCs during later phases of the pandemic to manage backlogs and restore access to deferred care [39,47,48]. Our results show that care delivery remained stable across all four care pathways. Only a minor increase for ITCs was seen over the years, taking over from academic hospitals, with no significant increase in the initial COVID-19 phase. This suggests that ITCs—despite being less involved in acute COVID care—were not consistently leveraged to absorb overflow [4]. This finding echoes concerns that system-level integration of ITCs remains suboptimal, particularly during periods of constrained capacity [49].

Taken together, our findings suggest that the Dutch health system prioritized continuity within pathways rather than radical reorganization. Efforts to minimize harm focused on preserving existing access where possible, rather than shifting care between settings or modalities. While this conservative approach may have protected core services, it also highlights missed opportunities to trial alternative, potentially more sustainable forms of care under real-world constraints.

Although our analyses focused on benign gynaecologic care, the underlying mechanisms are likely not unique to this specialty. The care we studied largely concerned planned, non‑urgent procedures and consultations, where alternative treatment options, potential substitution or shifting care towards primary care are already part of routine decision‑making. It is therefore plausible that similar patterns of limited restructuring and an emphasis on continuity rather than transformation would be observed in other forms of elective, non‑life‑threatening care in which shared decision‑making about treatment options is common. At the same time, generalizability to settings involving life‑threatening conditions, severe morbidity, or the absence of evidence‑based alternatives in primary care may be limited, as perceived urgency, acceptable risk, and ethical considerations differ fundamentally in those contexts. Future research should examine whether and how care delivery adaptations during crises differ between elective and urgent care pathways, and across other medical disciplines.

This study adds to ongoing discussions about the resilience of elective care and its readiness to adapt under pressure [19,20]. Rather than large-scale innovation or substitution, we observed small, pragmatic adjustments, such as increased teleconsultations and limited decentralization. These experiences provide insight into the strengths and constraints of current care models and offer valuable lessons for improving flexibility and preparedness [50].

Conclusion

While the COVID-19 pandemic severely restricted surgical capacity for benign gynecological care in the Netherlands, we observed little in the way of strategic triage to select patients who stood to benefit most from the remaining capacity. Our findings suggest that the Dutch healthcare system focused on preserving continuity rather than restructuring care delivery. Targeted adaptations, such as the use of telephone consultations and outpatient alternatives, may have helped minimize patient harm, but broader system flexibility was limited. As future shocks and ongoing capacity constraints loom, building a more responsive care model will be essential to protect access to and quality of care for all patient groups.

Supporting information