The Influence of Social Distancing on COVID-19 Mortality in US Counties: Cross-sectional Study.

BACKGROUND: Previous studies on the impact of social distancing on COVID-19 mortality in the United States have predominantly examined this relationship at the national level and have not separated COVID-19 deaths in nursing homes from total COVID-19 deaths. This approach may obscure differences in social distancing behaviors by county in addition to the actual effectiveness of social distancing in preventing COVID-19 deaths. OBJECTIVE: This study aimed to determine the influence of county-level social distancing behavior on COVID-19 mortality (deaths per 100,000 people) across US counties over the period of the implementation of stay-at-home orders in most US states (March-May 2020). METHODS: Using social distancing data from tracked mobile phones in all US counties, we estimated the relationship between social distancing (average proportion of mobile phone usage outside of home between March and May 2020) and COVID-19 mortality (when the state in which the county is located reported its first confirmed case of COVID-19 and up to May 31, 2020) with a mixed-effects negative binomial model while distinguishing COVID-19 deaths in nursing homes from total COVID-19 deaths and accounting for social distancing- and COVID-19-related factors (including the period between the report of the first confirmed case of COVID-19 and May 31, 2020; population density; social vulnerability; and hospital resource availability). Results from the mixed-effects negative binomial model were then used to generate marginal effects at the mean, which helped separate the influence of social distancing on COVID-19 deaths from other covariates while calculating COVID-19 deaths per 100,000 people. RESULTS: We observed that a 1% increase in average mobile phone usage outside of home between March and May 2020 led to a significant increase in COVID-19 mortality by a factor of 1.18 (P<.001), while every 1% increase in the average proportion of mobile phone usage outside of home in February 2020 was found to significantly decrease COVID-19 mortality by a factor of 0.90 (P<.001). CONCLUSIONS: As stay-at-home orders have been lifted in many US states, continued adherence to other social distancing measures, such as avoiding large gatherings and maintaining physical distance in public, are key to preventing additional COVID-19 deaths in counties across the country.

Discussion on "Improving precision and power in randomized trials for COVID-19 treatments using covariate adjustment for binary, ordinal, and time-to-event outcomes".

Benkeser et al. present a very informative paper evaluating the efficiency gains of covariate adjustment in settings with binary, ordinal, and time-to-event outcomes. The adjustment method focuses on estimating the marginal treatment effect averaged over the covariate distribution in both arms combined. The authors show that covariate adjustment can achieve power gains that could find answers more quickly. The suggested approach is an important weapon in the armamentarium against epidemics like COVID-19. I recommend evaluating the procedure against more traditional approaches for conditional analyses (e.g., logistic regression) and against blinded methods of building prediction models followed by randomization-based inference.