Determination of COVID-19 intensive care costs in Germany and assessment of the economic impact on the healthcare system - a nationwide retrospective cohort study from January 2020 to March 2022

Determination of COVID-19 intensive care costs in Germany and assessment of the economic impact on the healthcare system - a nationwide retrospective cohort study from January 2020 to March 2022 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Determination of COVID-19 intensive care costs in Germany and assessment of the economic impact on the healthcare system - a nationwide retrospective cohort study from January 2020 to March 2022 Matthäus Lottes, Klaus Kaier, Nicholas Graves, Martin Wolkewitz This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4151752/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background In late 2021, the German statutory health insurance (SHI) funds reported average expenditures for the treatment of coronavirus disease 2019 (COVID-19) intensive care patients without mechanical ventilation at €8,000 and even more than €30,000 for those with mechanical ventilation. In this context, there is currently no further information on the total COVID-19 intensive care costs or an assessment of the economic impact on the German health care system. Methods A retrospective cohort study was conducted from January 01, 2020, to March 31, 2022, using nationwide inpatient billing data and the proportion of mechanically ventilated COVID-19 intensive care patients in Germany. The COVID-19 intensive care costs were then determined based on reported cost accounting estimates for nonventilated and ventilated intensive care unit (ICU) bed days. The health economic impact was assessed by relating the COVID-19 intensive care costs to SHI expenditures and the cost of illness for the German hospital sector. Results By the end of March 2022, German hospitals had spent a total of 2.2 million ICU bed days, including 1.2 million (55%) ventilated ICU bed days, for COVID-19 intensive care patients. Up to this point, the corresponding treatment costs were almost €3.0 billion. The annual COVID-19 intensive care costs more than doubled from €776 million in 2020 to €1.7 billion in 2021. This meant a cost increase of €203.1 million to €486 million for nonventilated ICU bed days and €573.2 million to €1.2 billion for ventilated ICU bed days. The cost share of COVID-19 intensive care in SHI expenditures for hospital treatment was predominantly less than 2.0%, and approximately 6.0% of the cost of illness for the hospital sector in 2020. Conclusions In conclusion, COVID-19 intensive care has become a rapidly growing cost factor for the German healthcare system, with the frequent use of mechanical ventilation being an important cost driver. However, compared to the SHI expenditures and cost of illness for the hospital sector, the cost share of COVID-19 intensive care appeared rather low. A more valid assessment of the health economic impact of COVID-19 intensive care in Germany requires case-specific billing data and consideration of costs associated with the displaced treatment of non-COVID-19 patients. COVID-19 intensive care mechanical ventilation treatment costs cost impact Figures Figure 1 Figure 2 Background The coronavirus disease 2019 (COVID-19) pandemic has placed a heavy burden on German intensive care units (ICUs) and their healthcare staff ( 1 – 3 ). COVID-19 ICU bed occupancy increased massively during the pandemic waves, even surpassing 5,000 adult COVID-19 patients nationwide in early 2021, and spread across nearly 1,300 adult ICUs ( 4 ). In terms of the clinical severity of COVID-19 intensive care patients, the proportion of those who received mechanical ventilation or extracorporeal membrane oxygenation (ECMO) repeatedly exceeded 60% nationwide ( 5 ). Moreover, COVID-19 intensive care also appears to have an enormous economic impact on the German healthcare system. In late 2021, German statutory health insurance (SHI) reported average expenditures of €8,000 for patients without mechanical ventilation and even more than €30,000 for those requiring this specific therapy ( 6 ). Furthermore, a single-center study including patients admitted to the ICU due to severe COVID-19 between April 2020 and April 2021 reported mean direct treatment costs of €72,701 per intensive care patient and €3,720 per ICU day ( 7 ). In principle, the diagnoses of a patient, the severity of the disease, clinical interventions and the length of hospital stay are decisive for the treatment costs incurred, which are billed by hospitals as per-case flat rates according to the German diagnosis-related group (G-DRG) system and then reimbursed by health insurance funds ( 8 ). In 2020 and 2021, the total SHI expenditure on hospital treatment, its largest service sector, amounted to €81.5 billion and €85.9 billion, respectively, representing almost one-third of its total health care spending. In 2022, there was a further increase to €88.1 billion ( 9 ). Considering the cost of illness, German hospitals spent €7.1 billion on treating patients with a main diagnosis of respiratory disease in 2020, including €2.8 billion (39%) on pneumonia, which seems most appropriate in the context of severe clinical manifestations of COVID-19. Compared with the total cost of illness for the German hospital sector of €114.2 billion, this corresponded to approximately 6.0% and 2.5%, respectively ( 10 ). Since further information on COVID-19 intensive care costs in Germany is not yet publicly available, our first aim was to determine these costs over the course of the pandemic, considering mechanical ventilation in particular as an important cost driver ( 11 – 13 ). In doing so, we exclusively relied on the direct treatment costs of COVID-19 intensive care. Other cost factors, such as the flat rate compensation of German hospitals for providing free COVID-19 ICU capacities, were not included ( 14 – 16 ). Furthermore, we have attempted to assess the economic impact of COVID-19 intensive care on the German health system by relating the costs incurred to SHI expenditures and the cost of illness for the hospital sector. Methods Data sources and study design We conducted a retrospective cohort study based on the daily nationwide number of COVID-19 intensive care patients (confirmed COVID-19 diagnosis according to the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) code U07.1!) between January 1, 2020, and May 31, 2022, provided by the Institute for the Hospital Remuneration System GmbH (InEK) ( 17 , 18 ). Since all German hospitals are obliged to regularly submit their billing data on completed inpatient treatments to the InEK, the potential for nonreporting is generally considered to be low and thus representative full coverage of COVID-19 inpatient cases. However, we limited the end of our study period to March 31, 2022, to still include the first quarter of 2022 for determining COVID-19 intensive care costs and to exclude expected underreporting for later dates since, as mentioned, only data on completed inpatient treatments were provided. We further distinguished our study period for the different phases of the pandemic for Germany based on the classification published by the Robert Koch Institute ( 19 ). In the absence of more detailed information, we pragmatically assumed that all COVID-19 intensive care patients had a main diagnosis of respiratory disease and that their daily nationwide number corresponded to ICU (occupancy) days. Accordingly, our cost calculation was based on the number of ICU bed days spent and thus billed by German hospitals for treating COVID-19 patients but not on individual patient histories, which could not be provided to us. Since we also had no information on the use and duration of mechanical ventilation, we relied on reports from the nationwide DIVI Intensive Care Registry (DIVI), which provides the current daily number of COVID-19 patients treated in German ICUs and the number of those receiving mechanical ventilation ( 20 ). Determination of COVID-19 intensive care costs To determine the COVID-19 intensive care costs in our study period, we first derived the daily nationwide proportion of mechanically ventilated COVID-19 intensive care patients from the DIVI reports (see Supplementary Fig. S1 ) and then transferred this to the InEK data (see Fig. 1 and Fig. 2). Since the DIVI reports were only available from April 24, 2020, we set this proportion for the previous dates at 70%, which was the mean of all reported values for the first pandemic wave (from March 2, 2020 (beginning of calendar week 10) to May 18, 2020 (end of calendar week 20) ( 21 ). Second, we relied on a study by Kaier et al., which used the G-DRG-based cost accounting standard of the InEK to estimate the costs per nonventilated and (mechanically) ventilated ICU bed day across main diagnosis groups for more than 10,500 adult intensive care patients admitted to the University Medical Center Freiburg ( 13 ). Since we focused on underlying respiratory disease, the corresponding costs averaged approximately €795 per nonventilated ICU bed day and €1,539 per ventilated ICU bed day, representing a relative cost increase of 94%. Third, we extrapolated these amounts for each of the years 2020 to 2022 according to the consumer price index for Germany (see Supplementary Table S1 ) and then calculated the daily costs of nonventilated and ventilated ICU bed days for COVID-19 patients in our study period ( 22 ). Finally, we summarized our results on a quarterly and annual basis to facilitate comparisons with SHI expenditures and the cost of illness for the German hospital sector (see Table 1 ). Table 1 Nonventilated and ventilated intensive care unit bed days (N, %) and corresponding intensive care costs (€, %) for COVID-19 patients in Germany quarterly from Q1/2020 to Q1/2022 Quarter/year Nonventilated ICU a bed days Costs for nonventilated ICU a bed days Ventilated ICU bed days Costs for ventilated ICU a bed days Total ICU a bed days Total ICU a costs Q1/2020 9,134 (30.0) 7,795,869 (18.1) 21,298 (70.0) 35,194,945 (81.9) 30,432 42,990,814 Q2/2020 47,265 (31.8) 40,340,678 (19.4) 101,497 (68.2) 167,723,793 (80.6) 148,762 208,064,471 Q3/2020 12,940 (46.1) 11,044,290 (30.7) 15,106 (53.9) 24,962,665 (69.3) 28,046 36,006,955 Q4/2020 168,566 (44.6) 143,871,081 (29.4) 208,997 (55.4) 345,367,543 (70.6) 377,563 489,238,624 Total in 2020 237,905 (40.7) 203,051,918 (26.2) 346,898 (59.3) 573,248,946 (73.8) 584,803 776,300,864 Q1/2021 195,384 (43.8) 171,957,458 (28.7) 250,431 (56.2) 426,759,467 (71.3) 445,815 598,716,925 Q2/2021 142,746 (40.1) 125,630,755 (25.7) 213,122 (59.9) 363,181,200 (74.3) 355,868 488,811,955 Q3/2021 44,364 (46.2) 39,044,756 (30.8) 51,566 (53.8) 87,873,621 (69.2) 95,930 126,918,377 Q4/2021 169,728 (45.9) 149,377,613 (30.5) 199,779 (54.1) 340,443,394 (69.5) 369,507 489,821,007 Total in 2021 552,222 (43.6) 486,010,582 (28.5) 714,898 (56.4) 1,218,257,682 (71.5) 1,267,120 1,704,268,264 Q1/2022 181,782 (50.8) 171,020,506 (34.7) 176,324 (49.2) 321,209,431 (65.3) 358,106 492,229,937 Total 971,909 (44.0) 860,083,006 (28.9) 1,238,120 (56.0) 2,112,716,059 (71.1) 2,210,029 2,972,799,065 a Intensive care unit Results COVID-19 intensive care unit bed days As shown in Fig. 1, the number of billed ICU bed days for COVID-19 patients in Germany peaked during the second pandemic wave in December 2020 at almost 7,400, of which approximately 4,000 were ventilated ICU days (54%). During the third wave and toward the end of the fourth wave of the pandemic, which were dominated by the Alpha and Delta variants, respectively, there was also a large increase to nearly 6,000 COVID-19-related ICU bed days nationwide. At the beginning of 2022, the total number of ICU bed days due to COVID-19 patients leveled off at around 4,000 under the dominance of Omicron variants, with the number of nonventilated ICU days steadily declining to less than 2,000 (< 40%). As shown in Fig. 2, the cumulative number of COVID-19-related ICU bed days in Germany increased more than tenfold from 20,6000 at the beginning of the second pandemic wave in September 2020 to 2.2 million at the end of March 2022, of which 1.2 million (55%) were ventilated ICU bed days by then. COVID-19 intensive care costs As shown in Table 1 , ventilated ICU bed days consistently accounted for more than two-thirds of the corresponding quarterly total COVID-19 intensive care costs in German hospitals. The highest COVID-19 intensive care costs were incurred in the first quarter of 2021, with approximately €172 million for 195,384 billed nonventilated ICU bed days and €426.8 million for 25,0431 billed ventilated ICU bed days. Compared to those in 2020, the COVID-19 intensive care costs incurred in 2021 more than doubled to €486 million for nonventilated ICU bed days and €1.2 billion for ventilated ICU bed days in German hospitals. Therefore, the total annual COVID-19 intensive care costs increased from €776 million in 2020 to €1.7 billion in 2021. By the end of March 2022, the total COVID-19 intensive care costs incurred in Germany for the 2.2 million ICU bed days billed by hospitals up to that point amounted to almost €3.0 billion. Discussion Using nationwide inpatient billing data from the InEK and information on mechanical ventilation from the DIVI, we first aimed to determine the COVID-19 intensive care costs in Germany over the course of the pandemic and, second, to assess the economic impact of COVID-19 intensive care from the perspective of the German health care system. In doing so, we calculated the intensive care costs incurred for the nonventilated and ventilated ICU bed days of COVID-19 patients from January 1, 2020, to March 31, 2022, and related these to SHI expenditures and the cost of illness for the German hospital sector. In this respect, we emphasize that our cost calculation served as an approximation for the respective SHI expenses, as their actual reimbursement of COVID-19 intensive care may have been different. Furthermore, COVID-19 intensive care patients may well have had a main diagnosis other than a respiratory disease, which we generally assumed in our study, also in view of the increasing number of viral pneumonia cases (ICD-10 code J12) ( 18 , 23 ). The COVID-19 intensive care costs we determined for Germany were €776 million in 2020 and €1.7 billion in 2021, representing a relative cost increase of 220%. Compared to the total annual SHI expenditures on hospital treatment of €81.5 billion and €85.9 billion, our findings were less than 2.0% ( 9 ). On a quarterly basis, our cost figures ranged slightly above this percentage, particularly at the turn of the year, which appeared to be in line with the large increase in COVID-19 intensive care patients during the two winter seasons captured ( 24 – 27 ). The rather low SHI expenditures for COVID-19 intensive care, which we have derived (one-to-one) from our cost figures, seemed quite plausible given a total of 17.3 million hospitalizations in 2020 and 17.2 million in 2021, of which less than 10% were COVID-19 intensive care patients in each case according to our results ( 28 ). For further comparison, inpatient treatments for neoplasms, injuries and diseases of the circulatory system were nearly or more than twice as common as for respiratory diseases, to which we assigned all COVID-19 intensive care patients ( 29 , 30 ). Therefore, the COVID-19 intensive care costs we determined for 2020 (€776 million) amounted to 11% of the cost of respiratory disease illness for hospitals. When further narrowed down to pneumonia, whose cost of illness amounted to approximately €2.8 billion, the share was as high as 30% ( 10 ). However, respiratory diseases only accounted for around 6.0% of total cost of illness for German hospitals and pneumonia for just under 2.5%. Given that all COVID-19 intensive care patients had a main diagnosis of respiratory disease, this could also suggest that the corresponding SHI expenditure was rather low compared to that of other ICD-10 diagnosis groups. We would like to point out once again that although this restrictive allocation made it possible to calculate COVID-19 intensive care costs, it certainly did not apply to every patient. Although more recent illness figures for 2021 are not yet available for comparison, the immense cost increase to €1.7 billion (+ 220% compared to 2020) revealed the growing health economic impact of COVID-19 intensive care, which was due to more than doubling the number of patients and the still high proportion of patients receiving mechanical ventilation ( 5 ). The sharp increase in the number of diagnosed viral pneumonia cases, which more than doubled to over 200,000 in 2021, also appeared to substantiate this ( 23 ). In summary, the cost share of COVID-19 intensive care in SHI expenditures for hospital treatment in 2020 and 2021 appeared to be rather low. If the respective expenditures of the private health insurance funds of €8.4 billion and €8.3 billion had also been considered, this cost share would have been even lower ( 31 ). A similar picture emerged when COVID-19 intensive care costs were compared to the cost of illness in the German hospital sector. However, the sheer number of critically ill COVID-19 patients has become a rapidly growing cost factor, with the frequent use of mechanical ventilation, in particular, increasing treatment costs ( 6 , 11 – 13 ). According to our results, a total of 2.2 million ICU bed days, including 1.2 million (55%) ventilated ICU bed days, were spent by German hospitals on COVID-19 patients until the end of March 2022, for which the required healthcare resources, such as ICU beds, ventilators, medical and nursing staff, etc., were (to some extent) used at the expense of care for other patients ( 14 ). In this context, the costs incurred by the German health care system due to the postponement of elective procedures to provide free ICU capacity for COVID-19 patients must also be considered, as hospitals, for example, were remunerated with flat rates for providing free COVID-19 ICU capacity ( 15 , 16 ). Hence, our cost calculation did not take into account that COVID-19 intensive care patients may have displaced treatment for non-COVID-19 patients. From the hospital's perspective, such a displacement scenario would mean that overall costs increased only by the additional variable costs of treating COVID-19, assuming these exceed the variable costs compared to a "traditional" patient. However, from a societal perspective, the overall cost of this displacement scenario would be much greater, as displaced patients may have suffered a substantial health loss (for example, through the postponement of elective procedures), which also entailed costs. Unfortunately, in this study, we were unable to quantify the degree of displacement or its financial consequences. Instead, our cost calculation implicitly assumed that COVID-19 intensive care patients were 100% additional to “traditional” patients. This assumption may seem unrealistic in its entirety, but it was necessary to obtain the COVID-19-related intensive care costs in Germany using the chosen approach. Ultimately, it seems adequate to assume that the societal costs of a displaced non-COVID-19 patient exceeded those of the refused treatment. Therefore, we believe that the direct treatment costs presented here should be interpreted as the lower bound because the displacement scenario was not captured. Nevertheless, we would like to substantiate our approach to determining COVID-19 intensive care costs in Germany, which was essentially based on the study by Kaier et al., whereby the economic valuation of an ICU day is based on the cost accounting method following the InEK handbook of calculation ( 13 ). According to this method, standardized unit costs per inpatient case are defined on the basis of the average expenditure (within the cost categories of staff, material and infrastructure) for an ICU day. In doing so, Kaier et al. included more than 10,500 adult intensive care patients to explicitly address the cost impact of mechanical ventilation per ICU day. Using the same ‘bottom-up’ method for cost accounting, a study by Schallner et al. reported a mean cost of €3,720 per ICU day for COVID-19 patients, which is more than twice as high as the cost figures per ventilated ICU day that we referred to (see Supplementary Table S1 ) ( 7 ). However, the number of included COVID-19 intensive care patients was relatively low at 49, almost half of whom also received ECMO therapy, which may further have increased the cost of treatment. Furthermore, no explicit distinction was made according to the use of mechanical ventilation, which was of central importance to our cost calculation, as it was frequently used in COVID-19 patients (mostly above 50% of patients nationwide during our study period) ( 5 ). A competing method of cost accounting is the willingness-to-pay (WTP) approach, which uses questionnaires to assess the WTP to liberate ICU beds given (or contingent on) a set of hypothetical conditions ( 32 ). The resulting amount of costs per ICU day then reflects the mean amount respondents would pay to release an additional ICU bed. Typically, WTP-based estimates are substantially lower than the accounting-based costs we used. On the other hand, those estimates usually represent the average WTP under low-, medium-, and high-demand scenarios. WTP-based estimates under pandemic conditions, where the demand for ICU beds has increased dramatically, are not currently available. However, as the per-case flat rates of the G-DRG system are based on a standardized cost accounting scheme for defined medically and economically homogeneous groups, the WTP approach appears to be less reliable for determining the COVID-19 intensive care costs actually billed by German hospitals ( 8 ). A key strength of the present study is the representativeness of the InEK data, which includes inpatient billing cases from all hospitals in Germany that are subject to data transmission obligations according to the Hospital Remuneration Act ( 17 ). In addition, we relied on the study by Kaier et al., which explicitly distinguished between nonventilated and ventilated ICU bed days for cost estimation ( 13 ). This allowed us to account for the cost impact of mechanical ventilation while incorporating the clinical severity of COVID-19 in intensive care patients. One limitation, however, is that we calculated our cost figures based on ICU treatments in 2013, while the G-DRG-based cost accounting standard changed from 2020 onward, with nursing staff costs being separated from the per-case flat rates and financed through a hospital-specific nursing budget based on cost coverage ( 33 ). Furthermore, our cost figures only reflect direct COVID-19-related treatment, without considering the potential costs of displaced treatment for non-COVID-19 patients. Overall, more accurate cost figures would have required case-specific billing data for the entire course of the COVID-19 pandemic. Conclusions In conclusion, COVID-19 intensive care has become a rapidly growing cost factor for the German healthcare system, with the frequent use of mechanical ventilation being an important cost driver. However, compared to the SHI expenditures and cost of illness for the hospital sector, the cost share of COVID-19 intensive care appeared rather low. A more valid assessment of the health economic impact of COVID-19 intensive care in Germany requires case-specific billing data and consideration of costs associated with the displaced treatment of non-COVID-19 patients. Abbreviations COVID-19 Coronavirus disease 2019 DIVI DIVI Intensive Care Registry ECMO Extracorporeal membrane oxygenation G-DRG German Diagnosis-Related Groups system ICD-10 International Statistical Classification of Diseases and Related Health Problems 10th Revision ICU Intensive care unit InEK Institute for the Hospital Remuneration System GmbH SHI Statutory health insurance WTP Willingness-to-pay Declarations Ethics approval and consent to participate The data used in this study are subject to the obligation to transmit data during the year in accordance with Section 21 (3b) of the Hospital Remuneration Act. Accordingly, all hospitals that are subject to the data transmission obligation pursuant to Section 21 of the Hospital Remuneration Act are obliged to transmit their inpatient billing data to the Institute for the Hospital Remuneration System GmbH (InEK) on June 15, October 15 and January 15 of each year. The data are made available by the hospitals for the purpose of review in accordance with Section 24 of the Hospital Financing Act and for supplementary analyses for the further development of the remuneration systems. InEK provides public access to these data via its InEK Data Browser (https://datenbrowser.inek.org/). For the purpose of this study, the corresponding author requested the data directly from the InEK. The evaluation results were provided to the corresponding author with the consent of the Federal Ministry of Health. The ethics approval of this study and the need for informed consent were deemed unnecessary according to Section 21 (3b) of the Hospital Remuneration Act; hence, this information was not required for this study. Consent for publication Not applicable. Availability of data and materials The data that support the findings of this study are available from the Institute for the Hospital Remuneration System GmbH (InEK), but restrictions apply to the availability of these data, which were used under license for the current study and are not publicly available. However, the data are available from the corresponding author upon reasonable request and with the permission of the Federal Ministry of Health. Competing Interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency or commercial or not-for-profit sector. Authors’ contributions All authors contributed to the conception and design of the study. M.L. organized the data provision, prepared all the tables and figures, conducted all the analyses and wrote the manuscript. K.K., N.G. and M.W. provided analytical advice and supported the interpretation of the findings. 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Bundesministerium für Gesundheit (BMG). Finanzentwicklung der GKV im 1. bis 3. Quartal 2021. 2021. https://www.bundesgesundheitsministerium.de/presse/pressemitteilungen/finanzentwicklung-der-gkv-im-1-bis-3-quartal-2021.html. Accessed 20 Mar 2024. Bundesministerium für Gesundheit (BMG). Finanzentwicklung der GKV im 1. Quartal 2022. 2022. https://www.bundesgesundheitsministerium.de/presse/pressemitteilungen/finanzentwicklung-der-gkv-im-1-quartal-2022.html. Accessed 20 Mar 2024. Gesundheitsberichterstatung des Bundes (GBE-Bund). Diagnostic data of the hospitals starting from 2000 (key figures of full-time inpatients). Classification: year, place of treatment/residence, ICD10. 2023. https://www.gbe-bund.de/gbe/pkg_isgbe5.prc_menu_olap?p_uid=gastd&p_aid=30801214&p_sprache=E&p_help=2&p_indnr=550&p_version=1&p_ansnr=80978339. Accessed 20 Mar 2024. Federal Statistical Office for Germany (Destatis). Hospitals. Capitel of diagnosis by sex 2020. 2023. https://www.destatis.de/EN/Themes/Society-Environment/Health/Hospitals/Tables/capitel-diagnosis-gender.html. Accessed 20 Mar 2024. Statistisches Bundesamt (Destatis). Vollstationäre Patientinnen und Patienten der Krankenhäuser. Diagnosekapitel 2021. 2023. https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Gesundheit/Krankenhaeuser/Tabellen/diagnose-kapitel-geschlecht.html. Accessed 20 Mar 2024. Statista GmbH. Ausgaben der privaten Krankenversicherung (PKV) für Krankenhausbehandlungen in den Jahren 1998 bis 2021. 2022. https://de.statista.com/statistik/daten/studie/157182/umfrage/pkv-ausgaben-fuer-krankenhausbehandlungen-seit-1998/. Accessed 20 Mar 2024. Graves N, Harbarth S, Stewardson AJ. Valuation of Hospital Bed-Days Released by Infection Control Programs: A Comparison of Methods. Infect Control Hosp Epidemiol. 2014;35(10):1294-7. GKV-Spitzenverband. aG-DRG-System. 2022. https://www.gkv-spitzenverband.de/krankenversicherung/krankenhaeuser/drg_system/g_drg_2021/drg_system_2021.jsp. Accessed 20 Mar 2024. Additional Declarations No competing interests reported. Supplementary Files FigureS1.png S1. Nationwide proportion of ventilated COVID-19 intensive care patients in Germany from April 24, 2020, to March 31, 2022, by pandemic phase TableS1.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4151752","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":284170627,"identity":"1af70759-1cb9-4a16-ade8-790a3b6dfeaa","order_by":0,"name":"Matthäus Lottes","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAArklEQVRIiWNgGAWjYBACPigtx8DD2MDAQ4wWNgZmoFIGBmPStSQ2gJQTp4W9//iDD3+2pW/vOdzA8KaCGC08hxkbZ7bdzp1ztrGBcc4ZYrRIJDM28zbczp3Bz9jAzNtGrJY/f26nS4C1/CNWCwPb7QQJ3kaglgZitPAcNpzZ23bbcAbPwYaDc44RoYWfvfHBhx9/bstL8KQ/fPCmhggtKOAAqRpGwSgYBaNgFOAAACutNH7TthAMAAAAAElFTkSuQmCC","orcid":"","institution":"Robert Koch Institute","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Matthäus","middleName":"","lastName":"Lottes","suffix":""},{"id":284170628,"identity":"2c8ea5e7-1fc3-4c4c-aab6-09522eba19ca","order_by":1,"name":"Klaus Kaier","email":"","orcid":"","institution":"University of Freiburg","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Klaus","middleName":"","lastName":"Kaier","suffix":""},{"id":284170629,"identity":"fe1dc43b-494e-488c-946c-e513cfc5e937","order_by":2,"name":"Nicholas Graves","email":"","orcid":"","institution":"National University of Singapore","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Nicholas","middleName":"","lastName":"Graves","suffix":""},{"id":284170630,"identity":"ec886d4c-006a-4102-8a85-ed371786fc3f","order_by":3,"name":"Martin Wolkewitz","email":"","orcid":"","institution":"University of Freiburg","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Martin","middleName":"","lastName":"Wolkewitz","suffix":""}],"badges":[],"createdAt":"2024-03-22 19:57:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4151752/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4151752/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":53671292,"identity":"67d40381-b7d8-4b8d-8e80-d2f21ba69469","added_by":"auto","created_at":"2024-03-28 17:55:34","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":262664,"visible":true,"origin":"","legend":"\u003cp\u003eAbsolute number of nonventilated (light blue) and ventilated (dark blue) COVID-19 intensive care unit bed days in Germany from January 1, 2020, to March 31, 2022, by pandemic phase\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4151752/v1/5d35891fad55fb91ab9f98e2.png"},{"id":53671821,"identity":"61bfbf30-3c72-4043-a1de-f18a43ea45ae","added_by":"auto","created_at":"2024-03-28 18:03:34","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":183955,"visible":true,"origin":"","legend":"\u003cp\u003eCumulative number of nonventilated (light blue) and ventilated (dark blue) COVID-19 intensive care unit bed days in Germany from January 1, 2020, to March 31, 2022, by pandemic phase\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4151752/v1/92b6b93cd4854c7b2a26adad.png"},{"id":81353088,"identity":"c7dc1afe-31f8-4e0d-9537-479cb61abad5","added_by":"auto","created_at":"2025-04-25 06:54:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1148083,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4151752/v1/7d5445ec-fe16-41ae-af67-9bf2613451cc.pdf"},{"id":53671294,"identity":"b2f1cd22-a3f7-4d6a-bb1e-6461f1196f40","added_by":"auto","created_at":"2024-03-28 17:55:34","extension":"png","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":241726,"visible":true,"origin":"","legend":"\u003cp\u003eS1. Nationwide proportion of ventilated COVID-19 intensive care patients in Germany from April 24, 2020, to March 31, 2022, by pandemic phase\u003c/p\u003e","description":"","filename":"FigureS1.png","url":"https://assets-eu.researchsquare.com/files/rs-4151752/v1/54673ff58760cb044034f3e0.png"},{"id":53671296,"identity":"7a2f64fc-98da-4c71-a8b8-b367695f5518","added_by":"auto","created_at":"2024-03-28 17:55:34","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":12570,"visible":true,"origin":"","legend":"","description":"","filename":"TableS1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4151752/v1/3fbf6d17e948741e1241c3b8.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Determination of COVID-19 intensive care costs in Germany and assessment of the economic impact on the healthcare system - a nationwide retrospective cohort study from January 2020 to March 2022","fulltext":[{"header":"Background","content":"\u003cp\u003eThe coronavirus disease 2019 (COVID-19) pandemic has placed a heavy burden on German intensive care units (ICUs) and their healthcare staff (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). COVID-19 ICU bed occupancy increased massively during the pandemic waves, even surpassing 5,000 adult COVID-19 patients nationwide in early 2021, and spread across nearly 1,300 adult ICUs (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). In terms of the clinical severity of COVID-19 intensive care patients, the proportion of those who received mechanical ventilation or extracorporeal membrane oxygenation (ECMO) repeatedly exceeded 60% nationwide (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMoreover, COVID-19 intensive care also appears to have an enormous economic impact on the German healthcare system. In late 2021, German statutory health insurance (SHI) reported average expenditures of \u0026euro;8,000 for patients without mechanical ventilation and even more than \u0026euro;30,000 for those requiring this specific therapy (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Furthermore, a single-center study including patients admitted to the ICU due to severe COVID-19 between April 2020 and April 2021 reported mean direct treatment costs of \u0026euro;72,701 per intensive care patient and \u0026euro;3,720 per ICU day (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In principle, the diagnoses of a patient, the severity of the disease, clinical interventions and the length of hospital stay are decisive for the treatment costs incurred, which are billed by hospitals as per-case flat rates according to the German diagnosis-related group (G-DRG) system and then reimbursed by health insurance funds (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). In 2020 and 2021, the total SHI expenditure on hospital treatment, its largest service sector, amounted to \u0026euro;81.5\u0026nbsp;billion and \u0026euro;85.9\u0026nbsp;billion, respectively, representing almost one-third of its total health care spending. In 2022, there was a further increase to \u0026euro;88.1\u0026nbsp;billion (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Considering the cost of illness, German hospitals spent \u0026euro;7.1\u0026nbsp;billion on treating patients with a main diagnosis of respiratory disease in 2020, including \u0026euro;2.8\u0026nbsp;billion (39%) on pneumonia, which seems most appropriate in the context of severe clinical manifestations of COVID-19. Compared with the total cost of illness for the German hospital sector of \u0026euro;114.2\u0026nbsp;billion, this corresponded to approximately 6.0% and 2.5%, respectively (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSince further information on COVID-19 intensive care costs in Germany is not yet publicly available, our first aim was to determine these costs over the course of the pandemic, considering mechanical ventilation in particular as an important cost driver (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In doing so, we exclusively relied on the direct treatment costs of COVID-19 intensive care. Other cost factors, such as the flat rate compensation of German hospitals for providing free COVID-19 ICU capacities, were not included (\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Furthermore, we have attempted to assess the economic impact of COVID-19 intensive care on the German health system by relating the costs incurred to SHI expenditures and the cost of illness for the hospital sector.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData sources and study design\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective cohort study based on the daily nationwide number of COVID-19 intensive care patients (confirmed COVID-19 diagnosis according to the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) code U07.1!) between January 1, 2020, and May 31, 2022, provided by the Institute for the Hospital Remuneration System GmbH (InEK) (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Since all German hospitals are obliged to regularly submit their billing data on completed inpatient treatments to the InEK, the potential for nonreporting is generally considered to be low and thus representative full coverage of COVID-19 inpatient cases. However, we limited the end of our study period to March 31, 2022, to still include the first quarter of 2022 for determining COVID-19 intensive care costs and to exclude expected underreporting for later dates since, as mentioned, only data on completed inpatient treatments were provided. We further distinguished our study period for the different phases of the pandemic for Germany based on the classification published by the Robert Koch Institute (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In the absence of more detailed information, we pragmatically assumed that all COVID-19 intensive care patients had a main diagnosis of respiratory disease and that their daily nationwide number corresponded to ICU (occupancy) days. Accordingly, our cost calculation was based on the number of ICU bed days spent and thus billed by German hospitals for treating COVID-19 patients but not on individual patient histories, which could not be provided to us. Since we also had no information on the use and duration of mechanical ventilation, we relied on reports from the nationwide DIVI Intensive Care Registry (DIVI), which provides the current daily number of COVID-19 patients treated in German ICUs and the number of those receiving mechanical ventilation (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eDetermination of COVID-19 intensive care costs\u003c/h2\u003e \u003cp\u003eTo determine the COVID-19 intensive care costs in our study period, we first derived the daily nationwide proportion of mechanically ventilated COVID-19 intensive care patients from the DIVI reports (see Supplementary Fig. \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e) and then transferred this to the InEK data (see Fig.\u0026nbsp;1 and Fig.\u0026nbsp;2). Since the DIVI reports were only available from April 24, 2020, we set this proportion for the previous dates at 70%, which was the mean of all reported values for the first pandemic wave (from March 2, 2020 (beginning of calendar week 10) to May 18, 2020 (end of calendar week 20) (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Second, we relied on a study by Kaier et al., which used the G-DRG-based cost accounting standard of the InEK to estimate the costs per nonventilated and (mechanically) ventilated ICU bed day across main diagnosis groups for more than 10,500 adult intensive care patients admitted to the University Medical Center Freiburg (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Since we focused on underlying respiratory disease, the corresponding costs averaged approximately \u0026euro;795 per nonventilated ICU bed day and \u0026euro;1,539 per ventilated ICU bed day, representing a relative cost increase of 94%. Third, we extrapolated these amounts for each of the years 2020 to 2022 according to the consumer price index for Germany (see Supplementary Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e) and then calculated the daily costs of nonventilated and ventilated ICU bed days for COVID-19 patients in our study period (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Finally, we summarized our results on a quarterly and annual basis to facilitate comparisons with SHI expenditures and the cost of illness for the German hospital sector (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNonventilated and ventilated intensive care unit bed days (N, %) and corresponding intensive care costs (\u0026euro;, %) for COVID-19 patients in Germany quarterly from Q1/2020 to Q1/2022\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuarter/year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNonventilated ICU\u003csup\u003ea\u003c/sup\u003e bed days\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCosts for nonventilated\u003c/p\u003e \u003cp\u003eICU\u003csup\u003ea\u003c/sup\u003e bed days\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVentilated ICU bed days\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCosts for ventilated\u003c/p\u003e \u003cp\u003eICU\u003csup\u003ea\u003c/sup\u003e bed days\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTotal ICU\u003csup\u003ea\u003c/sup\u003e bed days\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTotal ICU\u003csup\u003ea\u003c/sup\u003e costs\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ1/2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9,134 (30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7,795,869 (18.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21,298 (70.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e35,194,945 (81.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e30,432\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e42,990,814\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ2/2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47,265 (31.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40,340,678 (19.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e101,497 (68.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e167,723,793 (80.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e148,762\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e208,064,471\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ3/2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12,940 (46.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11,044,290 (30.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15,106 (53.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e24,962,665 (69.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e28,046\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e36,006,955\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ4/2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e168,566 (44.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e143,871,081 (29.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e208,997 (55.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e345,367,543 (70.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e377,563\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e489,238,624\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTotal in 2020\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e237,905 (40.7)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e203,051,918 (26.2)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e346,898 (59.3)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e573,248,946 (73.8)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e584,803\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003e776,300,864\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ1/2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e195,384 (43.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e171,957,458 (28.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e250,431 (56.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e426,759,467 (71.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e445,815\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e598,716,925\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ2/2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e142,746 (40.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e125,630,755 (25.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e213,122 (59.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e363,181,200 (74.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e355,868\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e488,811,955\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ3/2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44,364 (46.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39,044,756 (30.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51,566 (53.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e87,873,621 (69.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e95,930\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e126,918,377\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ4/2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e169,728 (45.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e149,377,613 (30.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e199,779 (54.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e340,443,394 (69.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e369,507\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e489,821,007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTotal in 2021\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e552,222 (43.6)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e486,010,582 (28.5)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e714,898 (56.4)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003e1,218,257,682 (71.5)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e1,267,120\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003e1,704,268,264\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ1/2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e181,782 (50.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e171,020,506 (34.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e176,324 (49.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e321,209,431 (65.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e358,106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e492,229,937\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e971,909 (44.0)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e860,083,006 (28.9)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e1,238,120 (56.0)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e2,112,716,059 (71.1)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e2,210,029\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e2,972,799,065\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003ea Intensive care unit\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eCOVID-19 intensive care unit bed days\u003c/h2\u003e \u003cp\u003eAs shown in Fig.\u0026nbsp;1, the number of billed ICU bed days for COVID-19 patients in Germany peaked during the second pandemic wave in December 2020 at almost 7,400, of which approximately 4,000 were ventilated ICU days (54%). During the third wave and toward the end of the fourth wave of the pandemic, which were dominated by the Alpha and Delta variants, respectively, there was also a large increase to nearly 6,000 COVID-19-related ICU bed days nationwide. At the beginning of 2022, the total number of ICU bed days due to COVID-19 patients leveled off at around 4,000 under the dominance of Omicron variants, with the number of nonventilated ICU days steadily declining to less than 2,000 (\u0026lt;\u0026thinsp;40%). As shown in Fig.\u0026nbsp;2, the cumulative number of COVID-19-related ICU bed days in Germany increased more than tenfold from 20,6000 at the beginning of the second pandemic wave in September 2020 to 2.2\u0026nbsp;million at the end of March 2022, of which 1.2\u0026nbsp;million (55%) were ventilated ICU bed days by then.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eCOVID-19 intensive care costs\u003c/h2\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, ventilated ICU bed days consistently accounted for more than two-thirds of the corresponding quarterly total COVID-19 intensive care costs in German hospitals. The highest COVID-19 intensive care costs were incurred in the first quarter of 2021, with approximately \u0026euro;172\u0026nbsp;million for 195,384 billed nonventilated ICU bed days and \u0026euro;426.8\u0026nbsp;million for 25,0431 billed ventilated ICU bed days. Compared to those in 2020, the COVID-19 intensive care costs incurred in 2021 more than doubled to \u0026euro;486\u0026nbsp;million for nonventilated ICU bed days and \u0026euro;1.2\u0026nbsp;billion for ventilated ICU bed days in German hospitals. Therefore, the total annual COVID-19 intensive care costs increased from \u0026euro;776\u0026nbsp;million in 2020 to \u0026euro;1.7\u0026nbsp;billion in 2021. By the end of March 2022, the total COVID-19 intensive care costs incurred in Germany for the 2.2\u0026nbsp;million ICU bed days billed by hospitals up to that point amounted to almost \u0026euro;3.0\u0026nbsp;billion.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eUsing nationwide inpatient billing data from the InEK and information on mechanical ventilation from the DIVI, we first aimed to determine the COVID-19 intensive care costs in Germany over the course of the pandemic and, second, to assess the economic impact of COVID-19 intensive care from the perspective of the German health care system. In doing so, we calculated the intensive care costs incurred for the nonventilated and ventilated ICU bed days of COVID-19 patients from January 1, 2020, to March 31, 2022, and related these to SHI expenditures and the cost of illness for the German hospital sector. In this respect, we emphasize that our cost calculation served as an approximation for the respective SHI expenses, as their actual reimbursement of COVID-19 intensive care may have been different. Furthermore, COVID-19 intensive care patients may well have had a main diagnosis other than a respiratory disease, which we generally assumed in our study, also in view of the increasing number of viral pneumonia cases (ICD-10 code J12) (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe COVID-19 intensive care costs we determined for Germany were \u0026euro;776\u0026nbsp;million in 2020 and \u0026euro;1.7\u0026nbsp;billion in 2021, representing a relative cost increase of 220%. Compared to the total annual SHI expenditures on hospital treatment of \u0026euro;81.5\u0026nbsp;billion and \u0026euro;85.9\u0026nbsp;billion, our findings were less than 2.0% (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). On a quarterly basis, our cost figures ranged slightly above this percentage, particularly at the turn of the year, which appeared to be in line with the large increase in COVID-19 intensive care patients during the two winter seasons captured (\u003cspan additionalcitationids=\"CR25 CR26\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The rather low SHI expenditures for COVID-19 intensive care, which we have derived (one-to-one) from our cost figures, seemed quite plausible given a total of 17.3\u0026nbsp;million hospitalizations in 2020 and 17.2\u0026nbsp;million in 2021, of which less than 10% were COVID-19 intensive care patients in each case according to our results (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). For further comparison, inpatient treatments for neoplasms, injuries and diseases of the circulatory system were nearly or more than twice as common as for respiratory diseases, to which we assigned all COVID-19 intensive care patients (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTherefore, the COVID-19 intensive care costs we determined for 2020 (\u0026euro;776\u0026nbsp;million) amounted to 11% of the cost of respiratory disease illness for hospitals. When further narrowed down to pneumonia, whose cost of illness amounted to approximately \u0026euro;2.8\u0026nbsp;billion, the share was as high as 30% (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). However, respiratory diseases only accounted for around 6.0% of total cost of illness for German hospitals and pneumonia for just under 2.5%. Given that all COVID-19 intensive care patients had a main diagnosis of respiratory disease, this could also suggest that the corresponding SHI expenditure was rather low compared to that of other ICD-10 diagnosis groups. We would like to point out once again that although this restrictive allocation made it possible to calculate COVID-19 intensive care costs, it certainly did not apply to every patient. Although more recent illness figures for 2021 are not yet available for comparison, the immense cost increase to \u0026euro;1.7\u0026nbsp;billion (+\u0026thinsp;220% compared to 2020) revealed the growing health economic impact of COVID-19 intensive care, which was due to more than doubling the number of patients and the still high proportion of patients receiving mechanical ventilation (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The sharp increase in the number of diagnosed viral pneumonia cases, which more than doubled to over 200,000 in 2021, also appeared to substantiate this (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn summary, the cost share of COVID-19 intensive care in SHI expenditures for hospital treatment in 2020 and 2021 appeared to be rather low. If the respective expenditures of the private health insurance funds of \u0026euro;8.4\u0026nbsp;billion and \u0026euro;8.3\u0026nbsp;billion had also been considered, this cost share would have been even lower (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). A similar picture emerged when COVID-19 intensive care costs were compared to the cost of illness in the German hospital sector. However, the sheer number of critically ill COVID-19 patients has become a rapidly growing cost factor, with the frequent use of mechanical ventilation, in particular, increasing treatment costs (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). According to our results, a total of 2.2\u0026nbsp;million ICU bed days, including 1.2\u0026nbsp;million (55%) ventilated ICU bed days, were spent by German hospitals on COVID-19 patients until the end of March 2022, for which the required healthcare resources, such as ICU beds, ventilators, medical and nursing staff, etc., were (to some extent) used at the expense of care for other patients (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In this context, the costs incurred by the German health care system due to the postponement of elective procedures to provide free ICU capacity for COVID-19 patients must also be considered, as hospitals, for example, were remunerated with flat rates for providing free COVID-19 ICU capacity (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Hence, our cost calculation did not take into account that COVID-19 intensive care patients may have displaced treatment for non-COVID-19 patients. From the hospital's perspective, such a displacement scenario would mean that overall costs increased only by the additional variable costs of treating COVID-19, assuming these exceed the variable costs compared to a \"traditional\" patient. However, from a societal perspective, the overall cost of this displacement scenario would be much greater, as displaced patients may have suffered a substantial health loss (for example, through the postponement of elective procedures), which also entailed costs. Unfortunately, in this study, we were unable to quantify the degree of displacement or its financial consequences. Instead, our cost calculation implicitly assumed that COVID-19 intensive care patients were 100% additional to \u0026ldquo;traditional\u0026rdquo; patients. This assumption may seem unrealistic in its entirety, but it was necessary to obtain the COVID-19-related intensive care costs in Germany using the chosen approach. Ultimately, it seems adequate to assume that the societal costs of a displaced non-COVID-19 patient exceeded those of the refused treatment. Therefore, we believe that the direct treatment costs presented here should be interpreted as the lower bound because the displacement scenario was not captured.\u003c/p\u003e \u003cp\u003eNevertheless, we would like to substantiate our approach to determining COVID-19 intensive care costs in Germany, which was essentially based on the study by Kaier et al., whereby the economic valuation of an ICU day is based on the cost accounting method following the InEK handbook of calculation (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). According to this method, standardized unit costs per inpatient case are defined on the basis of the average expenditure (within the cost categories of staff, material and infrastructure) for an ICU day. In doing so, Kaier et al. included more than 10,500 adult intensive care patients to explicitly address the cost impact of mechanical ventilation per ICU day. Using the same \u0026lsquo;bottom-up\u0026rsquo; method for cost accounting, a study by Schallner et al. reported a mean cost of \u0026euro;3,720 per ICU day for COVID-19 patients, which is more than twice as high as the cost figures per ventilated ICU day that we referred to (see Supplementary Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). However, the number of included COVID-19 intensive care patients was relatively low at 49, almost half of whom also received ECMO therapy, which may further have increased the cost of treatment. Furthermore, no explicit distinction was made according to the use of mechanical ventilation, which was of central importance to our cost calculation, as it was frequently used in COVID-19 patients (mostly above 50% of patients nationwide during our study period) (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). A competing method of cost accounting is the willingness-to-pay (WTP) approach, which uses questionnaires to assess the WTP to liberate ICU beds given (or contingent on) a set of hypothetical conditions (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). The resulting amount of costs per ICU day then reflects the mean amount respondents would pay to release an additional ICU bed. Typically, WTP-based estimates are substantially lower than the accounting-based costs we used. On the other hand, those estimates usually represent the average WTP under low-, medium-, and high-demand scenarios. WTP-based estimates under pandemic conditions, where the demand for ICU beds has increased dramatically, are not currently available. However, as the per-case flat rates of the G-DRG system are based on a standardized cost accounting scheme for defined medically and economically homogeneous groups, the WTP approach appears to be less reliable for determining the COVID-19 intensive care costs actually billed by German hospitals (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA key strength of the present study is the representativeness of the InEK data, which includes inpatient billing cases from all hospitals in Germany that are subject to data transmission obligations according to the Hospital Remuneration Act (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In addition, we relied on the study by Kaier et al., which explicitly distinguished between nonventilated and ventilated ICU bed days for cost estimation (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). This allowed us to account for the cost impact of mechanical ventilation while incorporating the clinical severity of COVID-19 in intensive care patients. One limitation, however, is that we calculated our cost figures based on ICU treatments in 2013, while the G-DRG-based cost accounting standard changed from 2020 onward, with nursing staff costs being separated from the per-case flat rates and financed through a hospital-specific nursing budget based on cost coverage (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Furthermore, our cost figures only reflect direct COVID-19-related treatment, without considering the potential costs of displaced treatment for non-COVID-19 patients. Overall, more accurate cost figures would have required case-specific billing data for the entire course of the COVID-19 pandemic.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, COVID-19 intensive care has become a rapidly growing cost factor for the German healthcare system, with the frequent use of mechanical ventilation being an important cost driver. However, compared to the SHI expenditures and cost of illness for the hospital sector, the cost share of COVID-19 intensive care appeared rather low. A more valid assessment of the health economic impact of COVID-19 intensive care in Germany requires case-specific billing data and consideration of costs associated with the displaced treatment of non-COVID-19 patients.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCOVID-19 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Coronavirus disease 2019\u003c/p\u003e\n\u003cp\u003eDIVI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;DIVI Intensive Care Registry\u003c/p\u003e\n\u003cp\u003eECMO \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Extracorporeal membrane oxygenation\u003c/p\u003e\n\u003cp\u003eG-DRG \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; German Diagnosis-Related Groups system\u003c/p\u003e\n\u003cp\u003eICD-10 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;International Statistical Classification of Diseases and Related Health Problems 10th Revision\u003c/p\u003e\n\u003cp\u003eICU \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Intensive care unit\u003c/p\u003e\n\u003cp\u003eInEK \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Institute for the Hospital Remuneration System GmbH\u003c/p\u003e\n\u003cp\u003eSHI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Statutory health insurance\u003c/p\u003e\n\u003cp\u003eWTP \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Willingness-to-pay\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used in this study are subject to the obligation to transmit data during the year in accordance with Section 21 (3b) of the Hospital Remuneration Act. Accordingly, all hospitals that are subject to the data transmission obligation pursuant to Section 21 of the Hospital Remuneration Act are obliged to transmit their inpatient billing data to the Institute for the Hospital Remuneration System GmbH (InEK) on June 15, October 15 and January 15 of each year. The data are made available by the hospitals for the purpose of review in accordance with Section 24 of the Hospital Financing Act and for supplementary analyses for the further development of the remuneration systems. InEK provides public access to these data via its InEK Data Browser (https://datenbrowser.inek.org/). For the purpose of this study, the corresponding author requested the data directly from the InEK. The evaluation results were provided to the corresponding author with the consent of the Federal Ministry of Health. The ethics approval of this study and the need for informed consent were deemed unnecessary according to Section 21 (3b) of the Hospital Remuneration Act; hence, this information was not required for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the Institute for the Hospital Remuneration System GmbH (InEK),\u0026nbsp;but restrictions apply to the availability of these data, which were used under license for the current study and are not publicly available.\u0026nbsp;However, the data are\u0026nbsp;available from the corresponding author upon reasonable request and with\u0026nbsp;the\u0026nbsp;permission of the Federal Ministry of Health.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency\u0026nbsp;or\u0026nbsp;commercial or not-for-profit\u0026nbsp;sector.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the conception and design of the study. M.L. organized the data provision, prepared all\u0026nbsp;the\u0026nbsp;tables and figures, conducted all\u0026nbsp;the\u0026nbsp;analyses and wrote the manuscript. K.K., N.G. and M.W. provided analytical advice and supported\u0026nbsp;the\u0026nbsp;interpretation of\u0026nbsp;the\u0026nbsp;findings. All authors have read and approved the final manuscript for submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eZerbini G, Ebigbo A, Reicherts P, Kunz M, Messman H. Psychosocial burden of healthcare professionals in times of COVID-19 - a survey conducted at the University Hospital Augsburg. German medical science : GMS e-journal. 2020;18:Doc05.\u003c/li\u003e\n\u003cli\u003eKramer V, Papazova I, Thoma A, Kunz M, Falkai P, Schneider-Axmann T, et al. Subjective burden and perspectives of German healthcare workers during the COVID-19 pandemic. European archives of psychiatry and clinical neuroscience. 2021;271(2):271-81.\u003c/li\u003e\n\u003cli\u003eMorawa E, Schug C, Geiser F, Beschoner P, Jerg-Bretzke L, Albus C, et al. Psychosocial burden and working conditions during the COVID-19 pandemic in Germany: The VOICE survey among 3678 health care workers in hospitals. J Psychosom Res. 2021;144:110415.\u003c/li\u003e\n\u003cli\u003eEuropean Centre for Disease Prevention and Control (ECDC). Data on Hospital and ICU Admission Rates and Current Occupancy for COVID-19. 2023. https://www.ecdc.europa.eu/en/publications-data/download-data-hospital-and-icu-admission-rates-and-current-occupancy-covid-19. Accessed 20 Mar 2024\u003c/li\u003e\n\u003cli\u003eDIVI-Intensivregister. Aktuelle Lage. Bundesland-Berichte. Deutschland insgesamt. 2023. https://www.intensivregister.de/#/aktuelle-lage/bundesland-berichte/bericht/ALL. Accessed 20 Mar 2024.\u003c/li\u003e\n\u003cli\u003eDeutsches \u0026Auml;rzteblatt. Teils zehntausende Euro f\u0026uuml;r Intensivbehandlung von Coronapatienten. 2021. https://www.aerzteblatt.de/nachrichten/129753/Teils-zehntausende-Euro-fuer-Intensivbehandlung-von-Coronapatienten. Accessed 20 Mar 2024.\u003c/li\u003e\n\u003cli\u003eSchallner N, Lieberum J, Kalbhenn J, B\u0026uuml;rkle H, Daumann F. Intensive care unit resources and patient-centred outcomes in severe COVID-19: a prospective single-centre economic evaluation. Anaesthesia. 2022;77(12):1336-45.\u003c/li\u003e\n\u003cli\u003eQuentin W, Geissler A, Scheller-Kreinsen D, Busse R. DRG-type hospital payment in Germany: The G-DRG system. Euro Observer. 2010;12.\u003c/li\u003e\n\u003cli\u003eVerband der Ersatzkassen (VDEK). Daten zum Gesundheitswesen: Ausgaben. 2023. https://www.vdek.com/presse/daten/d_versorgung_leistungsausgaben.html. Accessed 20 Mar 2024\u003c/li\u003e\n\u003cli\u003eGesundheitsberichterstatung des Bundes (GBE-Bund). Cost of illness in millions of Euro for Germany. Classification: years, sex, ICD-10, facility. 2023. https://www.gbe-bund.de/gbe/pkg_olap_tables.prc_set_hierlevel?p_uid=gastd\u0026amp;p_aid=99596143\u0026amp;p_sprache=E\u0026amp;p_help=2\u0026amp;p_indnr=64\u0026amp;p_ansnr=82682266\u0026amp;p_version=8\u0026amp;p_dim=D.946\u0026amp;p_dw=14366\u0026amp;p_direction=drill. Accessed 20 Mar 2024.\u003c/li\u003e\n\u003cli\u003eDasta JF, McLaughlin TP, Mody SH, Piech CT. Daily cost of an intensive care unit day: the contribution of mechanical ventilation. Crit Care Med. 2005;33(6):1266-71.\u003c/li\u003e\n\u003cli\u003eKaier K, Heister T, Motschall E, Hehn P, Bluhmki T, Wolkewitz M. Impact of mechanical ventilation on the daily costs of ICU care: a systematic review and meta regression. Epidemiol Infect. 2019;147:e314.\u003c/li\u003e\n\u003cli\u003eKaier K, Heister T, Wolff J, Wolkewitz M. Mechanical ventilation and the daily cost of ICU care. BMC Health Serv Res. 2020;20(1):267.\u003c/li\u003e\n\u003cli\u003eOsterloh F. Coronavirus: Krankenh\u0026auml;user verschieben planbare Eingriffe. Dtsch Arztebl International. 2020;117(12):A-575-A-7.\u003c/li\u003e\n\u003cli\u003eBinder J, Brunner M, Maak M, Denz A, Weber GF, Gr\u0026uuml;tzmann R, Krautz C. [Economic impact of the COVID-19 pandemic in general and visceral surgery : A comparison of performance and revenue data from two departments of hospitals with different levels of referral]. Chirurg. 2021;92(7):630-9.\u003c/li\u003e\n\u003cli\u003eHunger R, K\u0026ouml;nig V, Stillger R, Mantke R. Impact of the COVID-19 pandemic on delays in surgical procedures in Germany: a multi-center analysis of an administrative registry of 176,783 patients. Patient Saf Surg. 2022;16(1):22.\u003c/li\u003e\n\u003cli\u003eInstitut f\u0026uuml;r das Entgeltsystem im Krankenhaus GmbH (InEK). Datenlieferung gem. \u0026sect; 21 Abs. 3b KHEntgG. 2023. https://www.g-drg.de/datenlieferung-gem.-21-khentgg/datenlieferung-gem.-21-abs.-3b-khentgg. Accessed 20 Mar 2024.\u003c/li\u003e\n\u003cli\u003eBundesinstitut f\u0026uuml;r Arzneimittel und Medizinprodukte (BfArM). ICD-10-GM Version 2023. Kapitel XXII Schl\u0026uuml;sselnummern f\u0026uuml;r besondere Zwecke (U00-U99). 2023. https://www.dimdi.de/static/de/klassifikationen/icd/icd-10-gm/kode-suche/htmlgm2023/block-u00-u49.htm. Accessed 20 Mar 2024.\u003c/li\u003e\n\u003cli\u003eTolksdorf K, Loenenbach A, Buda S. Dritte Aktualisierung der \u0026bdquo;Retrospektiven Phaseneinteilung der COVID-19-Pandemie in Deutschland\u0026ldquo;. Epidemiologisches Bulletin. 2022(38):3--6.\u003c/li\u003e\n\u003cli\u003eDIVI-Intensivregister. Aktuelle Lage. Downloads. Lankreis-Daten. 2023. Available from: https://www.intensivregister.de/#/aktuelle-lage/downloads. Accessed 20 Mar 2024.\u003c/li\u003e\n\u003cli\u003eSchilling J, Buda S, Fischer M, Goerlitz L, Grote U, Haas W, et al. Retrospektive Phaseneinteilung der COVID-19-Pandemie in Deutschland bis Februar 2021. 2021(15):3--12.\u003c/li\u003e\n\u003cli\u003eFederal Statistical Office for Germany (Destatis). GENESIS-Online Database. Statistics: Consumer price index for Germany. 2023. https://www-genesis.destatis.de/genesis/online?sequenz=statistikTabellen\u0026amp;selectionname=61111\u0026amp;language=en#abreadcrumb. Accessed 20 Mar 2024.\u003c/li\u003e\n\u003cli\u003eFederal Statistical Office for Germany (Destatis). GENESIS-Online Database. Hospital patients: Germany, years, main diagnosis ICD-10. 2023. https://www-genesis.destatis.de/genesis//online?operation=table\u0026amp;code=23131-0001\u0026amp;bypass=true\u0026amp;levelindex=0\u0026amp;levelid=1694443786664#abreadcrumb. Accessed 20 Mar 2024.\u003c/li\u003e\n\u003cli\u003eBundesministerium f\u0026uuml;r Gesundheit (BMG). Finanzentwicklung im 1. Quartal 2021. 2021. https://www.bundesgesundheitsministerium.de/presse/pressemitteilungen/2021/2-quartal/gkv-1-quartal-2021.html. Accessed 20 Mar 2024.\u003c/li\u003e\n\u003cli\u003eBundesministerium f\u0026uuml;r Gesundheit (BMG). Finanzentwicklung der GKV im 1. Halbjahr 2021. 2021. https://www.bundesgesundheitsministerium.de/presse/pressemitteilungen/2021/3-quartal/finanzentwicklung-der-gkv-im-1-halbjahr-2021.html. Accessed 20 Mar 2024.\u003c/li\u003e\n\u003cli\u003eBundesministerium f\u0026uuml;r Gesundheit (BMG). Finanzentwicklung der GKV im 1. bis 3. Quartal 2021. 2021. https://www.bundesgesundheitsministerium.de/presse/pressemitteilungen/finanzentwicklung-der-gkv-im-1-bis-3-quartal-2021.html. Accessed 20 Mar 2024.\u003c/li\u003e\n\u003cli\u003eBundesministerium f\u0026uuml;r Gesundheit (BMG). Finanzentwicklung der GKV im 1. Quartal 2022. 2022. https://www.bundesgesundheitsministerium.de/presse/pressemitteilungen/finanzentwicklung-der-gkv-im-1-quartal-2022.html. Accessed 20 Mar 2024.\u003c/li\u003e\n\u003cli\u003eGesundheitsberichterstatung des Bundes (GBE-Bund). Diagnostic data of the hospitals starting from 2000 (key figures of full-time inpatients). Classification: year, place of treatment/residence, ICD10. 2023. https://www.gbe-bund.de/gbe/pkg_isgbe5.prc_menu_olap?p_uid=gastd\u0026amp;p_aid=30801214\u0026amp;p_sprache=E\u0026amp;p_help=2\u0026amp;p_indnr=550\u0026amp;p_version=1\u0026amp;p_ansnr=80978339. Accessed 20 Mar 2024.\u003c/li\u003e\n\u003cli\u003eFederal Statistical Office for Germany (Destatis). Hospitals. Capitel of diagnosis by sex 2020. 2023. https://www.destatis.de/EN/Themes/Society-Environment/Health/Hospitals/Tables/capitel-diagnosis-gender.html. Accessed 20 Mar 2024.\u003c/li\u003e\n\u003cli\u003eStatistisches Bundesamt (Destatis). Vollstation\u0026auml;re Patientinnen und Patienten der Krankenh\u0026auml;user. Diagnosekapitel 2021. 2023. https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Gesundheit/Krankenhaeuser/Tabellen/diagnose-kapitel-geschlecht.html. Accessed 20 Mar 2024.\u003c/li\u003e\n\u003cli\u003eStatista GmbH. Ausgaben der privaten Krankenversicherung (PKV) f\u0026uuml;r Krankenhausbehandlungen in den Jahren 1998 bis 2021. 2022. https://de.statista.com/statistik/daten/studie/157182/umfrage/pkv-ausgaben-fuer-krankenhausbehandlungen-seit-1998/. Accessed 20 Mar 2024.\u003c/li\u003e\n\u003cli\u003eGraves N, Harbarth S, Stewardson AJ. Valuation of Hospital Bed-Days Released by Infection Control Programs: A Comparison of Methods. Infect Control Hosp Epidemiol. 2014;35(10):1294-7.\u003c/li\u003e\n\u003cli\u003eGKV-Spitzenverband. aG-DRG-System. 2022. https://www.gkv-spitzenverband.de/krankenversicherung/krankenhaeuser/drg_system/g_drg_2021/drg_system_2021.jsp. Accessed 20 Mar 2024.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"COVID-19, intensive care, mechanical ventilation, treatment costs, cost impact","lastPublishedDoi":"10.21203/rs.3.rs-4151752/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4151752/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIn late 2021, the German statutory health insurance (SHI) funds reported average expenditures for the treatment of coronavirus disease 2019 (COVID-19) intensive care patients without mechanical ventilation at \u0026euro;8,000 and even more than \u0026euro;30,000 for those with mechanical ventilation. In this context, there is currently no further information on the total COVID-19 intensive care costs or an assessment of the economic impact on the German health care system.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective cohort study was conducted from January 01, 2020, to March 31, 2022, using nationwide inpatient billing data and the proportion of mechanically ventilated COVID-19 intensive care patients in Germany. The COVID-19 intensive care costs were then determined based on reported cost accounting estimates for nonventilated and ventilated intensive care unit (ICU) bed days. The health economic impact was assessed by relating the COVID-19 intensive care costs to SHI expenditures and the cost of illness for the German hospital sector.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eBy the end of March 2022, German hospitals had spent a total of 2.2\u0026nbsp;million ICU bed days, including 1.2\u0026nbsp;million (55%) ventilated ICU bed days, for COVID-19 intensive care patients. Up to this point, the corresponding treatment costs were almost \u0026euro;3.0\u0026nbsp;billion. The annual COVID-19 intensive care costs more than doubled from \u0026euro;776\u0026nbsp;million in 2020 to \u0026euro;1.7\u0026nbsp;billion in 2021. This meant a cost increase of \u0026euro;203.1\u0026nbsp;million to \u0026euro;486\u0026nbsp;million for nonventilated ICU bed days and \u0026euro;573.2\u0026nbsp;million to \u0026euro;1.2\u0026nbsp;billion for ventilated ICU bed days. The cost share of COVID-19 intensive care in SHI expenditures for hospital treatment was predominantly less than 2.0%, and approximately 6.0% of the cost of illness for the hospital sector in 2020.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIn conclusion, COVID-19 intensive care has become a rapidly growing cost factor for the German healthcare system, with the frequent use of mechanical ventilation being an important cost driver. However, compared to the SHI expenditures and cost of illness for the hospital sector, the cost share of COVID-19 intensive care appeared rather low. A more valid assessment of the health economic impact of COVID-19 intensive care in Germany requires case-specific billing data and consideration of costs associated with the displaced treatment of non-COVID-19 patients.\u003c/p\u003e","manuscriptTitle":"Determination of COVID-19 intensive care costs in Germany and assessment of the economic impact on the healthcare system - a nationwide retrospective cohort study from January 2020 to March 2022","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-28 17:55:29","doi":"10.21203/rs.3.rs-4151752/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7fbdc6e2-7a17-49a3-ac80-73ec1c6364f0","owner":[],"postedDate":"March 28th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-04-25T06:53:53+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-28 17:55:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4151752","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4151752","identity":"rs-4151752","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}