Lead/Presenter: Kevin Griffith, Partnered Evidence-Based Policy Resource Center
All Authors: Avila CJ (Partnered Evidence-Based Policy Resource Center, Boston University), Feyman Y (Partnered Evidence-Based Policy Resource Center, Boston University) Auty SG (Boston University) Mulugeta M (Boston University) Strombotne, KL (Partnered Evidence-Based Policy Resource Center, Boston University) Legler, A (Partnered Evidence-Based Policy Resource Center) Griffith, KN (Partnered Evidence-Based Policy Resource Center, Vanderbilt University)
Objectives:
The long-standing history of structural racism in the United States negatively affects the health of minoritized communities via several pathways including health care access, economic, and occupational inequities. The COVID-19 pandemic reinforced these disparities; racial and ethnic minorities have a greater prevalence of risk factors for severe COVID-19 illness and are experiencing disproportionately higher rates COVID-19 infections, hospitalizations, and mortality. However, veterans of the U.S. armed forces face a unique set of circumstances and their experiences during the pandemic may differ from the general population. In this study, our objectives were to identify the extent to which veterans experienced increased mortality attributable to COVID-19 stratified by race and ethnicity.
Methods:
We obtained administrative data from the Veterans Health Administration’s (VHA) Corporate Data Warehouse for 11.4 million enrolled veterans who sought care during 2016-2020. Potential predictors of mortality included individual-level demographics, priority group (an eligibility determination which reflects disability related to military service or economic hardship), and major comorbidities. We used enrollee data from January 2016 through February 2020 to estimate a mortality risk prediction model using five-fold cross-validation and Poisson quasi-likelihood regression. We then estimated excess mortality and observed versus expected (O/E) mortality ratios for veterans during March-December 2020., stratified by race/ethnicity categories. Differences in O/E ratios between race/ethnicity were used to characterize disparities.
Results:
There were a total of 359,418 deaths among Veterans from March-December 2020. We estimated that excess mortality for all veterans was 18% above normal during this span, which equates to 55,855 excess deaths. However, there was substantial variation by racial and ethnic group. Non-Hispanic White veterans had the lowest rate of excess mortality (17%, 95% CI 11% to 24%), while Native American veterans had the highest excess mortality (40%, 95% CI 17% to 73%). Black veterans (32%, 95% CI 27% to 39%) and Hispanic veterans (26%, 95% CI 17% to 36%) had somewhat lower excess mortality, although these rates were significantly higher compared to White veterans.
Implications:
While VHA experienced substantial disparities in excess all-cause mortality by race and ethnicity in 2020, our analyses show that excess mortality was substantially lower in magnitude than previous estimates for the general population.
Impacts:
Previous research demonstrated that veterans experienced lower rates of excess all-cause mortality compared to the general population, and several unique features of VHA care may explain this divergence. Unlike employer-sponsored health insurance, VHA care is also decoupled from employment and facilitates continuity of care despite pandemic-related job losses. The VHA also had robust pre-existing telehealth infrastructure and racial disparities in COVID-19 vaccine uptake were effectively absent among VHA enrollees. However, our work demonstrates more work remains to be done to mitigate excess mortality among minoritized populations. Identifying targeted interventions, i.e., incentivizing clinicians of color to serve in these communities so that patients might feel represented, could assist in improving care and thus lower the excess mortality rate for future pandemics, regardless of veterans’ race or ethnicity.