Effect of Stay-at-Home orders and other COVID-related policies on trauma hospitalization rates and disparities in the USA: a statewide time-series analysis

Abstract

Background: To combat the coronavirus pandemic, states implemented several public health policies to reduce infection and transmission. Increasing evidence suggests that these prevention strategies also have had a profound impact on non-COVID healthcare utilization. The goal of this study was to determine the impact of a statewide Stay-at-Home order and other COVID-related policies on trauma hospitalizations, stratified by race/ethnicity, age, and sex.

Methods: We used the North Carolina Trauma Registry, a statewide registry of trauma hospitalizations for 18 hospitals across North Carolina, including all North Carolina trauma centers, to calculate weekly rates of assault, self-inflicted, unintentional motor vehicle collision (MVC), and other unintentional injury hospitalizations between January 1, 2019, and December 31, 2020. Interrupted time-series design and segmented linear regression were used to estimate changes in hospitalization rates after several COVID-related executive orders, overall and stratified by race/ethnicity, age, and sex. Changes in hospitalization rates were assessed after 1) USA declaration of a public health emergency; 2) North Carolina statewide Stay-at-Home order; 3) Stay-at-Home order lifted with restrictions (Phase 2: Safer-at-Home); and 4) further lifting of restrictions (Phase 2.5: Safer-at-Home).

Results: There were 70,478 trauma hospitalizations in North Carolina, 2019-2020. In 2020, median age was 53 years old and 59% were male. Assault hospitalization rates (per 1,000,000 NC residents) increased after the Stay-at-Home order, but substantial increases were only observed among Black/African American residents (weekly trend change = 1.147, 95% CI = 0.634 to 1.662) and 18-44-year-old males (weekly trend change = 1.708, 95% CI = 0.870 to 2.545). After major restrictions were lifted, assault rates decreased but remained elevated compared to pre-COVID levels. Unintentional non-MVC injury hospitalizations decreased after the USA declared a public health emergency, especially among women ≥ 65 years old (weekly trend change = -4.010, 95% CI = -6.166 to -1.855), but returned to pre-pandemic levels within several months.

Conclusions: Statewide Stay-at-Home orders placed Black/African American residents at higher risk of assault hospitalizations, exacerbating pre-existing disparities. Males 18-44 years old were also at higher risk of assault hospitalization. Fear of COVID-19 may have led to decreases in unintentional non-MVC hospitalization rates, particularly among older females. Policy makers must anticipate policy-related harms that may disproportionately affect already disadvantaged communities and develop mitigation approaches.

Keywords: Assault; Motor vehicle collisions; Stay-at-Home; Trauma disparities.

Fig. 1

Overall impact of COVID-19 executive orders on the weekly number of trauma admissions for A) intentional and B) unintentional injuries between January 2019 and December 2020 in North Carolina. The black lines represent the timing of the four executive orders assessed in the analyses (the USA declares public health emergency, North Carolina statewide Stay-at-Home order, statewide Phase 2: Safer-at-Home order, and statewide Phase 2.5: Safer-at-Home order); gray lines represent the time of the other COVID-related executive orders. Weekly trend changes in bold are statistically significant (p < 0.05)

Fig. 2

Impact of COVID-19 executive orders on the weekly number of assault admissions between January 2019 and December 2020 in North Carolina, stratified by A) race/ethnicity, B) age group among females, and C) age group among males. The black lines represent the timing of the four executive orders assessed in the analyses (the USA declares public health emergency, North Carolina statewide Stay-at-Home order, statewide Phase 2: Safer-at-Home order, and statewide Phase 2.5: Safer-at-Home order); gray lines represent the time of the other COVID-related executive orders. Weekly trend changes in bold are statistically significant (p < 0.05)

Fig. 3

Impact of COVID-19 executive orders on the weekly number of unintentional MVC admissions between January 2019 and December 2020 in North Carolina, stratified by A) race/ethnicity, B) age group among females, and C) age group among males. The black lines represent the timing of the four executive orders assessed in the analyses (the USA declares public health emergency, North Carolina statewide Stay-at-Home order, statewide Phase 2: Safer-at-Home order, and statewide Phase 2.5: Safer-at-Home order); gray lines represent the time of the other COVID-related executive orders. Weekly trend changes in bold are statistically significant (p < 0.05)

Fig. 4

Impact of COVID-19 executive orders on the weekly number of unintentional non-MVC admissions between January 2019 and December 2020 in North Carolina, stratified by A) race/ethnicity, B) age group among females, and C) age group among males. The black lines represent the timing of the four executive orders assessed in the analyses (the USA declares public health emergency, North Carolina statewide Stay-at-Home order, statewide Phase 2: Safer-at-Home order, and statewide Phase 2.5: Safer-at-Home order); gray lines represent the time of the other COVID-related executive orders. Weekly trend changes in bold are statistically significant (p < 0.05)