The Decline in Medical Rehabilitation for Children and Adolescents in Germany in the First Year of the SARS-CoV-2 Pandemic

The spread of SARS-CoV-2 has affected the living conditions of children and adolescents worldwide. In Germany, discussions currently focus not only on the risk of development and educational deficits due to infection control measures, but also on potential effects on the health and needs-based care of children and adolescents. Studies have shown an increase in mental health problems and a decrease in health-related quality of life (1). Chronically ill children and their relatives have been especially affected by the pandemic situation. Further, the use of health services by children and adolescents, such as visits to pediatricians, has declined (2). Rehabilitative care is particularly important for providing opportunities to participate to children with chronic illnesses. However, reduction of pediatric care, closure of rehabilitation facilities, and reduced admission capacities due to infection control measures in the rehabilitation facilities are likely to have led to a significant decrease in child and youth rehabilitation (CYR) in the first year of the pandemic. Nonetheless, a comparative analysis of the pre- and peri-pandemic CYR utilization in Germany has not yet been carried out. We therefore examined whether CYR utilization changed following the declaration of an epidemic situation by the German Bundestag at the end of March 2020, as compared to the previous year.

Methods

The pandemic-related reduction in CYR utilization was estimated using the difference-in-differences (DiD) approach (3) based on monthly cross-sectional data from the statutory German Pension Insurance (GPI). Completed CYR that began and ended in 2019 or 2020 were taken into account. Gender, federal state, diagnosis group, and the month of rehabilitation start were included in the analyses as stratifying characteristics. The calculated DiD estimator was determined using a Poisson regression and describes the difference between the pre- and post-observation periods in 2019 or 2020, whereby the pre-observation period was in the first quarter of each year, and the post-observation period was considered from April to December. The incidence rate ratio (IRR) was calculated for estimating the DiD. The difference between the IRR value and 1 corresponds to the average pandemic-related decline in rehabilitation in the follow-up period of 2020. In addition, sensitivity analyses were carried out using a pre-observation period from January to February, and a follow-up period from March to December.

Results

The analyses take into account 30 817 cases of CYR in the pre-pandemic year 2019, and 20 945 cases of CYR in the pandemic year 2020. In 2020, CYR utilization decreased on average by 32.1% as compared to the previous year (IRR: 0.679; 95% confidence interval [CI] [0.654; 0.706]) (Figure). The decline was similar for boys and girls. The three most common diagnosis groups were mental disorders, metabolic and digestive disorders (and in particular, obesity), and respiratory diseases; of these, rehabilitation due to mental disorders showed the lowest reduction of use, of 16.5% (IRR: 0.835 [0.779; 0.894]). Rehabilitation due to respiratory diseases showed the highest reduction of utilization, of 45.4% (IRR: 0.546 [0.501; 0.594]). Regionally, the reduction of CYR utilization in the western federal states (IRR: 0.652 [0.622; 0.683]) was higher than that in the eastern federal states (including Berlin) (IRR: 0.746 [0.696; 0.798]). The highest reduction was observed for GPI-insured residents of Bremen (IRR: 0.378 [0.220; 0.650]), while the lowest reduction was for GPI-insured residents of Brandenburg (IRR: 0.898 [0.758; 1.064]) (Table).

Figure

Difference-in-differences estimator for the pandemic-related reduction based on stratifying characteristics (primary and sensitivity analyses)

Table

Pandemic-related reduction in medical rehabilitation for children and adolescents in the federal states of Germany in 2020

Including the month of March in the follow-up period for the sensitivity analyses led to an even clearer overall reduction in CYR utilization, of 39.6% (IRR: 0.604 [0.579; 0.631]) (Figure).

Discussion

Recent analyses have shown a 14.5% decrease in rehabilitation requests during the first year of the pandemic (3). In contrast, we observed a significantly greater decrease in CYR utilization, of 32.1%. Possible reasons for this reduction in requests include a changed willingness to use the service by those affected, as well as barriers to access caused by the pandemic, such as fewer contacts with advising pediatricians. Use was also possibly influenced by the availability of an appropriate, GPI-approved practice and the consideration of regionally applicable hygiene and infection protection guidelines at the clinic locations for implementing medical CYR. Regionally different guidelines of the state governments and the pension insurance institutions could also explain the differences in decline between the federal states. In the case of psychological problems, the decrease in use is comparatively small, at 16.5%. Due to the increase in stressors and mental stress during the pandemic, it can be assumed that the need for support for children and adolescents increased in particular with regard to mental health issues (1, 4). The large decrease in respiratory disease may be associated with greater COVID-19–related anxiety for parents of children with chronic respiratory disease and therefore reduced use of respiratory disease outpatient services. For chronically ill children and adolescents, forgoing medical rehabilitation may entail the risk of worsening the primary disease as well as psychological comorbidities if needs-based care is not provided in the long term (5). In addition, associated problems in the areas of education and participation could be aggravated.

Hannes Banaschak, David Fauser, Annika Sternberg, Pia Zollmann, Marco Streibelt, Matthias Bethge

Conflict of interest statement
The Institute for Social Medicine and Epidemiology has received several third-party project funding from the Federal German Pension Insurance.

Matthias Bethge is the Vice-President of the Deutsche Gesellschaft für Rehabilitationswissenschaften (German Society for Rehabilitation Sciences) and Board Member of the Verein zur Förderung der Rehabilitationsforschung (Association for the Promotion of Rehabilitation Research) in Hamburg, Mecklenburg-Western Pomerania, and Schleswig-Holstein.

Manuscript received on 2 February 2022, revised version accepted on 7 March 202.

Translated from the original German by Veronica A. Raker, PhD.

Cite this as:
Banaschak H, Fauser D, Sternberg A, Zollmann P, Streibelt M, Bethge M: The decline in medical rehabilitation for children and adolescents in Germany in the first year of the SARS-CoV-2 pandemic. Dtsch Arztebl Int 2022; 119: 350–1. DOI: 10.3238/arztebl.m2022.0164

References

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