Trust and the impact of state interventions on healthcare utilization during the COVID-19 pandemic in Germany: An instrumental variables approach

BACKGROUND: Non-pharmaceutical interventions were enacted to minimize COVID-19-related mortality and morbidity during the pandemic. OBJECTIVE: To examine the causal effect of state interventions, implemented to limit COVID-19 mortality and morbidity, on non-COVID-19 hospital utilization, and whether this effect varied by the level of trust in the healthcare system. METHODS: The causal effect of state interventions on non-COVID-19 hospital utilization is estimated using an instrumental variables framework, exploiting the variation in the timing of municipal and state elections, and by level of trust in the healthcare system. Main data source is all hospital admissions from 2016-2021 in Germany. All non-respiratory hospital admissions, admissions for emergency conditions, elective surgeries, and chronic conditions are examined. RESULTS: On average, non-respiratory hospital admissions declined by 19.2 admissions per 10,000 population per four-weeks (-12.5%, p-value