Abstract

ABSTRACT – Background: The global pandemic brought on by SARS-CoV-2 has profoundly impacted health and care for veterans, who are generally older, sicker and more economically vulnerable than the overall U.S. population. Veterans are likely to face lasting risks related to care disruptions. Disruptions and varied responses across VA Medical Centers (VAMC) provide an unprecedented opportunity to examine 1) how massive changes in care delivery impact outcomes and 2) the extent to which disruptions exacerbated health disparities. Significance: Our current work points to the existence of complex linkages between chronic disease care, social vulnerability and outcomes. Ability to adapt to the pandemic may be explained by variation in patient-level resources, community-level resources and access to healthcare. Disruptions in care may also exacerbate known disparities in care. Therefore, we will leverage our expertise in geographic information systems (GIS) analysis and advanced spatio-temporal statistics to conduct a robust evaluation of the impacts of the pandemic on care delivery and outcomes for diabetes and hypertension as chronic disease indicators. Specific Aims: Our aims are (1) to determine the impact of the pandemic on chronic disease outcomes across the nation at the level of the VAMC and to examine the extent to which changes in care delivery explain lower extremity amputation, stroke, hospitalizations and all-cause mortality; (2) to determine the extent to which disparities with respect to race-ethnic group, rural-urban residence and comorbidity burden/profile have widened during the pandemic; and (3) to identify VAMC health system attributes, census tract attributes (e.g., social vulnerability), and pandemic burden metrics that lead to adverse outcomes. Methodology: We will create two retrospective cohorts of Veterans receiving primary care from 2017 through 2022: a diabetes and a hypertension cohort. Social vulnerability measures will be assigned at the census-tract level based on a veterans’ residence. Our models are designed to investigate associations between individual-, census tract- and VAMC- level factors, health care delivery metrics, and health outcomes using complex GIS linkages and advanced spatio-temporal statistical methods. Delivery of care metrics include extent to which HbA1c, blood pressure and diabetic retinopathy are monitored; receipt of appropriate prescriptions; number of visits, visit wait times and mode of visit (i.e., telephone, in-person, video telehealth). Chronic disease outcomes include lower extremity amputations, stroke events, hospitalizations and all-cause mortality. Aspects of our work that set it apart from ongoing projects are (1) our ability to include comprehensive data on inpatient hospital visits and ED visits when analyses are limited to South Carolina, (2) the advanced statistical modeling that enables us to account for multiple factors at multiple levels (i.e., patient, census tract, VAMC); and (3) the spatio-temporal aspects of the proposal which are critical given the spatio-temporal nature of the pandemic Next Steps/Implementation: We plan to create a dashboard in Power BI, a VA supported business intelligence tool, that allows users to display data in visual format allowing data to inform strategic decisions. Our dashboard will provide adjusted quarterly mortality rates and other specified outcomes at the level of the VAMC from 2017 through 2022. The dashboard will also enable leadership/stakeholders to examine quarterly mortality rates for pre-specified categories, including racial-ethnic group, rural-urban residence, and VAMC level metrics of care disruption. Our analyses will focus on identifying healthcare delivery factors potentially responsible for changes in chronic disease outcomes. Variations in response to the pandemic across VAMCs provides a unique learning opportunity. Our use of area-level data and our focus on the VAMC level analyses will inform policy-level decision making during and following the pandemic. Lessons learned on the relationship between changes in care delivery, VAMC-level adaptability and chronic disease outcomes will inform post- pandemic care throughout the VA.

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DRA: Health Systems, Cardiovascular Disease, Diabetes and Other Endocrine Disorders

DRE: TRL - Applied/Translational

Keywords: Outcomes - System

MeSH Terms: None at this time.