key: cord-0985029-3ocg3cvs authors: Schwab, Jörg Otto; Wiese, Jan; Hauser, Tino title: The Influence of the 2020 COVID-19 Pandemic on the Implantation Rates of Cardiac Implantable Electronic Devices (CIEDs) in Germany date: 2021-11-29 journal: Eur Heart J Qual Care Clin Outcomes DOI: 10.1093/ehjqcco/qcab091 sha: 5f981625e58b7f3963b8f7a7a2f1d5e38a48b809 doc_id: 985029 cord_uid: 3ocg3cvs AIM: During the early phase of the COVID-19 pandemic, hospital admissions for several medical and surgical conditions have declined. Few data are available with respect to elective cardiac implantable electronic devices (CIEDs) implantation. The aim of the present study was to determine the impact of the COVID-19 pandemic on the monthly CIED implantation rates in Germany. METHODS AND RESULTS: The monthly rates of CIED implantation for the 2019 pre- and 2020 pandemic periods were retrieved from the “Institute für das Entgeltsystem im Krankenhaus” (InEK) using OPS codes to identify pacemakers (PMs), implantable cardioverter/defibrillators (ICDs) and cardiac resynchronisation therapy (CRT) systems. Compared with 2019, the COVID-19 pandemic was associated with an overall decline of CIED implantation rates of -2.6%, reaching -22,9% in April 2020. Stratified by device type, the patterns of implantation were similar between PMs and ICDs, with maximal declines of -24.3% and -23.2% in April, respectively. Thereafter, the implantation rates gradually increased before stabilizing to rates similar to those observed in 2019. CRT implantation rates also declined in the early pandemic wave, but the overall 2020 rates increased by +4.3% likely driven by an increase of +16.5% (June to September). All observed percentage differences of monthly device type related implantation rates demonstrated a statistical significance. CONCLUSIONS: The COVID-19 pandemic had a significant impact on the implantation of CIEDs in Germany. A differential pattern of resource utilization was observed with a catch-up effect for PMs and ICDs. The implantation rates of CRT also declined, but they increased rapidly and remained higher than those of 2019. The months of January through September were analyzed for the years 2019 and 2020. The investigation period was chosen in order to reflect what became known as the first COVID-19 wave in 2020. To ensure the comparability of data, we have also analyzed the data set of the year 2019. The monthly data of both years were then compared to each other. The respective data basis for the query from the InEK data browser was the "DRG 2019 data delivery grouped according to 2020" and the "In-year data delivery January through December 2020" (https://datenbrowser.inek.org/; last accessed on May 19, 2021). Data were retrieved via the InEK data browser (supplementary Figure 1S vorab.pdf), it was ensured that the selected OPS codes for the procedures were identical for both data years and were thus comparable. All statistical analyses are based on a full survey of administrative data from InEK. The January to September 2020 time-course of the incidence of infections during the COVID- Table 1 . All monthly % differences for each device types were statistically significant (p < 0.001). Figure An analysis of health insurance billing data of the large German health insurance AOK The catch-up effect we observed with CIED implantations was only detected in the AOK analysis for osteoarthritis-related hip prosthesis implantations. In our investigation, the catch-up effect was seen for all types of CIED systems. The highest increase was observed for CRT systems with 16.5% more implantations in the period June to September 2020. Due to this catch-up effect, the overall decline in CIED implantations during the complete observation period (January to September 2020) was relatively low at -2.6%. In contrast, the number of treatment cases billed according to DRG decline by over -12% during the same time period. 11 When looking at other European countries, Arbelo and colleagues reported their finding in Catalonia (reflecting approximately 16 % of the Spanish population). 12 concerning as it appears the COVID-19 pandemic disrupted the entire health care system with a massive impact on the activities and procedures related to arrhythmia management. In Campania, data from 14 implantations centers were collected for the time between March 10 th and May 4 th 2020. 16 Compared to 2019, Russo and co-workers found a heterogeneous pattern of CIED implantations. The reduction of new implantation was -30 % for pacemakers up to -48 % for CRT. Of note, device replacements were not affected significantly. Marini and co-workers found in their regional referral center analysis that urgent PM Gonzales-Luna and colleagues found a significant reduction of over 73 % of new pacemaker implantations in Peru. 20 However, they did not report on a potential catch-up effect. The analysis or query procedure with the admission date in the respective month as the only temporal search criterion has the advantage that patients who remained in-hospital from the previous month and also from the previous year (2018 to 2019 and 2019 to 2020) were not included in the study. The data years can be separately analyzed and compared. However, the analysis or query procedure has the disadvantage that the admission date may not equal the implantation date. This means that for patients who have been hospitalized at the end of a month, it is possible that the implantation or replacement of the active cardiac device only took place at the beginning of the following month. As a result, the procedures are allocated to the month of hospital admission. trends for the different device types which showed an annual increase for CRT pacemakers or decrease for single and dual chamber ICDs implantation and replacement rates. 21, 22, 23 The reasons being these differences are numerous such as new therapeutic or treatment guidelines, further product developments (longevity of battery) or introduction of new medical devices innovations. Our study is the first to highlight nationwide German data on the impact of the COVID-19 pandemic on CIED implantation during the first COVID-19 pandemic wave. In contrast to other European countries or small investigations in Germany, our results clearly show, an increase of the number of device implantations in the months following the first pandemic wave. Moreover, with respect to CRT, the number of implantations performed in 2020 exceeded that of 2019. This German scenario provides information about the rapid response of electrophysiologist-guided device therapy after the government decided to re-start usual medical care. This shows a reduced idleness of this system. For future and unexpected events, it would be desirable and necessary to provide the population with a nearly continuous high level medical therapy. Hence, changes in the health care system are necessary: The data underlying this article were accessed from "Institute für das Entgeltsystem im Krankenhaus" (InEK), https://datenbrowser.inek.org/. The derived data generated in this research will be shared on reasonable request to the corresponding author. Meeting Resolution by Chancellor Angela Merkel and the heads of government of the federal states of Germany A new daily routine also for hospital management in Germany") envisages using part of the hospital capacities for scheduled operations again as of COVID-19 Hospital COVID-19 Compensation-Adjustment-Regulation Meeting Resolution by Chancellor Angela Merkel and the heads of government of the federal states of Germany Meeting Resolution by Chancellor Angela Merkel and the heads of government of the federal states of Germany Auswirkungen der Covid-19-Pandemie auf die Krankenhausleistungen im Jahr 2020 DAK-Gesundheit health insurance: Analyzes of emergency hospitalizations Hospitalization deficit of in-and outpatient cases with cardiovascular diseases and utilization of cardiological interventions during the COVID-19 pandemic: Insights from the German-wide helios hospital network Emergency hospital admissions and interventional treatments for heart failure and cardiac arrhythmias in Germany during the Covid-19 outbreak: insights from the German-wide Helios hospital network Analysen zur Erlössituation und zum Leistungsgeschen von Krankenhäusern in der Corona-Krise Reduction in new cardiac electronic device implantations in Catalonia during COVID-19 Impact of the first wave of the SARS-CoV-2 pandemic on preferential/emergent pacemaker implantation rate. Spanish study Urgent pacemaker implantation rates in the Veneto region of Italy after the COVID-19 outbreak Impact of COVID-19 pandemic on the clinical activities related to arrhythmias and electrophysiology in Italy: results of a survey promoted by AIAC (Italian Association of Arrhythmology and Cardiac Pacing) Cardiac pacing procedures during coronavirus disease 2019 lockdown in Southern Italy: insights from Campania Region COVID-19 pandemic and elderly: is the curtain dropped for urgent pacemaker implantations? Impact of COVID-19 on cardiac procedure activity in England and associated 30-day mortality Impact of COVID-19 pandemic on cardiac electronic device implantations in Northwestern Greece Impact of COVID-19 on pacemaker implant Deutscher Herzbericht 2020, Hrsg. Deutsche Herzstiftung e We thank Ulrike von Hehn (medistat GmbH) for performing the statistical calculations.We thank Danielle Libersan, PhD for reviewing the manuscript.We also thank Paul Korb for supporting our own calculations of the data from Robert-Koch-Institut.