BACKGROUND/RATIONALE:
In 2020, the rapid spread of coronavirus worldwide forced VHA hospitals across the country to start triaging the delivery of medical procedures, in efforts to flatten the curve of COVID-19 growth and its associated high mortality. On March 17, 2020, with a shelter-in-place order first deployed across a 6-county region of Northern California, and soon after, across the state of California and other regions across the country, VA hospitals started postponing all elective cardiovascular procedures, while permitting only urgent, life-threatening ones. Days later, professional societies published guidelines recommending similar rationing at scale, both to conserve resources and to prevent elderly, at-risk patients from unnecessary exposure to the highly contagious virus. There are important reasons why this approach warrants rapid evaluation: (1) COVID-19 has produced an unprecedented natural experiment to demonstrate the comparative effectiveness of a vast number of high cost procedures to guide future treatment decisions on usefulness of therapies or de-implementation, which traditional randomized controlled trials will likely never accomplish, (2) evaluation of this approach will inform how to best manage healthcare rationing responses in disaster situations, pandemics, workforce disruptions, and abrupt changes in operational capacity or funding, (3) we must determine whether vulnerable populations are disproportionately impacted by this approach to ensure that we are delivering equitable care to our Veterans at highest risk of adverse health outcomes. To achieve this, we have adapted the structure-process-outcome conceptual model to assess the impact of delays within the VHA (Fig 1, "S"= structure, "P"= process, "O"=outcome).

OBJECTIVE(S):
Specific Aim 1. To describe the impact of the COVID-19 pandemic on cardiovascular procedural volumes across the VHA nationally.

Specific Aim 2. To assess whether there were differences in procedural treatment among vulnerable populations within the VHA comparing the pre to post-COVID-19 period.

Specific Aim 3. To compare downstream outcomes in Veterans hospitalized with incident STEMI, NSTEMI, severe aortic stenosis, and AV block before and after the COVID-19 pandemic and to determine if inpatient procedure use mediates those outcomes.

METHODS:
We will assess the total number of procedures performed from Dec 2018 to present, across the spectrum of cardiovascular disease treatments (e.g. PCI, TAVR, pacemaker, atrial fibrillation ablation, etc). We will compare Mar-July 2019 to Mar-July 2020 to see differences in volumes impacted by COVID 19. We will compare across the following demographic and disease categories: race, gender, geography (less than or farther than 200 miles from tertiary care center), socioeconomic status (income quartile by zip code), education (by zip code) and age (less than or older than 65), COVID-19 positive status. We will assess inpatient mortality and LOS, with comparison over time. We will also assess complexity of procedure by MS-DRG codes.

FINDINGS/RESULTS:
Results: NSTEMI volumes dropped significantly with the pandemic onset (62.7% of pre-pandemic peak) and did not revert to pre-pandemic levels in subsequent phases, even after vaccine availability. Percutaneous coronary intervention (PCI) and/or coronary artery bypass grafting (CABG) volumes declined proportionally. Compared to the pre-pandemic period, NSTEMI patients experienced higher 30-day mortality during Phase 2 and 3, even after adjustment for COVID-19 positive status, demographics, baseline comorbidities, and receipt of procedural treatment (adjusted OR for Phase 2-3 combined: 1.26 [95% CI 1.13-1.43], p<0.01). Patients receiving VA-paid community care had a higher adjusted risk of 30-day mortality compared to those at VA hospitals across all six pandemic phases.

Conclusions: Higher mortality after NSTEMI occurred during the initial spread and first peak of the pandemic, but resolved before the second, higher peak - suggesting effective adaptation of care delivery but a costly delay to implementation. Investigation into the vulnerabilities of the early pandemic spread are vital to informing future resource-constrained practices.


IMPACT:
This study, recently published in the Journal of the American Heart Association, provides important understanding about heart attack care in the VA and outside the VA over the course of the many pandemic phases. It demonstrates how the VA adapted to meet the pandemic needs, with appropriate triage of procedural care (revealing a potential delay to implementation of adapted systems). Importantly, it also suggests that Veterans treated in the VA had better mortality outcomes after heart attack compared to those treated outside the VA. Additionally, we found that the COVID-19 pandemic appears to have had a lasting impact on health-seeking behaviors among NSTEMI patients, with unclear long-term effects of this increased threshold to obtain cardiovascular care.

PUBLICATIONS:

Journal Articles

1. Yong CM, Graham L, Beyene TJ, Sadri S, Hong J, Burdon T, Fearon WF, Asch SM, Turakhia M, Heidenreich P. Myocardial Infarction Across COVID-19 Pandemic Phases: Insights From the Veterans Health Affairs System. Journal of the American Heart Association. 2023 Jul 18; 12(14):e029910. [view]