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Publication Briefs

Social and Behavioral Risk Factors Are Not Associated with Higher Mortality among VA Patients with COVID-19

Social and behavioral risk factors are becoming increasingly linked to COVID-19 outcomes. Poor, vulnerable, and marginalized populations have a high prevalence of tobacco, alcohol, and drug use, and these substances can also be independent risk factors that influence COVID-19 outcomes. Moreover, COVID-19 studies increasingly report that mortality is impacted by race and ethnicity. The VA healthcare system offers strong programs intended to reduce barriers to care for all Veterans, including those struggling with housing instability, poverty, and substance abuse; in this setting, it is unclear if social and behavioral risk factors contribute to poor COVID-19 outcomes. This study sought to determine if social and behavioral risk factors were associated with mortality from COVID-19 among Veterans, and whether the association was modified by race/ethnicity. Using VA data, investigators identified 27,640 Veterans who received VA primary care and tested positive for COVID-19 in VA between March 2 and September 30, 2020. The primary outcome was all-cause mortality in the 30-day period after a positive COVID-19 test date. Social risk factors included housing problems and financial hardship. Behavioral risk factors included current tobacco, alcohol, and substance use. Investigators also assessed patient demographics, body mass index, and comorbidities.


  • Despite relatively high levels of social and behavioral risk among Veterans in this study, no association with mortality from COVID-19 was found. Housing problems, financial hardship, current tobacco, alcohol, and substance use did not have statistically significant associations with mortality. Analyses by race/ethnicity did not find associations between mortality and these risk factors.
  • Predictors of mortality in this study were consistent with other studies, including older age, Asian and American Indian or Alaska Native race, and certain comorbid conditions, such as diabetes, chronic kidney disease, dementia, and cirrhosis or hepatitis.


  • This study highlights how integrated health systems such as VA can transcend social vulnerabilities and serve as models of support services for COVID-affected households and at-risk populations.


  • Survivor bias is one possible explanation for these findings. Veterans with poor health behaviors, such as heavy tobacco users, may have died prior to the COVID-19 pandemic – and those who survived may have been less susceptible to poor outcomes from these health behaviors.
  • Despite analyzing a large group of covariates, certain covariates (i.e., occupational history) were not available from VA data and may account for unmeasured confounding.
  • This study, which was restricted to those already diagnosed with COVID-19, does not address the possibility that social and behavioral risk factors may increase risk of being exposed to and infected with COVID-19.

Drs. Kelly, Bent, Wray, and Keyhani are part of the San Francisco VA Health Care System. Drs. Bravata and Myers are part of HSR&D’s Center for Health Information and Communication (CHIC).

Kelly J, Bravata D, Bent S, Wray C, Leonard S, Boscardin W, Myers L, and Keyhani S. Association of Social and Behavioral Risk Factors with Mortality Among US Veterans with COVID-19. JAMA Network Open. June 9, 2021;4(6)e2113031.

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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