Alcohol-Related Hospitalizations During the Initial COVID-19 Lockdown in Massachusetts: An Interrupted Time-Series Analysis
Background: The effect of initial COVID-19 pandemic–associated lockdowns on alcohol-related hospitalizations remains uncertain. This study compares alcohol-related hospitalizations at a US Department of Veterans Affairs (VA) system in Massachusetts before, during, and after the initial COVID-19 lockdown.
Methods: This study is an interrupted time-series analysis at the VA Boston Healthcare System. Participants included all patients hospitalized on the medical, psychiatry, and neurology services at VA Boston Healthcare System from January 1, 2017, to December 31, 2020, excluding those under observation status. The period January 1, 2017, to March 9, 2020, was defined as prelockdown (the reference group); March 10, 2020, to May 18, 2020, was lockdown; and May 19, 2020, to December 31, 2020, was postlockdown. Alcohol-related hospitalizations were determined using International Statistical Classification of Diseases, Tenth Revision primary diagnosis codes.
Results: We identified 27,508 hospitalizations during the study periods. There were 72 alcohol-related hospitalizations per 100,000 patient-months during the prelockdown period, 10 per 100,000 patient-months during the lockdown, and 46 per 100,000 patient-months in the postlockdown period. Compared with the prelockdown period, the adjusted rate ratio for daily alcohol-related hospitalizations during lockdown was 0.20 (95% CI, 0.10-0.39) vs 0.72 (95% CI, 0.57-0.92) after the lockdown. A similar pattern was observed for all-cause hospitalizations.
Conclusions: Our results suggest that COVID-19 pandemic lockdown measures were associated with fewer alcohol-related hospitalizations. Proactive outreach for vulnerable populations during lockdowns is needed.
Results
During the study period, 27,508 hospitalizations were available for analysis. The 7-day moving average of total daily hospitalizations and total daily alcohol-related hospitalizations over time for the period January 1, 2017, to December 31, 2020, are shown in the Figure.
The incidence of alcohol-related hospitalizations in the population dropped from 72 per 100,000 patient-months to 10 per 100,000 patient-months during the lockdown period and increased to 46 per 100,000 patient-months during the postlockdown period (Table).
Our results were not substantially different when we ran a sensitivity analysis that excluded the total daily number of admissions from our model. Compared with the prelockdown period, the rate ratio for the number of alcohol-related hospitalizations during the lockdown period was 0.16 (95% CI, 0.08-0.30), and the rate ratio for the postlockdown period was 0.65 (95% CI, 0.52-0.82). We conducted an additional sensitivity analysis using a broader definition of the primary outcome to include all alcohol-related diagnosis codes; however, the results were unchanged.
Discussion
During the spring 2020 COVID-19 lockdown period in Massachusetts, the daily number of VABHS alcohol-related hospitalizations decreased by nearly 80% compared with the prelockdown period. During the postlockdown period, the daily number of alcohol-related hospitalizations increased but only to 72% of the prelockdown baseline by the end of December 2020. A similar trend was observed for all-cause hospitalizations for the same exposure periods.
These results differ from 2 related studies on the effect of the COVID-19 pandemic on alcohol-related hospitalizations.10,11 In a retrospective study of ED visits to 4 hospitals in New York City, Schimmel and colleagues reported that from March 1 to 31, 2020 (the initial COVID-19 peak), hospital visits for alcohol withdrawal increased while those for alcohol use decreased.10 However, these results are reported as a percentage of total ED visits rather than the total number of visits, which are vulnerable to spurious correlation because of concomitant changes in the total number of ED visits. In their study, the absolute number of alcohol-related ED visits did not increase during the initial 2020 COVID-19 peak, and the number of visits for alcohol withdrawal syndrome declined slightly (195 in 2019 and 180 in 2020). However, the percentage of visits increased from 7% to 10% because of a greater decline in total ED visits. This pattern of decline in the number of alcohol-related ED visits, accompanied by an increase in the percentage of alcohol-related ED visits, has been observed in at least 1 nationwide surveillance study.17 This apparent increase does not reflect an absolute increase in ED visits for alcohol withdrawal syndrome and represents a greater relative decline in visits for other causes during the study period.
Sharma and colleagues reported an increase in the percentage of patients who developed alcohol withdrawal syndrome while hospitalized in Delaware per 1000 hospitalizations during consecutive 2-week periods during the pandemic in 2020 compared with corresponding weeks in 2019.11 The greatest increase occurred during the last 2 weeks of the Delaware stay-at-home order. The Clinical Institute Withdrawal Assessment of Alcohol Scale, revised (CIWA-Ar) score of > 8 was used to define alcohol withdrawal syndrome. The American Society of Addiction Medicine does not recommend using CIWA-Ar to diagnose alcohol withdrawal syndrome because the scale was developed to monitor response to treatment, not to establish a diagnosis.18
Although the true population incidence of alcohol-related hospitalizations is difficult to estimate because the size of the population at risk (ie, the denominator) often is not known, the total number of hospitalizations is not a reliable surrogate.19 Individuals hospitalized for nonalcohol causes are no longer at risk for alcohol-related hospitalization.
In our study, we assume the population at risk during the study period is constant and model changes in the absolute number—rather than percentage—of alcohol-related ED visits. These absolute estimates of alcohol-related hospitalizations better reflect the true burden on the health care system and avoid the confounding effect of declining total ED visits and hospitalizations that could lead to artificially increased percentages and spurious correlation.20 The absolute percentage of alcohol-related hospitalizations also decreased during this period; therefore, our results are not sensitive to this approach.
Several factors could have contributed to the decrease in alcohol-related hospitalizations. Our findings suggest that patient likelihood to seek care and clinician threshold to admit patients for alcohol-related conditions are influenced by external factors, in this case, a public health lockdown. Although our data do not inform why hospitalizations did not return to prelockdown levels, our experience suggests that limited bed capacity and longer length of stay might have contributed. Other hypotheses include a shift to outpatient care, increased use of telehealth (a significant focus early in the pandemic), and avoiding care for less severe alcohol-related complications because of lingering concerns about exposure to COVID-19 in health care settings reported early in the pandemic. Massachusetts experienced a particularly deadly outbreak of COVID-19 in the Soldiers’ Home, a long-term care facility for veterans in Holyoke.21
Evidence suggests that in-home consumption of alcohol increased during lockdowns.8-10 Our results show that during this period hospitalizations for alcohol-related conditions decreased at VABHS, a large urban VA medical system, while alcohol-related deaths increased nationally.13 Although this observation is not evidence of causality, these outcomes could be related.
In the 2 decades before the pandemic, alcohol-related deaths increased by about 2% per year.22 From 2019 to 2020, there was a 25% increase that continued through 2021.13 Death certificate data often are inaccurate, and it is difficult to determine whether COVID-19 had a substantial contributing role to these deaths, particularly during the initial period when testing was limited or unavailable. Nonetheless, deaths due to alcohol-associated liver disease, overdoses involving alcohol, and alcohol-related traffic fatalities increased by > 10%.13,23 These trends, along with a decrease in hospitalization for alcohol-related conditions, suggest missed opportunities for intervention with patients experiencing alcohol use disorder.
