No Health Emergency
"At no point did the pandemic push inpatient care to its limits."
by Ralf Wurzbacher
[This article published on 5/20/2021 is translated from the German on the Internet, „Die Pandemie hat die stationäre Versorgung zu keinem Zeitpunkt an ihre Grenzen gebracht.“ (nachdenkseiten.de).]
The sentence in the title comes from the expert advisory board of the German Federal Ministry of Health. It confirms what critics of crisis management have been saying for a long time, and for which they have to take abuse as "conspiracy nuts." Among them is internist Matthias Schrappe, who has been revolting against overly harsh and disproportionate Corona measures since the beginning of the crisis. His latest analysis raises all sorts of uncomfortable questions: Why does Germany lead in the number of covid 19 intern patients? Where have thousands of emergency beds gone and what happened to all those funding millions? He is taking a beating for his theses precisely because he made it into the media mainstream with them. This, however, is new and a sign that the discussion about the sense and nonsense of the lockdown policy can no longer be stopped. By Ralf Wurzbacher.
At the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), the Marburger Bund Federal Association and the German Hospital Federation (DKG), the wires must have run hot over the weekend. On Sunday a group of experts around the health economist Matthias Schrappe had published an "ad hoc statement" to the intensive medical supply, which holds plentifully explosive. The 32-page report contains a mountain of incriminating information: figures on emergency capacities in German hospitals are manipulated, there are indications of subsidy fraud, and the handling of Covid 19 patients provides evidence of "overuse" that is unique in an international comparison. In an interview with "Welt"-Online (behind paywall), Schrappe followed up: "Strange, incomprehensible things are happening in intensive care units." Accompanying this, the Springer paper launched an article that shakes up the image of intensive care units "overflowing" under a Covid 19 overload. Editor Elke Bodderas titled her article, which is also not available free of charge, "Always stick to the truth!"
That was apparently too much of the insubordination. In a common explanation of Monday the attacked federations rejected the reproaches "in the sharpest way". This concerns in particular the insinuation to operate a "game of fear", to falsify official statistics or "to treat patients intensively purely out of financial interest". Many of the accusations were based "on misconceptions and a lack of knowledge of the actual situation in hospitals." Hanno Kautz, spokesman for the Federal Ministry of Health (BMG), also defended himself against the accusations at the Federal Press Conference on Monday: The "very strong accusation" that people are admitted to intensive care units who actually do not belong there is "not substantiated and therefore rejected." SPD health expert Karl Lauterbach called the attacks "absurd and not true." On Twitter he expressed: "Now legends are formed. Covid-infected people would have been provided with intensive medical care out of greed for money. One had manipulated data to make pressure on politics. This is unworthy."
No health emergency
What did Schrappe allow himself to do that was so bad as to merit the concentrated outrage of the German lockdown faction? First, something about his person: the 66-year-old physician was full-time medical director of the Marburg University Hospital from 2002 to 2005, between 2007 and 2011 General Representative of the Supervisory Board of the University Hospital Frankfurt am Main, and since 2005 a member of the Council of Experts on the Assessment of Developments in Health Care. From 2007 to 2011, he served as its vice chairman. Schrappe is therefore not just anyone. Some of the nine members of his group of authors are also well-known. Since the beginning of the pandemic, they have published a series of articles against the crisis management of the German government and the disproportionate nature of the harsh Corona measures. Among them is Klaus Püschel, who until six months ago headed the Institute of Legal Medicine at the University Medical Center Hamburg-Eppendorf. He had incurred the displeasure of politicians by going it alone and performing autopsies on Covid 19 deaths.
Schrappe's team has therefore been uncomfortable for some time. It's just that their theses have not received the attention they deserve. With the "Welt" reporting, things are suddenly different. All of a sudden, what has always been a taboo subject is being discussed in public: the question of whether the political leaders and their scientific advisors have overdramatized the threat posed by the virus and whether the lockdown strategy has overshot the mark. Schrappe's main objection, namely that the German healthcare system was never on the verge of collapse during the crisis, has now even been confirmed by a full-time official. In an analysis presented on April 30 by the Expert Advisory Council of the Federal Ministry of Health, the authors from the Leibniz Institute for Economic Research and the Technical University of Berlin (TUB) state "that the pandemic at no time pushed inpatient care to its limits." On the contrary: "Despite the German government's call in spring 2020 to postpone services that could be planned, inpatient care in Germany was guaranteed across the board in 2020."
All-time low in bed utilization
According to the findings, Covid 19 patients used an average of just under four percent of intensive care beds in 2020. Overall utilization of intensive care units is estimated to be between 63 percent and 73 percent, depending on hospital type. Bed occupancy had fallen to an all-time low of 67.3 percent, with intensive care beds at 68.6 percent. The underlying data come from the Institut für das Entgeltsystem im Krankenhaus GmbH (InEK), about whose evaluation by researchers of the TUB the NachDenkSeiten had already reported here. According to the data, the number of treatments performed in German hospitals plummeted from 19.2 million in 2019 to 16.8 million, or 13 percent, in the first year of the pandemic.
Instead of the conjured up overload of the system, retrospectively an unprecedented underutilization of hospital operations is evident. Of course, this development is largely due to the large number of canceled and postponed surgeries and the fact that many people refrained from seeking medical care for fear of infection. Nevertheless, the freeing up of capacity was always justified by the "spectre" of a corona overkill that would bring the clinics to their knees. The reality was different: Beds were empty on a grand scale, employees were put on short-time work in many places, and 20 hospitals were secretly shut down.
Groundless fear campaign
Schrappe does not deny in his paper that individual hospitals sometimes reached their limits. He does, however, contradict the message of a state of emergency as the normal case, which is frequently conveyed politically and in the media. The text states:
"Implicitly, there were threats that patients should be 'allowed to suffocate.' This fear-based campaign played a decisive role in enforcing the measures to restrict contact. In terms of their factual basis, however, these statements cannot be verified; at the very least, the dramatic nature of the statements is matched by a distinct lack of usable data."
Before the imposition of the so-called federal emergency brake, it was DIVI President Gernot Marx in particular who repeatedly warned of "clinics at the limit" and evoked the need for even more drastic measures. In said "Welt" article, however, several experts have their say who see things quite differently. "Germany has never had a problem in intensive care units," virologist Alexander Kekulé was quoted as saying. Looking at the current situation, Göran Kauermann, dean of the Faculty of Statistics at Ludwig Maximilian University in Munich, commented, "Overall, we don't see a strong dynamic in intensive care units during the third wave." And epidemiologist Klaus Stöhr noted that "you always had enough beds," adding, "At the time of the greatest health challenge since World War II, there are many advantages to living in Germany. Six out of ten intensive care beds are still free for everyone who wants and needs surgery."
World champion Germany
Speaking to Die Welt, Schrappe compared the situation here with that in other countries:
"We are European or even world champions in every respect. We have the longest length of stay, the highest hospital density, the highest number of intensive care beds per 100,000 inhabitants, we have more than three times more intensive care beds than France with 7,000 beds. (...) We are scaring ourselves at a high level."
Now, intensive care beds in Germany were never full to capacity during the crisis, and the so-called emergency reserve was never used. Nevertheless, there were certainly moments when the limits came within reach. And if the forecasts, such as those of modeler Kai Nagel of the Technical University of Berlin, according to which incidences of 2,000 could be expected in May, had actually occurred, the stocks might not have been sufficient. But this horror scenario has not even remotely materialized, just as there is no truth in Karl Lauterbach's statement that those treated with intensive care would be "on average 47 to 48 years old". "Half of them die. Many children lose their parents. That's a tragedy." Lauterbach, meanwhile, himself complained that he was off the mark with his steep thesis that those suffering from the disease were getting younger and younger. Nevertheless, this did not diminish his appeal as a talk show guest.
As Schrappe determined on the basis of recent findings of the Robert Koch Institute (RKI) and the DIVI intensive care register, the age group of 30 to 40-year-olds "does not account for three percent of all covid patients in intensive care". In absolute terms, that equates to "about 130" sufferers, while 7.8 percent are between 40 and 49 years old, 22 percent are up to 59 years old, and the "bulk" are older than 60, with a median age of 65. Although in recent times the media have reported an increased relative risk of hospitalization (...) in the younger age groups," he said. Whereby the internist criticizes that appropriate data to the average age of the treatment cases "up to 6 May (!)" were not even available.
In general, the paper complains about a deficit of usable data - although the crisis has already lasted 15 months. Neither does the DIVI register "provide information on gender, nor are data on comorbidity and other risk factors published at the time of intensive care obligation." This makes a more precise analysis on demographic and clinical characteristics "almost impossible." In this respect, no statement can be made to date on the severity of the disease and the cost of treatment. Thus, it remains unclear whether patients are admitted to an ICU "because of or with SARS-CoV-2." However, the authors state that the indicators, which remain limited but have recently improved, "raise doubts about a relevant deterioration in intensive care."
A conspicuously large number of intensive care patients
It is significant that Schrappe, who criticized the inadequate data, is now being framed for this very reason. ZDF then immediately made a "#DiviGate" out of the case and took the "carelessness and inconsistencies of his paper" to task. This applies in particular to his statements according to which intensive care utilization is kept high artificially and possibly for financial reasons. Here, too, it is worth making a comparison with other countries: according to the analysis, nowhere else in the world have so many Covid 19 patients been treated in intensive care units as in this country, measured by the seven-day reporting rate. Apparently, the indication for intensive care treatment is made "significantly faster" in Germany than elsewhere, they say. The fact that German citizens are more seriously ill than the rest of Europe can be "ruled out with a high degree of probability.
The newspaper Die Zeit had already presented evidence in February that people in Germany become Covid 19 hospital cases comparatively quickly. According to its research, between 20 and 30 percent of patients who appear in the RKI statistics are in fact hospitalized for other reasons and have only tested positive for Covid-19 by chance, but are otherwise symptom-free. This effect is even seen in intensive care units, where the rate is still ten percent. To whom did the paper refer? To the same DIVI, which Schrappe now pillories for "missing evidence." "This is just the strength of the German hospital structures to supply the seriously ill patients adequately in the intensive care capacities. Whoever constructs a 'misuse' from this would at the same time have to present data that the treatment results in other countries were equally good or even better." This should be countered: Why don't the German health authorities finally shed light on what has so far seemed like a "black box corona"?
An initial version of Schrappe's ad hoc statement put the percentage of hospitalized Covid 19 patients in intensive care at 61 percent as of April 27. The group determined the figure by reconciling RKI figures on hospitalizations with daily DIVI data on ICU bed occupancy. However, the RKI refers to a complete calendar week, while the DIVI only uses daily values. In addition, the RKI estimates an average length of stay of intensive care patients of nine days. Pointing this out, the authors' group lowered the rate of admissions to 41 percent, taking into account a ten-day length of stay. But even that would still put the FRG far ahead of countries such as Spain (24 percent), Italy (11 percent), France (29 percent) or Switzerland (25 percent).
The trend increase in size over time also appears strange. On March 30, the figure was still 31 percent, according to Schrappe's calculations. Why are more people apparently ending up in an intensive care bed at present, even though all the main crisis indicators - "case numbers", hospital admissions and death rates - have been in stable decline for weeks? Schrappe's observation that the number of intensive care patients has eclipsed the number of patients in normal wards for several weeks - with an upward trend - also seems strange. On April 27, of a total of 5,759 Covid 19 hospital cases, 5,063 (or 5,050 according to the DIVI) required intensive care, according to the RKI. That represents nearly 90 percent, up from 44 percent a month earlier. With all the provisional nature of the data due to possible subsequent reports and the fact that the status of not all infected persons is known, this is an "extremely contradictory finding."
Schrappe told Die Welt: "Could it be that some hospitals are trying to maximize their revenues? Or is it easier for some hospitals to bring corona patients immediately to the intensive care unit, although they do not yet need intensive medical care?"
NachDenkSeiten had already reported at the end of April on the striking fluctuation in intensive care beds as a function of political decisions and against the background of possible balance sheet requirements for hospitals. Schrappe's team also looked into this matter. For example, "not only have 10,000 intensive care beds" disappeared since mid-2020, but "obviously the figures from last summer have been corrected retrospectively." Instead of the peak of 34,000 beds at the time, the DIVI would have retroactively capped the inventory at 30,000 with its May 1, 2020, notification. The defendant now justifies the intervention by saying that "during the course of the pandemic, the pediatric intensive care unit beds were excluded from the total number of operable beds." However, this does not explain the elimination of thousands more beds, especially since, as the Schrappe paper notes, "efforts to expand ICU bed capacity would have been expected given the 'triage' discussion." In any case, "the drop in vacant beds appears to be a consequence of a decrease in overall capacity rather than increased utilization by Covid 19 patients."
10.2 billion euros for what?
Currently, the DIVI still lists about 23,500 intensive care beds, while Federal Health Minister Jens Spahn (CDU) had announced an increase to up to 40,000 with the condition of his "Hospital Relief Act" of March 2020, of which about 11,000 are so-called emergency reserves. According to Schrappe, these exist only on paper and would "never have been built up and never put into operation." He also doubts that the decline in beds can be explained solely by a lack of personnel. The Federal Employment Agency (BA), for example, has recorded "a considerable increase of 43,000 nursing staff in 2020 alone". However, again, there is a lack of data on how many critical care workers were among them. "In any case, a concerted, publicly visible and sustainably pursued action by the state's political leadership to encourage nursing staff to re-enter the profession did not take place," Schrappe said. In the course of 2020, politicians pumped an additional 10.2 billion euros into the hospital system...
"Everything opaque, untrustworthy, white lies. In any case, I don't see any consistency in the data that would back up a 'suffocation' narrative. If you even think you have to make policy with such a narrative."