Impact of the COVID-19 pandemic on surgical care in the Netherlands
Abstract Background The COVID-19 pandemic caused disruption of regular healthcare leading to reduced hospital attendances, repurposing of surgical facilities, and cancellation of cancer screening programmes. This study aimed to determine the impact of COVID-19 on surgical care in the Netherlands. Me...
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| Veröffentlicht in: | British journal of surgery 2022-11, Vol.109 (12), p.1282-1292 |
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| creator | de Graaff, Michelle R Hogenbirk, Rianne N M Janssen, Yester F Elfrink, Arthur K E Liem, Ronald S L Nienhuijs, Simon W de Vries, Jean-Paul P M Elshof, Jan-Willem Verdaasdonk, Emiel Melenhorst, Jarno van Westreenen, H L Besselink, Marc G H Ruurda, Jelle P van Berge Henegouwen, Mark I Klaase, Joost M den Dulk, Marcel van Heijl, Mark Hegeman, Johannes H Braun, Jerry Voeten, Daan M Würdemann, Franka S Warps, Anne-Loes K Alberga, Anna J Suurmeijer, J Annelie Akpinar, Erman O Wolfhagen, Nienke van den Boom, Anne Loes Bolster-van Eenennaam, Marieke J van Duijvendijk, Peter Heineman, David J Wouters, Michel W J M Kruijff, Schelto |
| description | Abstract
Background
The COVID-19 pandemic caused disruption of regular healthcare leading to reduced hospital attendances, repurposing of surgical facilities, and cancellation of cancer screening programmes. This study aimed to determine the impact of COVID-19 on surgical care in the Netherlands.
Methods
A nationwide study was conducted in collaboration with the Dutch Institute for Clinical Auditing. Eight surgical audits were expanded with items regarding alterations in scheduling and treatment plans. Data on procedures performed in 2020 were compared with those from a historical cohort (2018–2019). Endpoints included total numbers of procedures performed and altered treatment plans. Secondary endpoints included complication, readmission, and mortality rates.
Results
Some 12 154 procedures were performed in participating hospitals in 2020, representing a decrease of 13.6 per cent compared with 2018–2019. The largest reduction (29.2 per cent) was for non-cancer procedures during the first COVID-19 wave. Surgical treatment was postponed for 9.6 per cent of patients. Alterations in surgical treatment plans were observed in 1.7 per cent. Time from diagnosis to surgery decreased (to 28 days in 2020, from 34 days in 2019 and 36 days in 2018; P < 0.001). For cancer-related procedures, duration of hospital stay decreased (5 versus 6 days; P < 0.001). Audit-specific complications, readmission, and mortality rates were unchanged, but ICU admissions decreased (16.5 versus 16.8 per cent; P < 0.001).
Conclusion
The reduction in the number of surgical operations was greatest for those without cancer. Where surgery was undertaken, it appeared to be delivered safely, with similar complication and mortality rates, fewer admissions to ICU, and a shorter hospital stay.
During the COVID-19 pandemic, a 13.6 per cent reduction in the number of surgical procedures performed was observed in 2020. Despite great pressure on healthcare, the COVID-19 pandemic did not cause an increase in adverse surgical outcomes, and oncological surgery-related duration of hospital and ICU stay were significantly shorter.
Lay Summary
COVID-19 has had a significant impact on healthcare worldwide. Hospital visits were reduced, operating facilities were used for COVID-19 care, and cancer screening programmes were cancelled. This study describes the impact of the COVID-19 pandemic on Dutch surgical healthcare in 2020. Patterns of care in terms of changed or delayed treatment are described for patients |
| doi_str_mv | 10.1093/bjs/znac301 |
| format | Article |
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Background
The COVID-19 pandemic caused disruption of regular healthcare leading to reduced hospital attendances, repurposing of surgical facilities, and cancellation of cancer screening programmes. This study aimed to determine the impact of COVID-19 on surgical care in the Netherlands.
Methods
A nationwide study was conducted in collaboration with the Dutch Institute for Clinical Auditing. Eight surgical audits were expanded with items regarding alterations in scheduling and treatment plans. Data on procedures performed in 2020 were compared with those from a historical cohort (2018–2019). Endpoints included total numbers of procedures performed and altered treatment plans. Secondary endpoints included complication, readmission, and mortality rates.
Results
Some 12 154 procedures were performed in participating hospitals in 2020, representing a decrease of 13.6 per cent compared with 2018–2019. The largest reduction (29.2 per cent) was for non-cancer procedures during the first COVID-19 wave. Surgical treatment was postponed for 9.6 per cent of patients. Alterations in surgical treatment plans were observed in 1.7 per cent. Time from diagnosis to surgery decreased (to 28 days in 2020, from 34 days in 2019 and 36 days in 2018; P < 0.001). For cancer-related procedures, duration of hospital stay decreased (5 versus 6 days; P < 0.001). Audit-specific complications, readmission, and mortality rates were unchanged, but ICU admissions decreased (16.5 versus 16.8 per cent; P < 0.001).
Conclusion
The reduction in the number of surgical operations was greatest for those without cancer. Where surgery was undertaken, it appeared to be delivered safely, with similar complication and mortality rates, fewer admissions to ICU, and a shorter hospital stay.
During the COVID-19 pandemic, a 13.6 per cent reduction in the number of surgical procedures performed was observed in 2020. Despite great pressure on healthcare, the COVID-19 pandemic did not cause an increase in adverse surgical outcomes, and oncological surgery-related duration of hospital and ICU stay were significantly shorter.
Lay Summary
COVID-19 has had a significant impact on healthcare worldwide. Hospital visits were reduced, operating facilities were used for COVID-19 care, and cancer screening programmes were cancelled. This study describes the impact of the COVID-19 pandemic on Dutch surgical healthcare in 2020. Patterns of care in terms of changed or delayed treatment are described for patients who had surgery in 2020, compared with those who had surgery in 2018–2019. The study found that mainly non-cancer surgical treatments were cancelled during months with high COVID-19 rates. Outcomes for patients undergoing surgery were similar but with fewer ICU admissions and shorter hospital stay. These data provide no insight into the burden endured by patients who had postponed or cancelled operations.</description><identifier>ISSN: 0007-1323</identifier><identifier>EISSN: 1365-2168</identifier><identifier>DOI: 10.1093/bjs/znac301</identifier><identifier>PMID: 36811624</identifier><language>eng</language><publisher>US: Oxford University Press</publisher><subject>COVID-19 ; Hospitalization ; Hospitals ; Humans ; Netherlands ; Original ; Pandemics</subject><ispartof>British journal of surgery, 2022-11, Vol.109 (12), p.1282-1292</ispartof><rights>The Author(s) 2022. Published by Oxford University Press on behalf of BJS Society Ltd. 2022</rights><rights>The Author(s) 2022. Published by Oxford University Press on behalf of BJS Society Ltd.</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c377t-751014bcf32456af0ec39a5191de460ac02827ff5b1ea70aa5e11ff22be1b7cb3</citedby><orcidid>0000-0002-6161-161X ; 0000-0003-2972-5622 ; 0000-0002-2669-320X ; 0000-0002-1910-2723 ; 0000-0003-2188-2738 ; 0000-0001-5291-0688 ; 0000-0003-2332-2849 ; 0000-0002-7723-0256 ; 0000-0002-0165-5995 ; 0000-0001-5896-744X ; 0000-0003-0943-895X ; 0000-0001-6584-1677 ; 0000-0001-5778-6954 ; 0000-0002-5151-7320 ; 0000-0002-5434-850X ; 0000-0002-0441-6180 ; 0000-0002-2168-294X ; 0000-0002-4409-2280 ; 0000-0003-4292-6795 ; 0000-0003-2650-9350 ; 0000-0002-9070-3214 ; 0000-0001-6173-0662 ; 0000-0002-6500-8738 ; 0000-0002-0104-9477 ; 0000-0002-1495-4003 ; 0000-0003-1271-3780 ; 0000-0002-5502-964X ; 0000-0001-8689-3134 ; 0000-0002-4504-6235</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><link.rule.ids>230,314,776,780,881,1578,27901,27902</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/36811624$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>de Graaff, Michelle R</creatorcontrib><creatorcontrib>Hogenbirk, Rianne N M</creatorcontrib><creatorcontrib>Janssen, Yester F</creatorcontrib><creatorcontrib>Elfrink, Arthur K E</creatorcontrib><creatorcontrib>Liem, Ronald S L</creatorcontrib><creatorcontrib>Nienhuijs, Simon W</creatorcontrib><creatorcontrib>de Vries, Jean-Paul P M</creatorcontrib><creatorcontrib>Elshof, Jan-Willem</creatorcontrib><creatorcontrib>Verdaasdonk, Emiel</creatorcontrib><creatorcontrib>Melenhorst, Jarno</creatorcontrib><creatorcontrib>van Westreenen, H L</creatorcontrib><creatorcontrib>Besselink, Marc G H</creatorcontrib><creatorcontrib>Ruurda, Jelle P</creatorcontrib><creatorcontrib>van Berge Henegouwen, Mark I</creatorcontrib><creatorcontrib>Klaase, Joost M</creatorcontrib><creatorcontrib>den Dulk, Marcel</creatorcontrib><creatorcontrib>van Heijl, Mark</creatorcontrib><creatorcontrib>Hegeman, Johannes H</creatorcontrib><creatorcontrib>Braun, Jerry</creatorcontrib><creatorcontrib>Voeten, Daan M</creatorcontrib><creatorcontrib>Würdemann, Franka S</creatorcontrib><creatorcontrib>Warps, Anne-Loes K</creatorcontrib><creatorcontrib>Alberga, Anna J</creatorcontrib><creatorcontrib>Suurmeijer, J Annelie</creatorcontrib><creatorcontrib>Akpinar, Erman O</creatorcontrib><creatorcontrib>Wolfhagen, Nienke</creatorcontrib><creatorcontrib>van den Boom, Anne Loes</creatorcontrib><creatorcontrib>Bolster-van Eenennaam, Marieke J</creatorcontrib><creatorcontrib>van Duijvendijk, Peter</creatorcontrib><creatorcontrib>Heineman, David J</creatorcontrib><creatorcontrib>Wouters, Michel W J M</creatorcontrib><creatorcontrib>Kruijff, Schelto</creatorcontrib><creatorcontrib>Dutch CovidSurg Collaborative Study Group</creatorcontrib><title>Impact of the COVID-19 pandemic on surgical care in the Netherlands</title><title>British journal of surgery</title><addtitle>Br J Surg</addtitle><description>Abstract
Background
The COVID-19 pandemic caused disruption of regular healthcare leading to reduced hospital attendances, repurposing of surgical facilities, and cancellation of cancer screening programmes. This study aimed to determine the impact of COVID-19 on surgical care in the Netherlands.
Methods
A nationwide study was conducted in collaboration with the Dutch Institute for Clinical Auditing. Eight surgical audits were expanded with items regarding alterations in scheduling and treatment plans. Data on procedures performed in 2020 were compared with those from a historical cohort (2018–2019). Endpoints included total numbers of procedures performed and altered treatment plans. Secondary endpoints included complication, readmission, and mortality rates.
Results
Some 12 154 procedures were performed in participating hospitals in 2020, representing a decrease of 13.6 per cent compared with 2018–2019. The largest reduction (29.2 per cent) was for non-cancer procedures during the first COVID-19 wave. Surgical treatment was postponed for 9.6 per cent of patients. Alterations in surgical treatment plans were observed in 1.7 per cent. Time from diagnosis to surgery decreased (to 28 days in 2020, from 34 days in 2019 and 36 days in 2018; P < 0.001). For cancer-related procedures, duration of hospital stay decreased (5 versus 6 days; P < 0.001). Audit-specific complications, readmission, and mortality rates were unchanged, but ICU admissions decreased (16.5 versus 16.8 per cent; P < 0.001).
Conclusion
The reduction in the number of surgical operations was greatest for those without cancer. Where surgery was undertaken, it appeared to be delivered safely, with similar complication and mortality rates, fewer admissions to ICU, and a shorter hospital stay.
During the COVID-19 pandemic, a 13.6 per cent reduction in the number of surgical procedures performed was observed in 2020. Despite great pressure on healthcare, the COVID-19 pandemic did not cause an increase in adverse surgical outcomes, and oncological surgery-related duration of hospital and ICU stay were significantly shorter.
Lay Summary
COVID-19 has had a significant impact on healthcare worldwide. Hospital visits were reduced, operating facilities were used for COVID-19 care, and cancer screening programmes were cancelled. This study describes the impact of the COVID-19 pandemic on Dutch surgical healthcare in 2020. Patterns of care in terms of changed or delayed treatment are described for patients who had surgery in 2020, compared with those who had surgery in 2018–2019. The study found that mainly non-cancer surgical treatments were cancelled during months with high COVID-19 rates. Outcomes for patients undergoing surgery were similar but with fewer ICU admissions and shorter hospital stay. 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Hogenbirk, Rianne N M ; Janssen, Yester F ; Elfrink, Arthur K E ; Liem, Ronald S L ; Nienhuijs, Simon W ; de Vries, Jean-Paul P M ; Elshof, Jan-Willem ; Verdaasdonk, Emiel ; Melenhorst, Jarno ; van Westreenen, H L ; Besselink, Marc G H ; Ruurda, Jelle P ; van Berge Henegouwen, Mark I ; Klaase, Joost M ; den Dulk, Marcel ; van Heijl, Mark ; Hegeman, Johannes H ; Braun, Jerry ; Voeten, Daan M ; Würdemann, Franka S ; Warps, Anne-Loes K ; Alberga, Anna J ; Suurmeijer, J Annelie ; Akpinar, Erman O ; Wolfhagen, Nienke ; van den Boom, Anne Loes ; Bolster-van Eenennaam, Marieke J ; van Duijvendijk, Peter ; Heineman, David J ; Wouters, Michel W J M ; Kruijff, Schelto</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c377t-751014bcf32456af0ec39a5191de460ac02827ff5b1ea70aa5e11ff22be1b7cb3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2022</creationdate><topic>COVID-19</topic><topic>Hospitalization</topic><topic>Hospitals</topic><topic>Humans</topic><topic>Netherlands</topic><topic>Original</topic><topic>Pandemics</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>de Graaff, Michelle R</creatorcontrib><creatorcontrib>Hogenbirk, Rianne N M</creatorcontrib><creatorcontrib>Janssen, Yester F</creatorcontrib><creatorcontrib>Elfrink, Arthur K E</creatorcontrib><creatorcontrib>Liem, Ronald S L</creatorcontrib><creatorcontrib>Nienhuijs, Simon W</creatorcontrib><creatorcontrib>de Vries, Jean-Paul P M</creatorcontrib><creatorcontrib>Elshof, Jan-Willem</creatorcontrib><creatorcontrib>Verdaasdonk, Emiel</creatorcontrib><creatorcontrib>Melenhorst, Jarno</creatorcontrib><creatorcontrib>van Westreenen, H L</creatorcontrib><creatorcontrib>Besselink, Marc G H</creatorcontrib><creatorcontrib>Ruurda, Jelle P</creatorcontrib><creatorcontrib>van Berge Henegouwen, Mark I</creatorcontrib><creatorcontrib>Klaase, Joost M</creatorcontrib><creatorcontrib>den Dulk, Marcel</creatorcontrib><creatorcontrib>van Heijl, Mark</creatorcontrib><creatorcontrib>Hegeman, Johannes H</creatorcontrib><creatorcontrib>Braun, Jerry</creatorcontrib><creatorcontrib>Voeten, Daan M</creatorcontrib><creatorcontrib>Würdemann, Franka S</creatorcontrib><creatorcontrib>Warps, Anne-Loes K</creatorcontrib><creatorcontrib>Alberga, Anna J</creatorcontrib><creatorcontrib>Suurmeijer, J Annelie</creatorcontrib><creatorcontrib>Akpinar, Erman O</creatorcontrib><creatorcontrib>Wolfhagen, Nienke</creatorcontrib><creatorcontrib>van den Boom, Anne Loes</creatorcontrib><creatorcontrib>Bolster-van Eenennaam, Marieke J</creatorcontrib><creatorcontrib>van Duijvendijk, Peter</creatorcontrib><creatorcontrib>Heineman, David J</creatorcontrib><creatorcontrib>Wouters, Michel W J M</creatorcontrib><creatorcontrib>Kruijff, Schelto</creatorcontrib><creatorcontrib>Dutch CovidSurg Collaborative Study Group</creatorcontrib><collection>Oxford Journals Open Access Collection</collection><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>MEDLINE - Academic</collection><collection>PubMed Central (Full Participant titles)</collection><jtitle>British journal of surgery</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>de Graaff, Michelle R</au><au>Hogenbirk, Rianne N M</au><au>Janssen, Yester F</au><au>Elfrink, Arthur K E</au><au>Liem, Ronald S L</au><au>Nienhuijs, Simon W</au><au>de Vries, Jean-Paul P M</au><au>Elshof, Jan-Willem</au><au>Verdaasdonk, Emiel</au><au>Melenhorst, Jarno</au><au>van Westreenen, H L</au><au>Besselink, Marc G H</au><au>Ruurda, Jelle P</au><au>van Berge Henegouwen, Mark I</au><au>Klaase, Joost M</au><au>den Dulk, Marcel</au><au>van Heijl, Mark</au><au>Hegeman, Johannes H</au><au>Braun, Jerry</au><au>Voeten, Daan M</au><au>Würdemann, Franka S</au><au>Warps, Anne-Loes K</au><au>Alberga, Anna J</au><au>Suurmeijer, J Annelie</au><au>Akpinar, Erman O</au><au>Wolfhagen, Nienke</au><au>van den Boom, Anne Loes</au><au>Bolster-van Eenennaam, Marieke J</au><au>van Duijvendijk, Peter</au><au>Heineman, David J</au><au>Wouters, Michel W J M</au><au>Kruijff, Schelto</au><aucorp>Dutch CovidSurg Collaborative Study Group</aucorp><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Impact of the COVID-19 pandemic on surgical care in the Netherlands</atitle><jtitle>British journal of surgery</jtitle><addtitle>Br J Surg</addtitle><date>2022-11-22</date><risdate>2022</risdate><volume>109</volume><issue>12</issue><spage>1282</spage><epage>1292</epage><pages>1282-1292</pages><issn>0007-1323</issn><eissn>1365-2168</eissn><abstract>Abstract
Background
The COVID-19 pandemic caused disruption of regular healthcare leading to reduced hospital attendances, repurposing of surgical facilities, and cancellation of cancer screening programmes. This study aimed to determine the impact of COVID-19 on surgical care in the Netherlands.
Methods
A nationwide study was conducted in collaboration with the Dutch Institute for Clinical Auditing. Eight surgical audits were expanded with items regarding alterations in scheduling and treatment plans. Data on procedures performed in 2020 were compared with those from a historical cohort (2018–2019). Endpoints included total numbers of procedures performed and altered treatment plans. Secondary endpoints included complication, readmission, and mortality rates.
Results
Some 12 154 procedures were performed in participating hospitals in 2020, representing a decrease of 13.6 per cent compared with 2018–2019. The largest reduction (29.2 per cent) was for non-cancer procedures during the first COVID-19 wave. Surgical treatment was postponed for 9.6 per cent of patients. Alterations in surgical treatment plans were observed in 1.7 per cent. Time from diagnosis to surgery decreased (to 28 days in 2020, from 34 days in 2019 and 36 days in 2018; P < 0.001). For cancer-related procedures, duration of hospital stay decreased (5 versus 6 days; P < 0.001). Audit-specific complications, readmission, and mortality rates were unchanged, but ICU admissions decreased (16.5 versus 16.8 per cent; P < 0.001).
Conclusion
The reduction in the number of surgical operations was greatest for those without cancer. Where surgery was undertaken, it appeared to be delivered safely, with similar complication and mortality rates, fewer admissions to ICU, and a shorter hospital stay.
During the COVID-19 pandemic, a 13.6 per cent reduction in the number of surgical procedures performed was observed in 2020. Despite great pressure on healthcare, the COVID-19 pandemic did not cause an increase in adverse surgical outcomes, and oncological surgery-related duration of hospital and ICU stay were significantly shorter.
Lay Summary
COVID-19 has had a significant impact on healthcare worldwide. Hospital visits were reduced, operating facilities were used for COVID-19 care, and cancer screening programmes were cancelled. This study describes the impact of the COVID-19 pandemic on Dutch surgical healthcare in 2020. Patterns of care in terms of changed or delayed treatment are described for patients who had surgery in 2020, compared with those who had surgery in 2018–2019. The study found that mainly non-cancer surgical treatments were cancelled during months with high COVID-19 rates. Outcomes for patients undergoing surgery were similar but with fewer ICU admissions and shorter hospital stay. These data provide no insight into the burden endured by patients who had postponed or cancelled operations.</abstract><cop>US</cop><pub>Oxford University Press</pub><pmid>36811624</pmid><doi>10.1093/bjs/znac301</doi><tpages>11</tpages><orcidid>https://orcid.org/0000-0002-6161-161X</orcidid><orcidid>https://orcid.org/0000-0003-2972-5622</orcidid><orcidid>https://orcid.org/0000-0002-2669-320X</orcidid><orcidid>https://orcid.org/0000-0002-1910-2723</orcidid><orcidid>https://orcid.org/0000-0003-2188-2738</orcidid><orcidid>https://orcid.org/0000-0001-5291-0688</orcidid><orcidid>https://orcid.org/0000-0003-2332-2849</orcidid><orcidid>https://orcid.org/0000-0002-7723-0256</orcidid><orcidid>https://orcid.org/0000-0002-0165-5995</orcidid><orcidid>https://orcid.org/0000-0001-5896-744X</orcidid><orcidid>https://orcid.org/0000-0003-0943-895X</orcidid><orcidid>https://orcid.org/0000-0001-6584-1677</orcidid><orcidid>https://orcid.org/0000-0001-5778-6954</orcidid><orcidid>https://orcid.org/0000-0002-5151-7320</orcidid><orcidid>https://orcid.org/0000-0002-5434-850X</orcidid><orcidid>https://orcid.org/0000-0002-0441-6180</orcidid><orcidid>https://orcid.org/0000-0002-2168-294X</orcidid><orcidid>https://orcid.org/0000-0002-4409-2280</orcidid><orcidid>https://orcid.org/0000-0003-4292-6795</orcidid><orcidid>https://orcid.org/0000-0003-2650-9350</orcidid><orcidid>https://orcid.org/0000-0002-9070-3214</orcidid><orcidid>https://orcid.org/0000-0001-6173-0662</orcidid><orcidid>https://orcid.org/0000-0002-6500-8738</orcidid><orcidid>https://orcid.org/0000-0002-0104-9477</orcidid><orcidid>https://orcid.org/0000-0002-1495-4003</orcidid><orcidid>https://orcid.org/0000-0003-1271-3780</orcidid><orcidid>https://orcid.org/0000-0002-5502-964X</orcidid><orcidid>https://orcid.org/0000-0001-8689-3134</orcidid><orcidid>https://orcid.org/0000-0002-4504-6235</orcidid><oa>free_for_read</oa></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 0007-1323 |
| ispartof | British journal of surgery, 2022-11, Vol.109 (12), p.1282-1292 |
| issn | 0007-1323 1365-2168 |
| language | eng |
| recordid | cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_10364688 |
| source | Oxford University Press Journals All Titles (1996-Current); MEDLINE |
| subjects | COVID-19 Hospitalization Hospitals Humans Netherlands Original Pandemics |
| title | Impact of the COVID-19 pandemic on surgical care in the Netherlands |
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