Effects of COVID-19-targeted non-pharmaceutical interventions on pediatric emergency department use: a quasi-experimental study interrupted time-series analysis in North Italian hospitals, 2017 to 2022

Abstract

Background: The use of Non-Pharmaceutical Interventions (NPIs) during the COVID-19 pandemic is debated. Understanding the consequences these measures may have on vulnerable populations including children and adolescents is important.

Methods: This is a multicenter, quasi-experimental before-after study involving 12 hospitals of the North Italian Emilia-Romagna Region, with NPI implementation as the intervention event. The 3 years preceding NPI implementation (in March 2020) constituted the pre-pandemic phase. The subsequent 2 years were further subdivided into a school closure phase (SC) and a subsequent mitigation measures phase (MM) with milder restrictions. Interrupted Time Series (ITS) regression analysis was used to calculate PED Standardized Incidence Rate Ratios (SIRR) on the diagnostic categories exhibiting the greatest frequency and/or variation.

Results: In the 60 months of the study there were 765,215 PED visits. Compared to the pre-pandemic rate, overall PED presentations dropped by 58 and 39% during SC and MM, respectively. "Symptoms, signs and Ill-defined conditions," "Injury and poisoning" and "Diseases of the Respiratory System" accounted for 74% of the reduction. A different pattern was instead seen for "Mental Disorders," which exhibited the smallest decrease during SC, and is the only category which rose already at the end of SC. ITS analysis confirmed the strong decrease during SC (level change, IRR 0.17, 95%CI 0.12-0.27) and a significant increase in MM (slope change, IRR 1.23, 95%CI 1.13-1.33), with the sharpest decline (-94%) and rise (+36%) observed in the "Diseases of the Respiratory System" category. Mental Disorders showed a significant increasing trend of 1% monthly over the whole study period exceeding pre-pandemic levels at the end of MM. Females and adolescents showed higher increasing rates both in SC and MM.

Conclusion: NPIs appear to have influenced PED attendance in different ways according to diagnostic categories, mirroring different mechanisms of action. These effects are beneficial in some cases and harmful in others, and establishing a clear balance between pros and cons is a difficult task for public health decision makers. The role of NPIs on PED use appropriateness deserves investigation. The rise in pediatric mental disorders independent of the pandemic makes interventions addressing these issues urgent.

Keywords: COVID-19 epidemiology; Diseases of the Respiratory System; Interrupted Time Series regression analysis; Non-Pharmaceutical Intervention; Symptoms; injury and poisoning; mental disorders; quasi-experimental design.

Figure 1

Forest plot of Standardized Incidence Rate Ratios (SIRR) for individual ICD9-CM diagnostic categories and for “any diagnosis,” during the three time phases: the 3 years pre-COVID19 phase (PC), the subsequent 1 year “school closure” phase (SC, March to September 2020), and the 1 year “mitigation measures” phase (MM, October 2020 to February 2022), when schools were reopened but milder restrictions remained. Estimates are reported as x 100,000 person-month and are age & sex standardized using as Standard the European resident population in 2020. SIRR, Standardized Incidence Rate Ratio; PC, pre-COVID19 phase; SC, School closure phase; MM, Mitigation measures phase.

Figure 2

Monthly Pediatric Emergency Department Incidence Rate for any disease, with line trend from Interrupted Time Series (ITS) regression analysis during the three time phases: the 3 years pre-COVID19 phase (PC), the subsequent 1 year “school closure” phase (SC, March to September 2020), and the 1 year “mitigation measures” phase (MM, October 2020 to February 2022), when schools were reopened but milder restrictions remained. PC, pre-COVID19 phase; SC, School closure phase; MM, Mitigation measures phase.

Figure 3

Monthly Pediatric Emergency Department Incidence Rate for Symptom, signs and Ill-defined conditions (A), Injury and Poisoning (B), Diseases of the Respiratory System (C) and Mental Disorders (D) with line trend from Interrupted Time Series (ITS) regression analysis during the three time phases: the 3 years pre-COVID19 phase (PC), the subsequent 1 year “school closure” phase (SC, March to September 2020), and the 1 year “mitigation measures” phase (MM, October 2020 to February 2022), when schools were reopened but milder restrictions remained. PC, pre-COVID19 phase; SC, School closure phase; MM, Mitigation measures phase.