>> Despite all the research efforts to date, it remains unclear exactly what collateral damage caused the detected reduced utilization of benefits. This is what the new DGIM chairman Prof. Dr. Sebastian Schellong at a press conference at the beginning of February in his lecture entitled "Using services more sensibly, protecting resources - What medicine can learn from the corona crisis" argued that one should carefully check which services were shut down in the corona pandemic. were actually missing for the care of patients and which services should perhaps no longer be increased in the future. What exactly these could be remains to be researched. Of course, this definitely does not apply to those that could endanger patients' lives and/or their health. However, that is exactly what may have happened, especially in the first wave. Especially at the time when all German hospitals significantly reduced their range of services and had to postpone elective procedures that were not medically necessary in order to keep intensive care capacity free for seriously ill Covid-19 patients. At the beginning of the pandemic, no one could have known that they weren't needed to that extent. That's why we shouldn't blame politicians for this, but we should blame the fact that so far there have been no public research efforts to investigate the actual effects of reduced utilization of services. There are indications of this everywhere.
Schellong, chief physician of the second medical clinic at the Städtisches Klinikum Dresden, spoke at the DGIM press conference about the fact that it was worrying if fewer patients were currently seeing a doctor for acute life-threatening illnesses such as heart attacks or strokes. In the case of less dangerous illnesses, however, not every treatment that is postponed or canceled has the same negative consequences, emphasized Schellong. Nevertheless, in the opinion of the Dresden internist, “the consequences of the current care situation for patients should be researched”. Schellong: “In this way, we can find out which areas of medical care are indispensable and in which the current shortage has not had any negative consequences for the prognosis of certain disease progression.” However, it could also be the case that supply-induced demand has returned to a normal level in some cases reduced. For example, in the current Sanofi health trend it was found that 47% of those surveyed are doing well to very well, but they have substituted 62% fewer visits to the doctor with 26% more self-diagnosis and 46% more self-medication. What exactly is happening cannot be explained by health services research. Who else?
This kind of behavior can certainly work for mild illnesses, but not for many. Perhaps that is precisely why there are currently consequences of reduced use of benefits or even refusal of benefits, which certainly give cause for concern. Such as the high decline in the number of cases observed in the treatment of heart attacks. An evaluation by the WIdO (1) showed that when comparing the period spring 2019 to 2020, instead of 4,628 cases of heart attacks among AOK insured people, only 3,209 heart attacks were treated in the first lockdown phase - at least minus 31 percent. According to the WIdO figures, a similar picture emerges for strokes: here the number of cases treated fell from 6,190 to 5,046 (minus 18 percent). When treating the precursor to a stroke, the transient ischemic attack (TIA), the data even shows a decrease of 37 percent. “These sharp declines in the treatment of real emergencies indicate that affected patients alerted the emergency services less often during the lockdown phase,” said WIdO managing director Jürgen Klauber. Despite the acute need for treatment and possible serious consequences, those affected apparently did not seek medical help more often. “The data does not provide any information about the reasons for this behavior or the extent of possible secondary diseases,” explains Klauber. However, it can already be concluded that education of the population about the correct behavior in an emergency should be improved. Campaigns such as “Time is muscle” or “Time is brain” need to be intensified with reference to the corona pandemic. “Mortality rates and the development of secondary diseases due to untreated emergencies should also be analyzed at a later date,” emphasizes Klauber. In November 2020, the WIdO also published a more precise and comprehensive analysis of the effects of the first lockdown on the treatment of emergencies (2). It is shown here that the lower number of stroke patients who arrived at the clinics in the first lockdown resulted in a significantly higher mortality rate compared to the previous year: the 30-day mortality rose from twelve percent in spring 2019 to 15 percent this spring.
The number of emergency patients with mild or non-specific symptoms in particular has also decreased compared to the previous year. According to WIdO data, 35 percent fewer patients were treated for a transient ischemic attack (TIA), in which stroke symptoms occur for a maximum of 24 hours, than in the previous year. In contrast, treatments for severe strokes caused by cerebral infarction or cerebral hemorrhage fell by 15 percent over the same period. A similar picture occurs with heart attacks. According to figures from the WIdO, the number of treatments for severe heart attacks with complete occlusion of a large coronary artery and characteristic ECG changes (STEMI) has fallen by 24 percent compared to the same period last year. The decline was more pronounced at minus 29 percent in minor heart attacks (NSTEMI), in which the vessels are often not completely closed and therefore cause less damage to the heart. The authors' conclusion: The fear of a Covid-19 infection could have prevented patients with milder symptoms from going to hospital.
An analysis of the “Nationwide care of stroke patients in times of the Covid-19 pandemic in Germany” published in the “Stroke” journal reports something similar. Richter et al. (3) identified a sharp decline in hospitalization for AIS (-17.4%), transient ischemic attack (-22.9%) and intracerebral hemorrhage (-15.8%) during the pandemic compared to before. Despite the significant decrease in the absolute numbers of patients with AIS, TIA and ICH that is evident here - "most likely due to the patients' fear of becoming infected with the severe acute respiratory syndrome coronavirus during their hospital stay" - in the authors' opinion, the However, the data they examined suggested that patients with AIS not only sought acute hospital treatment during the pandemic, but were “treated with the same high quality as before the pandemic”.
However, Vivantes, with 5,856 beds, the largest public hospital group in Germany, reports a more detailed picture. A third of all patients in Berlin are treated every year in one of over 100 Vivantes clinics and institutes, with a total of almost half a million treatments per year. According to an internal Vivantes evaluation, when comparing the months of November 2019 to January 2020 with the same months in 2020/2021, the number of heart attacks only fell by 1% (Fig. 3). During the same period, however, the number of cerebral infarctions and TIAs each fell by 25%. Why there were 25% fewer cerebral infarctions/TIAs in the comparison period is inexplicable; Possible attempts at explanation - such as less stress through increased home office work that may promote work-life balance - are speculation.
The decrease in the number of cases becomes even more serious if you compare specifically the lockdown months of February 2020 and 2021: -32% fewer brain attacks, -33% TIA and still -14% heart attacks.
The reasons for this decrease in the number of cases should be researched in more detail - an original task of the healthcare system.
research! For example, also for institutes with their own data access, which could easily and quickly create a research setting using the data already available to explain possible collateral damage from Covid-19 - such as strokes and other clinical pictures. To do this, a research cohort from 2018 must be formed, which will then be observed in 2019 and 2020 (and perhaps even longer term).
the. However, such a project not only requires adequate financing, but above all the will to create important knowledge for the future from possible transparency. But not just for heart and cerebral infarctions, but for as many other illnesses as possible. <<
from: Dr. Eberhard Thombansen (1) and Peter Stegmaier (2)

1 = Vivantes; 2 = Monitor health services research