key: cord-0772640-1161eblq
authors: BOLLMANN, A.; Hohenstein, S.; Pellissier, V.; Koenig, S.; Ueberham, L.; Hindricks, G.; Meier-Hellmann, A.; Kuhlen, R.
title: Hospitalizations for emergency-sensitive conditions in Germany during the Covid-19 pandemic - Insights from the German-wide Helios hospital network
date: 2021-02-11
journal: nan
DOI: 10.1101/2021.02.08.21250309
sha: c71945996d5c06db04063fc1cb3a0da1c28c80d9
doc_id: 772640
cord_uid: 1161eblq

Background: While there are numerous reports that describe emergency care during the early Covid-19 pandemic, there is scarcity of data for later stages. This study analyzes hospitalization rates for 37 emergency-sensitive conditions in the largest German-wide hospital network during different pandemic phases. Methods: Using claims data of 80 hospitals, consecutive cases between January 1 and November 17, 2020 were analyzed and compared to a corresponding period in 2019. Incidence-rate ratios (IRR) comparing the both periods were calculated using Poisson regression to model the number of hospitalizations per day. Results: There was a hospitalization deficit between March 12 and June 13, 2020 (coinciding with the 1st pandemic wave) with 32,807 hospitalizations as opposed to 39,379 in 2019 (IRR 0.83, 95% CI 0.82-0.85, P<0.01). During the following period (June 14 to November 17, 2020, including the start of 2nd wave), hospitalizations were reduced from 63,799 in 2019 to 59,910 in 2020, but this reduction was not that pronounced (IRR 0.94, 95% CI 0.93-0.95, P<0.01). There was an increase in hospitalizations for acute myocardial infarction, aortic aneurism/dissection and pulmonary embolism after the 1st wave during which hospitalizations had been reduced for those conditions. In contrast, hospitalizations for sepsis, pneumonia, obstructive pulmonary disease, and intracranial injuries were reduced during the entire pandemic. Conclusions: There was an overall reduction of hospitalizations for emergency-sensitive conditions in Germany during the Covid-19 pandemic with heterogeneous effects on different disease categories. The increase of hospitalizations for acute myocardial infarction, aortic aneurism/dissection and pulmonary embolism is an alarming signal that requires attention and further studies.

What is already known on this subject • There has been a reduction in emergency room visits and hospital admissions for several emergent medical and surgical conditions during the early Covid-19 pandemic (1 st wave).

• Using claims data of 80 German-wide Helios hospitals, we found an overall reduction of hospitalizations for emergency-sensitive conditions in Germany during the Covid-19 pandemic until mid November 2020 with heterogeneous effects on different disease categories. While hospitalizations for sepsis, pneumonia, obstructive pulmonary disease, and intracranial injuries were reduced during the entire pandemic.

There was an alarming increase of hospitalizations for acute myocardial infarction, aortic aneurism/dissection and pulmonary embolism after the 1 st wave.

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The copyright holder for this preprint this version posted February 11, 2021.

While there are numerous reports that describe emergency calls, 1 emergency room visits 2 and hospital admissions 3-6 for several medical and surgical conditions during the early Covid-19 pandemic (1 st wave), there is scarcity of data during later pandemic stages (e.g. 2 nd wave, period between waves). In addition, a comprehensive overview covering previously defined emergency-sensitive conditions 7 is also missing.

With this study, we wish to complement previous reports by providing and comparing hospitalization data for patients with emergency-sensitive conditions hospitalized in a large German-wide hospital network during different pandemic phases.

We performed a retrospective analysis of claims data of 80 Helios hospitals in Germany.

Consecutive cases with an emergent hospital admission between January 1 and November 17, 2020 (study period) were analyzed and compared to a corresponding period covering the (Table 1) . 7 Cases with confirmed Covid-19 infection (U07.1) were not excluded from this analysis. This study was approved by the Ethics Committee at the Medical Faculty, Leipzig University (#490/20-ek). Due to the retrospective study of anonymized data informed consent was not obtained. Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Administrative data were extracted from QlikView (QlikTech, Radnor, Pennsylvania, USA).

Incidence rates for admissions were calculated by dividing the number of cumulative admissions by the number of days for each time period. Incidence-rate ratios (IRR) comparing the study period to the control period were calculated using Poisson regression to model the number of hospitalizations per day. Inferential statistics were based on generalized linear mixed models (GLMM) specifying hospitals as random factor. We report IRR (calculated by exponentiation of the regression coefficients) together with 95% confidence intervals (CI) for the comparisons of the two periods and P values for the interactions. For all tests we apply a two-tailed 5% error criterion for significance. Hospitalizations for the individual emergency-sensitive conditions stratified for both periods are summarized in Table 1 showing a heterogeneous pattern. Of note, despite the inclusion of Covid-19 cases, hospitalizations with sepsis, pneumonia, obstructive pulmonary disease, and intracranial injuries as primary diagnosis were reduced during the entire pandemic. Similarly, . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 

This study was performed in the largest German-wide hospital network serving about 10% of the German population by analyzing emergency-sensitive conditions from claims data. This comprehensive list 7 has been suggested for the assessment of the acute care system but modifications (e.g. expansion of definitions for unspecific pneumonia, J18) may be warranted. 8 We found an initial reduction in several emergency-sensitive conditions including myocardial infarction, heart failure, diabetes mellitus, or pancreatitis that is in agreement with previous studies. 2-6 Those observations corresponded with the initiation of national public health emergency measures, and this decline persisted for several weeks. On the one hand, there may be a true reduction in the incidence of emergencies as a result of lower physical or psychological stress, improved medication adherence, diminished air pollution, traffic, and infectious disease transmission, or better outpatient care delivery models. In fact, the consistently lower rates of exacerbations of respiratory conditions, or traumatic intracranial injuries support this hypothesis. On the other hand, it is the possibility that patients were reluctant to seek medical attention due to fear of contagion at the hospital. In addition, the emphasis on social distancing might have inappropriately persuaded patients to avoid in-. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 11, 2021. ; https://doi.org/10.1101/2021.02.08.21250309 doi: medRxiv preprint person medical care. While this reduction was pronounced during the 1 st wave and effected multiple conditions, hospitalizations for the majority of those resumed to previous year levels during later pandemic phases.

Of special concern is the increased incidence of hospitalizations for acute myocardial infarction, aortic aneurism and dissection as well as pulmonary embolism. While the former may be a result of reduced cardiovascular care during the early pandemic, 5,6 the latter could also be associated with preceding Covid-19 infections. 9 If the increased incidence of hospitalizations for acute myocardial infarction, aortic dissection and pulmonary embolism is a signal for a rising incidence of those conditions in the public, this could at least in part explain the observed excess mortality in Germany between late July and mid October 2020. 10 Those alarming signals require immediate attention and further studies.

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 11, 2021. ; . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 11, 2021. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 11, 2021. 

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted February 11, 2021. ; https://doi.org/10.1101/2021.02.08.21250309 doi: medRxiv preprint ischemic heart disease (I24) as well as cerebral infarction (I63) and unspecified stroke (I64) since case volume for I24 and I64 was < 10.

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted February 11, 2021. ; https://doi.org/10.1101/2021.02.08.21250309 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 11, 2021. 

Emergency medical services calls during Italy's COVID-19