The coronavirus disease 2019 (COVID-19) stay-at-home order's unequal effects on trauma volume by insurance status in Southern California

Abstract

Background: The rapid spread of coronavirus disease 2019 in the United States led to a variety of mandates intended to decrease population movement and "flatten the curve." However, there is evidence some are not able to stay-at-home due to certain disadvantages, thus remaining exposed to both coronavirus disease 2019 and trauma. We therefore sought to identify any unequal effects of the California stay-at-home orders between races and insurance statuses in a multicenter study utilizing trauma volume data.

Methods: A posthoc multicenter retrospective analysis of trauma patients presenting to 11 centers in Southern California between the dates of January 1, 2020, and June 30, 2020, and January 1, 2019, and June 30, 2019, was performed. The number of trauma patients of each race/insurance status was tabulated per day. We then calculated the changes in trauma volume related to stay-at-home orders for each race/insurance status and compared the magnitude of these changes using statistical resampling.

Results: Compared to baseline, there was a 40.1% drop in total trauma volume, which occurred 20 days after stay-at-home orders. During stay-at-home orders, the average daily trauma volume of patients with Medicaid increased by 13.7 ± 5.3%, whereas the volume of those with Medicare, private insurance, and no insurance decreased. The average daily trauma volume decreased for White, Black, Asian, and Latino patients with the volume of Black and Latino patients dropping to a similar degree compared to White patients.

Conclusion: This retrospective multicenter study demonstrated that patients with Medicaid had a paradoxical increase in trauma volume during stay-at-home orders, suggesting that the most impoverished groups remain disproportionately exposed to trauma during a pandemic, further exacerbating existing health disparities.

Fig. 1

Comparison of trauma volume from February through June in 2020 and 2019. Total cases per day were accumulated across 11 participating sites. California stay-at-home orders were initiated on March 19, 2020. The curves were subjected to a smoothing function (see Methods).

Fig. 2

Comparison of trauma volume over time as a function of patient insurance. The trauma volume numbers were normalized to a value of 1 for all insurance types over an initial time period (20 days). The curves were subjected to a smoothing function (see Methods). The horizontal line highlights the condition of 25% reduction from initial volume.

Fig. 3

Changes in daily trauma volume between pre and post stay-at-home orders (January 1, 2020, to February 29, 2020, versus March 1, 2020 to June 1, 2020) according to insurance type. Positive values (downward pointing bars) indicate a drop in volume during the stay-at-home period. The error bars indicate the uncertainty in the percentage drop expressed as a root mean square deviation from the observed value across random statistical resampling simulations (see Methods).

Fig. 4

Comparison of trauma volume over time as a function of patient race. The trauma volume numbers were normalized to a value of 1 for all races over an initial time period (20 days). The curves were subjected to a smoothing function (see Methods). The horizontal line highlights the condition of 25% reduction from initial volume.

Fig. 5

Changes in daily trauma volume between pre and post stay-at-home orders (January 1, 2020, to February 29, 2020 versus March 1, 2020 to June 1, 2020) according to patient race. Positive values (downward pointing bars) indicate a drop in volume during the stay-at-home period. The error bars indicate the uncertainty in the percentage drop expressed as a root mean square deviation from the observed value across random statistical resampling simulations (see Methods).