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Publication Briefs

COVID-19 Infection Not Associated with Clinically Significant Excess Mortality among Veterans Surviving at Least 180 Days

It is unclear whether survivors of COVID-19 experience excess mortality after acute infection and, if so, how long any excess mortality persists. This retrospective cohort study compared the time course of differential mortality among Veterans who had a first-documented COVID-19 infection between March 2020 and April 2021, and were followed through April 2022. Investigators separately evaluated acute mortality (e.g., on days 0-90 after infection) and later mortality (i.e., on days 181-365 and days 366-730) among matched groups of infected (n = 208,061) and uninfected Veterans (n = 1,037,423) who had survived to the beginning of the respective period. The VA COVID-19 Shared Data Resource (VA network access only) database was used to identify Veterans with COVID-19. Each Veteran with COVID-19 was matched with up to five comparators who had not been infected at the time of matching. This match balanced, on a month-by-month basis, the risk of developing COVID-19 using 37 variables measured in the 24 months before the date of the infection or match.


  • Although overall 2-year mortality risk was worse among those infected with COVID-19, by day 180 after infection Veterans on average had no excess mortality over the next 1.5 years. Thus, despite growing evidence of persistent risks after acute COVID-19, the excess mortality risk associated with COVID-19 did not persist as long as expected.
  • Veterans with COVID-19 had an unadjusted mortality rate of 9% during the 2-year period after the initial infection compared with 4% among uninfected comparators, which suggests an excess of 9,625 deaths among infected Veterans.
  • The risk of excess death varied, being highest during days 0 to 90 after infection and remaining elevated during days 91 to 180. On average, those who survived COVID-19 had modestly decreased mortality on days 181 to 365 and days 366 to 730.
  • Veterans hospitalized for COVID-19 experienced increased mortality at all time periods through 730 days post-infection, so resolution of excess mortality risk was driven by the non-hospitalized subset.


  • For ongoing clinical care after COVID-19, efforts that focus on improving survival outcomes may be less relevant than addressing the needs of survivors, particularly those not initially hospitalized.


  • Only up to 24 months of follow-up had accrued for Veterans who became infected in March 2020 through April 2021, so results should not be generalized to Veterans who became infected with more recent variants of COVID-19.
  • The potential cumulative effects of COVID-19 will not be fully seen for years or decades to come, therefore, these data suggest ongoing differences for which follow-up is needed.

This study was supported by HSR&D. Drs. Iwashyna and Seelye are part of HSR&D’s Center for Clinical Management Research (CCMR) and Mr. Berkowitz is with HSR&D’s Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT).

: Iwashyna T, Seelye S, Berkowitz T, et al., for the VA HSR&D COVID-19 Observational Research Collaboratory (CORC). Late Mortality after COVID-19 Infection among US Veterans vs Risk-Matched Comparators: A 2-Year Cohort Analysis. JAMA Internal Medicine. August 21, 2023; online ahead of print.

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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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