Dutch hospitals show wide variation in pelvic floor care

Hospitals in the Netherlands differ markedly in how they diagnose and treat pelvic floor disorders, with the largest gaps appearing in diagnostic testing and surgery, according to a nationwide analysis that combined clinical guidance, doctors’ expectations and insurance claims. The findings concern pelvic organ prolapse and the three main forms of urinary incontinence examined in the study: stress urinary incontinence, urge urinary incontinence and mixed urinary incontinence. The work did not determine that any hospital provided harmful care. Instead, it identified differences that specialists themselves did not anticipate, raising questions about whether some variation is justified by differences in patients and whether other differences reflect inconsistent care.

Pelvic organ prolapse occurs when pelvic organs descend from their normal position, while urinary incontinence involves involuntary urine leakage. Both conditions are common and can require an assortment of assessments and interventions, from conservative management and medication to surgery and electrical nerve stimulation. Such options make a shared clinical framework important, but the new research suggests that hospital practice can diverge sharply even when specialists agree broadly on how many procedures should occur. The authors say the results provide a practical method for finding areas where hospital-level consistency may be improving or requires closer review.

The researchers used a mixed-methods design spanning 90 combinations of diagnoses, procedures and medical specialties. They systematically assessed Dutch clinical practice guidelines, mapped what specialists expected in terms of treatment volumes and variation between hospitals, and then compared those expectations with actual patterns in nationwide claims data. The claims analysis was cross-sectional, providing a snapshot rather than following patients over time. Two complementary measures quantified differences: coefficients of variation, which describe dispersion around the average, and treatment rate ratios, which compare rates in hospitals with the highest activity against those with the lowest.

Variation was substantial in both diagnosis and surgery. For diagnostic procedures, coefficients of variation ranged from 0.4 to 2.7, while treatment rate ratios ranged from 5.1 to 94.7. That upper ratio means the rate of a diagnostic procedure could be almost 95 times higher at the high end than at the low end of the hospital distribution. Surgical procedures also showed wide differences, with coefficients of variation of 0.6 to 2.9 and treatment rate ratios of 4.0 to 33.9. In other words, a patient’s chances of receiving a particular test or operation could depend considerably on which hospital she or he visited.

Clinical guidelines were the study’s main candidate explanation. Recommendations can standardize who should receive a diagnostic test, which procedures are appropriate and how treatment choices should be made, thereby reducing the scope for hospitals to diverge. Yet the analysis found that 54% of the 90 treatment combinations had no guideline recommendation. The result is important because a substantial part of routine pelvic floor care operates in areas where clinicians are not given a single, explicit standard to follow. Even where recommendations exist, the evidence did not reveal a simple, universal relationship between how clear the guidance is and how much hospitals vary.

There were important condition-specific exceptions. For both stress and urge urinary incontinence, procedures supported by clear recommendations were associated with less variation between hospitals. The same pattern was not observed for pelvic organ prolapse, where practice differences remained even when guidance was available. This distinction suggests that a guideline’s presence alone is not enough to produce uniformity. Recommendation clarity may matter, but implementation, local organizational capacity, patient selection and the interpretation of clinical evidence can also shape how a procedure is used. The observational data cannot establish which of these factors directly caused the differences.

Doctors’ forecasts revealed another layer of the problem. Specialists were generally accurate when estimating how many cases or procedures hospitals would handle, suggesting that they had a good grasp of overall workload. They were much less accurate at predicting the degree of practice variation between institutions. In other words, clinicians may know the scale of a service without recognizing how differently that service is delivered across the country. Such a blind spot matters because routine professional experience is often drawn from a handful of hospitals and may not capture the full national picture.

The study’s combination of methods is its most consequential feature. Claims data reveal what happened in practice, but by themselves they cannot show whether the resulting patterns are appropriate. Specialist expectations provide a reference point for identifying differences that the profession may not have anticipated. Guideline analysis then helps determine whether a particular practice falls into a well-defined standard, an underspecified area or a domain where recommendations exist but have not produced consistency. Linking these three sources does not automatically label a hospital as an outlier or an outlier as wrong, but it can prioritize cases for clinical review and quality-improvement work.

For patients, the practical implication is that hospital choice may matter more than expected in pelvic floor care. The results do not mean that every difference in treatment is undesirable: hospitals may serve populations with different ages, comorbidities, severity, prior treatments or preferences, and those differences can legitimately affect what clinicians do. But the scale of the reported disparities means that raw differences cannot simply be assumed to reflect patient mix. Some may be warranted, while others could reflect divergent referral patterns, inconsistent thresholds for testing and surgery, or uneven adoption of treatments.

The authors emphasize that the framework can help distinguish unwarranted variation from justified clinical difference and direct interventions toward areas where care quality may be improved. More complete recommendations could address the many combinations now lacking guidance, while clearer implementation pathways might help hospitals apply existing advice consistently. The study was funded by the Foundation for Quality Funds for Medical Specialists, which was jointly governed by the federation of medical specialists and an umbrella organization representing health-care insurers; the funders had no role in conducting the research or publishing it.

What the analysis ultimately reveals is a common health-systems paradox: a condition can be well known, clinically studied and supported by a national network of specialists while still being treated quite differently from one hospital to another. For pelvic floor disorders, clear guidance was associated with more consistent care in some forms of urinary incontinence, but the effect did not extend across every diagnosis. The next challenge is to move beyond counting differences and determine which ones matter for outcomes, access and patient experience, then use that knowledge to make care more predictable without suppressing clinically justified customization.

Subject of Research: Hospital practice variation in the diagnosis and treatment of pelvic organ prolapse and urinary incontinence

Article Title: Practice variation in hospital care for pelvic organ prolapse and urinary incontinence: an analysis of specialists’ expectations, cross-sectional claims data, and the role of clinical guidelines

Article References: Loop, S. J. L. M., Stam, P. J. A., Stadhouders, N., Mostovaya, I., van Barneveld, T., Engberts, M. K., van Eijndhoven, H. W. F., Veen, J., Hermans, K. E. P. E., & van der Hijden, E. J. E. (2026). Practice variation in hospital care for pelvic organ prolapse and urinary incontinence: an analysis of specialists’ expectations, cross-sectional claims data, and the role of clinical guidelines. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15634-4

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15634-4

Keywords: pelvic floor disorders, pelvic organ prolapse, urinary incontinence, practice variation, clinical guidelines, hospital care, claims data, urogynecology, health services research, quality improvement, Practice, variation