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COVID-19 Infection Associated with More Depression Symptoms among Veterans at 18 months Post-Infection
This study robustly matched COVID-19 infected patients with contemporaneous, uninfected controls to assess the effects of COVID-19 on depression symptoms. Findings showed that COVID-19 infection was associated with more depression symptoms among Veterans at 18 months post-infection, with a significantly higher prevalence of positive depression screening among Veterans with COVID compared to those without (49% vs 12%). COVID-19 infection was associated with significantly elevated psychological depression symptoms, but not physical depression symptoms. History of depression diagnosis did not appear to affect the risk of depression symptoms after COVID-19 infection. Primary care and Primary Care-Mental Health Integration providers may consider monitoring depression symptoms among Veterans after being infected with COVID-19 and should be aware that such symptoms may be present long after infection (up to 18 months post-infection).
Date: April 16, 2024
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Veterans with COVID-19 have Greater Risk of Potentially Preventable Hospitalization than Non-infected Veterans
This study sought to determine whether infection with SARS-CoV-2 is associated with an increased risk of a potentially preventable hospitalization and, if so, how long this association persists after infection. Findings showed that Veterans with COVID-19 had three times greater risk of potentially preventable hospitalization than matched uninfected Veterans within 30 days after infection and more than 40% greater risk at 1 year. Potentially preventable hospitalizations for acute conditions (i.e., bacterial pneumonia, urinary tract infection) accounted for 20% of all preventable hospitalizations; those for exacerbations of chronic conditions (e.g., diabetes complications, asthma) accounted for the remainder. Although exploratory, subgroup results suggest sub-optimal access to ambulatory care either before or after infection increases the risk of a potentially preventable hospitalization in those with COVID-19. Solutions are needed to mitigate preventable hospitalization after COVID-19.
Date: April 10, 2024
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Significant Increase in Telehealth for Primary Care among Homeless Veterans Following the Pandemic
This study sought to examine the extent to which homeless-experienced Veterans used telehealth services in primary care – and to characterize users before and after the onset of the pandemic. Findings showed that despite decreased access to health information technology and low pre-pandemic telehealth use, Veterans experiencing homelessness sustained a high use of telehealth in primary care post-pandemic: 1 in 5 Veterans experiencing homelessness participated in video visits, and the majority contacted their primary care teams by phone. High telehealth use was also maintained beyond the first year of COVID-19. For example, compared to pre-pandemic, telehealth use increased substantially two years post-pandemic (video: 1% versus 21%; phone: 61% versus 77%). Women and racial-ethnic minorities had higher video uptake proportionately, suggesting that telehealth may address access disparities among these homeless-experienced patient groups.
Date: January 22, 2024
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Veterans with a Racial/Ethnic Minority Background, Rural Residence, or Mental Health Disability History Were Less Likely to Complete Preoperative Goals of Care Documentation
This study assessed factors – including race, ethnicity, rurality, history of mental health disability, and VA facility type – that are known or hypothesized to be linked with disparities in preoperative life-sustaining treatment (LST) documentation. The study also described the COVID-19 pandemic’s effect on completion of preoperative LST. Findings showed that Veterans with a racial or ethnic minority background, rural residence, mental health disability history, or who were seen at low-complexity, low-volume facilities were significantly less likely to complete preoperative LST compared to Veterans who were white or non-Hispanic, urban residents, without a mental health disability history, or who had access to a high-complexity, high-volume facility. Of the 229,737 Veterans in the cohort, 13,408 (6%) completed preoperative LST documentation within 30 days prior to surgery. With each passing year, Veterans undergoing surgical procedures had greater likelihoods of completing LST before surgery, including during the COVID-19 pandemic. Findings suggest there is continued need for interventions that target Veteran groups at risk of not engaging in serious illness communication.
Date: December 19, 2023
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Telework Association with VA Physician Burnout During COVID Pandemic
This study examined whether physician burnout was associated with telework within the VA healthcare system. Findings showed that VA physician burnout continued to increase during the COVID-19 pandemic. Averaged across 3 years (2020, 2021, and 2022), 35% of VA physicians reported burnout (29%, 36%, and 39%, respectively). Burnout was highest among primary care physicians (52%) and psychiatry (41%). More than half of physicians did not have telework arrangements – on average, 12% chose not to, 33% were unable to, and 11% were unapproved to telework. Adjusted odds of burnout were 57% higher for physicians who were unapproved to telework compared to those who were full-time telework: 43% vs 33% for all physicians, 52% vs 43% for psychiatry specialties, and 35% vs 26% for other physicians. Lower burnout was seen among primary care physicians with greater ability to telework: 47% (full-time) vs 52% (part-time) vs 61% (telework unapproved). Telework has been linked to lower burnout, as well as higher autonomy and engagement, which is also associated with lower burnout. If flexible telework arrangements are associated with lower physician burnout, they have the potential to improve job retention and, in turn, quality of care.
Date: October 27, 2023
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Veterans with COVID-19 Have Elevated Rates of Suicide Attempt and Other Self-Directed Violence
In this study, researchers used electronic health record data to examine associations between suicide attempt and other self-directed violence (SDV) and time since COVID-19 infection in VA patients who were infected between March 1, 2020, and March 31, 2021, and similar but uninfected VA patients. Findings showed that Veterans infected with COVID-19 had a 41% higher risk of a suicide attempt and 38% higher risk of other SDV compared to members of the uninfected cohort for at least one year following infection. Suicide attempt and SDV rates were higher in the COVID-19 group than in the uninfected group during all of the reviewed time periods, with the highest rates occurring in the first 30 days following the date of infection. Among the infected and uninfected cohorts, rates of suicide attempts and other SDV were substantially lower than those reported during the two years prior to the pandemic, possibly indicating that care disruption and limited care access during the pandemic reduced the opportunity to report these events. Results support suicide risk screening of those infected with COVID-19 to identify opportunities to prevent self-harm.
Date: October 26, 2023
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Substantial Health Risks Remain for Veterans Two Years after Hospitalization for COVID-19
Investigators in this study conducted a comprehensive assessment of the risks and burdens of post-acute sequelae of COVID-19 among Veterans across care settings two years post-infection. Findings showed that while the risks of many sequelae became non-statistically significant at two years, substantial risk remained that impacted several major organ systems. The risk horizon for those hospitalized during the acute phase was even longer, with persistently increased risk of most sequelae at two years. The risk of death was non-significant at six months after infection among non- hospitalized Veterans but remained significantly elevated through the two years in hospitalized Veterans. Within the 80 pre-specified sequelae, 69% and 35% of them became non-significant at two years after infection among non-hospitalized and hospitalized individuals, respectively. Findings highlight the importance of reducing the risk of hospitalization among Veterans with COVID-19 infection (and reinfection), in order to reduce the risk of long-term health loss.
Date: August 21, 2023
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COVID-19 Infection Not Associated with Clinically Significant Excess Mortality among Veterans Surviving at Least 180 Days
This 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. Findings showed that 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.
Date: August 21, 2023
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Thirty-Day Mortality Higher for Older Veterans Hospitalized with COVID-19 in Community vs. VA Hospitals
This study compared outcomes among Veterans ages 65+ admitted for COVID-19 in VA and community hospitals. Findings showed that admission to community hospitals was associated with higher unadjusted (27% vs. 18%) and risk adjusted 30-day mortality compared to admission to VA hospitals. Readmission within 30 days was less common following admission to community compared to VA hospitals (13% vs. 14%). This difference was not sensitive to adjustment for patient characteristics, suggesting that higher readmission in VA hospitals may reflect a feature of the VA healthcare system and not case-mix. Community hospitals played a disproportionate role in care for rural Veterans with COVID-19, likely because of poor geographic access to VA hospitals among this population: 46% of community hospitals caring for VA enrollees with COVID-19 were in rural areas.
Date: May 30, 2023
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Early Months of Pandemic Increased Overall Death Rates Comparably for General Population and Veterans
This study sought to quantify excess all-cause mortality during the first nine months of the COVID-19 pandemic among Veterans compared with the general US population. Findings showed that in 2020, 85% of the overall increase in the US death rate was directly associated with COVID-19. Comparable data are not yet available for VA. Veterans receiving VA healthcare had similar relative increases in mortality compared with the general US population during the first 9 months of the COVID-19 pandemic. However, the absolute pre-pandemic death rate was higher among VA patients, which translated to higher absolute excess death rates among Veterans. The relative increase in deaths was smaller among the White population than in other racial and ethnic groups. These patterns were consistent between the general and VA populations, but the disparities were less pronounced in VA, particularly among young age groups.
Date: May 8, 2023
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Higher Preventive Health Inventory Use Associated with Improved Quality of Care
This study examined associations between Preventive Health Inventory (PHI) adoption and clinical quality measures at 216 VA primary care clinics nationwide that implemented the PHI and had the highest and lowest PHI use as of February 2021. Findings showed that higher uptake of the PHI was associated with improved quality of diabetes and hypertension care. Compared to the lowest use clinics, the highest use clinics had fewer Veterans with an HbA1c >9 or missing, more Veterans with an annual HbA1c measurement, and more Veterans with adequate blood pressure control. The highest use clinics completed an average of 32,997 notes per 100,000 Veterans compared to 57 notes per 100,000 Veterans at the lowest use clinics. Results indicate that a proactive care management intervention can significantly improve the quality of care, including chronic disease care that has been disrupted by the COVID-19 pandemic.
Date: April 17, 2023
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Rural-Urban Telemedicine Disparity among Veterans Worsens Following Onset of COVID-19 Pandemic
This study examined changes over time in rural-urban differences in telemedicine use for primary care and mental health integration services among nearly 64 million primary care and 4 million mental health integration visits. Findings showed that the pandemic exacerbated the rural-urban telemedicine divide across VA, possibly because underlying causes of digital inequity were not addressed as initiatives to expand telemedicine use across VA were instituted. Prior to the pandemic, telemedicine use for primary care services was higher at rural VA healthcare systems than urban ones (34% vs. 29%). Following the onset of the pandemic, usage rates switched (55% vs. 60%). The rural-urban telemedicine gap was even larger post pandemic for mental health integration than for primary care services, with unadjusted analyses showing 76% rural vs. 84% urban telemedicine use. Future telemedicine research, implementation efforts, and policy must address rural-urban structural disparities (e.g., internet bandwidth) and possibly tailor technology to encourage telemedicine adoption among rural users at the patient, provider, and healthcare system level.
Date: March 7, 2023
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Home-Based Cardiac Rehabilitation May Decrease Mortality
This study evaluated all Veterans referred to home-based cardiac rehabilitation (HBCR) at one VA Medical Center and compared outcomes for those who participated in the program and those who did not. Findings showed that Veterans who underwent HBCR had 36% lower risk of mortality after 4 median years of follow-up compared to non-participants, suggesting that participation in HBCR may benefit patients who cannot attend traditional CR programs. However, even when home-based cardiac rehabilitation was offered at the time and place of their choosing, only 44% of eligible Veterans chose to participate. Findings are especially relevant given that COVID-19 has caused many CR programs to offer HBCR as a temporary intervention.
Date: March 1, 2023
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Black and Hispanic Veterans Experienced Greater Access Barriers to VA Care During Pandemic
This study sought to determine whether wait times increased differentially for Black and Hispanic compared with White Veterans for VA outpatient orthopedic and cardiology services from the pre–COVID-19 to COVID-19 periods. Findings showed that national wait time disparities increased significantly for Black and Hispanic Veterans for orthopedic services. During the COVID-19 period, Black and Hispanic Veterans’ mean wait times exceeded those of White Veterans by 2.45 days for Black Veterans and 1.98 days for Hispanic Veterans. There were only modest national disparities for cardiology services (<1-day difference). There was variation in wait times across the 140 VA facilities. For example, pre-COVID, there were Black/White differences for cardiology at 6 facilities (Black Veterans waited longer at 4 facilities, White Veterans waited longer at 2 facilities). During COVID, 21 facilities had Black/White differences for cardiology (Black Veterans waited longer at 14 facilities, while White Veterans waited longer at 7 facilities). Although differences in wait times were only a few days, any wait time disparity is concerning. It will be important for future work to monitor these trends, understand their sources, and implement appropriate interventions as needed. Findings also underscore the critical importance of facility-level analyses for highlighting opportunities to reduce disparities and target quality improvement efforts.
Date: January 23, 2023
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Readmission Rates for Veterans who Survived COVID-19 – Prior to Availability of Vaccine
This study examined VA hospital readmissions within 90 days following discharges during three initial waves of COVID-19 infection in the first year of the pandemic – prior to the availability of a vaccine. Findings showed that approximately 1 of every 6 Veterans discharged alive following a COVID-19 hospitalization were readmitted within 90 days. Among COVID survivors in this study, 16% were readmitted within 90 days of hospital discharge – with a mean time to readmission of nearly 22 days.
Readmissions were more likely when the initial admission was longer, required mechanical ventilation, or the Veteran had more comorbidities, smoked, or lived in an urban area. More than 60% of readmissions were due to a reason other than infectious disease, even COVID. Twenty-two percent of Veterans readmitted died within 90 days of their initial hospitalization vs. 11% of Veterans not readmitted. Thirteen percent of the Veterans in this study died during their initial COVID-19 hospitalization.
Date: December 1, 2022
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Black Veterans with Chronic Pain Express Dissatisfaction with VA Telehealth Options during Pandemic
This study sought to understand how Black Veterans with chronic pain experienced pandemic-related changes in VA healthcare delivery. Investigators conducted qualitative interviews with Black Veterans who had completed a randomized controlled trial of an intervention focused on communication and patient activation for Black patients with chronic pain. Findings showed that Veterans described mostly negative effects from the shift to telecare after the pandemic’s onset including: decreased ability to self-manage their chronic pain; difficulty obtaining non-pharmacological services such as physical therapy; difficulty seeing their primary care providers; and trouble scheduling surgery. Many Veterans said phone and video visits were inadequate to handle complaints related to their pain. Some Veterans were willing to accept the tradeoff of telehealth to avoid possible exposure to COVID-19, while others saw positive aspects to a virtual format.
Date: November 14, 2022
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Difficulty of Diagnosing and Treating Veterans Suspected of Having Long COVID
Using data from VA’s electronic health record (EHR), investigators identified a random, nation-wide sample of 200 VA patients who were assigned a new ICD-10 diagnostic code for long COVID between October 1, 2021, and March 1, 2022. Investigators then conducted a text word search and qualitative analysis of Veterans’ EHRs to identify dominant themes pertaining to the diagnosis and management of long COVID. Findings showed that there was substantial clinical uncertainty around the diagnosis and management of long COVID; most Veterans had one or more comorbid conditions with symptoms that might overlap those of long COVID. Some patients had prolonged or repeated hospital admissions or nursing home stays, blurring the boundaries between outcomes associated with acute infection, prolonged hospitalization, and long COVID. Patients’ own reports of how they had been impacted by COVID often referenced an exacerbation of pre-existing symptoms rather than an entirely new set of symptoms. Uncertainty about the etiology of patients’ symptoms led to ongoing monitoring, diagnostic testing, and specialist referral. Long COVID-specific care processes were often siloed and poorly coordinated with the care patients were already receiving for other health conditions and could lead to care that was burdensome and even unwanted, particularly among those with complex medical conditions and functional limitations.
Date: November 3, 2022
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Age and Certain Comorbidities are Risk Factors for Breakthrough COVID-19 Infection with Severe Outcomes among Veterans
This study sought to identify risk factors associated with severe COVID-19 disease despite vaccination among Veterans. Among 110,760 Veterans with COVID-19 following vaccination, 10% had severe infection and 1% died. Increasing age was most strongly associated with severe disease, with risk increasing steadily as Veterans aged (50 years and older). Deaths were rare under age 50 and nearly 60% of deaths occurred in Veterans 75 and older. Immunocompromising medications and conditions and comorbidities indicating chronic heart, lung, kidney, or neurologic damage also increased the risk of having severe disease. Boosting was associated with a decreased risk of severe breakthrough infection as was COVID infection prior to initial vaccination. Identification of the risk factors for severe breakthrough COVID-19 could be used to guide policies and decision-making about preventive measures for those who remain at risk of disease progression despite vaccination.
Date: October 3, 2022
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Early Temperature Trends May Identify COVID-19 Infection in Pre-Symptomatic Long-Term Care Residents
Pre-symptomatic COVID-19 transmission in nursing homes is common and older patients often have blunted febrile response to infection. As a result, current clinical screening for temperature above 38°C may not identify infected subclinical cases that risk transmission until later. This study sought to determine whether early temperature trends in the course of COVID-19 infection could identify pre-symptomatic Veterans in nursing homes. Findings showed that a change in temperature of 0.4°C from baseline identified 47% of VA nursing home residents who became COVID positive, earlier than standard testing by an average of 42 hours. Temperature variability of 0.5°C over three days, when paired with a 37.2°C temperature cutoff (instead of the VA standard of 38°C), identified 55% of VA nursing home residents who became COVID positive earlier than standard testing by an average of 44 hours. A change from baseline temperature of 0.4°C, when combined with temperature variability of 0.7°C over three days, identified 52% of VA nursing home residents who became COVID positive, earlier than standard testing by an average of 40 hours, and by more than 3 days in 22% of Veterans.
Date: August 4, 2022
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Factors Associated with Long COVID Care Documentation among VA Patients
This study examined the rates, clinical setting, and factors associated with documented receipt of COVID-19-related care three or more months after acute infection. Findings showed that long COVID care was documented in 26,745 Veterans (14%) in the study cohort. Factors significantly associated with long COVID care included: older age, Black or American Indian/Alaska Native race, Hispanic ethnicity, geographic region, multiple comorbidities, having documented symptoms at the time of acute infection, and requiring hospitalization or mechanical ventilation. Veterans who had received both doses of mRNA vaccine at the time of COVID-19 infection (considered fully vaccinated) were less likely to have received care for long COVID. There was significant variability in rates of long COVID care documentation across VISNs (11%-18%) and VAMCs (3%-41%); 16 VA facilities with dedicated clinics for long COVID follow-up had higher rates. The most common outpatient clinics at which Veterans with long COVID presented were primary care and general internal medicine (33% of encounters).
Date: July 29, 2022
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VA Treatment of Opioid Use Disorder was Maintained During the COVID Pandemic Through Rapid Shift to Telehealth
At the beginning of the COVID pandemic, key federal policy changes were implemented to decrease barriers to telehealth-delivery of buprenorphine, a life-saving medication treatment for patients with opioid use disorder (OUD). This study examined the impact of these COVID-19 policies on buprenorphine treatment across different modalities (telephone, video, and in-person visits). Findings showed that buprenorphine treatment for OUD was maintained during the COVID-19 pandemic – across the VA healthcare system – through a rapid shift to telehealth, at a time when other healthcare delivery decreased. The number of Veterans receiving buprenorphine increased from 13,415 in March 2019 to 15,339 in February 2021. By February 2021, phone visits were used by the most patients (50%), followed by video (32%) and in-person (17%). Among Veterans receiving a buprenorphine treatment visit each month, the proportion of telehealth visits (phone and video) increased dramatically from 12% in March 2019 to 83% in February 2021. The proportion of Veterans reaching 90-day retention on buprenorphine treatment decreased significantly from the pre- to post-pandemic periods (50% to 48%), but days on buprenorphine increased significantly from 204 to 209. Policy changes that were rapidly implemented to reduce barriers to telehealth allowed continued delivery of buprenorphine treatment. Future changes to these policies (e.g., reversing support for telehealth prescribing of buprenorphine) could have major implications for patient care.
Date: July 28, 2022
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Characteristics of the Rise in Telehealth During COVID Pandemic
This study sought to examine patient, provider, and site-level characteristics of any virtual and video-based care in primary care (PC). Findings showed that before the onset of COVID-19, only 14% of PC patients used any telehealth services, and only 0.3% used video-based care. However, during the first 12 months of COVID-19, 63% of patients used telehealth services, and 11% used video-based care. Veterans at community-based clinics had a higher percentage of any telehealth use (38%) compared to Veterans receiving primary care at the main medical facility (30%). Conversely, video use was lower among community-based PC patients (10%) compared to PC patients at the medical facility (13%). Social workers, nutritionists, and pharmacists had the highest percentage of telehealth use (54%, mostly telephone) compared to primary care providers (34%), whereas mental healthcare providers were more likely to provide video-based care (43%) compared to PC clinicians (15%). Among all age groups except the oldest (75+), women were more likely to use telehealth or video. Additional research is needed to identify which PC outpatient services are better suited for telephone (e.g., case management) vs video-based care (e.g., integrated mental health visits).
Date: June 18, 2022
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Receipt of Video Tablets among Rural Veterans Associated with Increased Use of Mental Health Care and Less Suicidal Behavior
This study sought to evaluate the association between the escalated distribution of VA’s video-enabled tablets during the COVID-19 pandemic and rural Veterans’ mental health service use and suicide-related outcomes. Findings showed that receipt of a video tablet was associated with the increased use of mental healthcare via video and increased psychotherapy visits across all modalities. Tablets also were associated with an overall 20% reduction in the likelihood of an ED visit, a 36% reduction in the likelihood of a suicide-related ED visit, and a 22% reduction in the likelihood of suicide behavior. VA and other health systems should consider leveraging video-enabled tablets for improving access to mental healthcare via telehealth and for preventing suicides among rural residents.
Date: April 6, 2022
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Quality of Care for Veterans with Stroke Did Not Diminish During Pandemic
This study compared the quality of care and outcomes for Veterans with acute ischemic stroke (AIS)/ transient ischemic attack (TIA) before vs during the COVID-19 pandemic across the VA healthcare system. Findings showed that the overall quality of care did not diminish among Veterans with stroke and TIA who received care in VA facilities during the COVID-19 pandemic. As measured by the without-fail rate, quality of care improved from 50% in 2019 to 56% in 2020. The without-fail rate remained relatively stable for Veterans with TIA (44% in 2019 vs 44% in 2020) and increased for Veterans with stroke (54% in 2019 vs 62% in 2020). Fewer patients were eligible for the hypertension control measure in 2020 than in prior years due to lack of blood pressure (BP) measurements: 31% in 2020 vs 67% in prior years, likely explained by fewer patients having a primary care visit in the 90 days after discharge. When measured, BP was not as well controlled during the pandemic period (72%) as during the pre-pandemic period (78%). Healthcare providers should ensure that patients who have had an AIS/TIA receive priority as healthcare systems address deferred primary care, particularly hypertension management.
Date: April 5, 2022
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Increased Risk for Cardiovascular Conditions among Veterans for Up to One Year Following COVID-19 Infection
This study evaluated the risks and 12-month burdens of cardiovascular outcomes among Veterans who survived the first 30 days of COVID compared to VA healthcare users with no COVID and Veterans who used VA healthcare before the COVID pandemic. Findings showed that COVID-19 increased the risk of developing cardiovascular conditions – spanning several categories – within the first month to one year after infection. The risk increased even in Veterans without previous heart conditions and in those with mild COVID-19 infection. Overall, heart disease was seen in 4% more people who contracted COVID-19 than in those without. COVID-19 patients were 72% more likely to suffer from coronary artery disease, 63% more likely to have a heart attack, and 52% more likely to have a stroke. Health systems should prepare for a significant contribution of COVID-19 to a rise in the burden of cardiovascular diseases and the potential long-lasting consequences for patients and the health system.
Date: February 7, 2022
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Shift to Virtual Visits for Veterans with Type 2 Diabetes During the Pandemic Was Not Associated with Adverse Outcomes
This study sought to describe the changes in management, control, and outcomes in older people with type 2 diabetes (T2D) associated with the shift from in-person to virtual visits. Findings showed that despite a shift to virtual visits and decreased A1c measurement rates during the pandemic, no association with A1c level or short-term T2D-related outcomes (i.e., ER visit or hospitalization for hypo or hyperglycemia) was observed, providing some reassurance about the adequacy of virtual visits. Relative to baseline, among the 740,602 Veterans in this study, there were 55% fewer in-person visits and 824% more virtual visits, with a net result of 10% more total visits during the pandemic relative to the pre-pandemic period. There also were 6% fewer A1c measurements, and 14% more treatment intensifications.
Date: January 6, 2022
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Impact of COVID-19 Pandemic on Healthcare Workers and First Responders
This study examined the relationships between COVID-19 related occupational stressors, psychiatric symptoms, and occupational outcomes (likelihood of leaving current field and occupational functioning). Findings showed high levels of psychiatric symptoms and distress in healthcare workers during the COVID-19 pandemic. Half of the healthcare workers in this study – and 59% of all nurses – indicated a decreased likelihood of staying in their current occupation due to the pandemic. Nurses and emergency medical service workers reported the greatest burdens: more than 40% had PTSD symptoms and more than 80% had depression symptoms. Among all respondents, more than one-third (38%) had PTSD symptoms, and nearly three-quarters had depression (74%) and anxiety (75%) symptoms. More than 15% of participants reported thoughts of suicide or self-harm in the preceding two weeks. More than 18% of respondents reported trouble completing work-related tasks. The volume of critically ill patients, risk of COVID-19 exposure, and factors promoting demoralization were associated with psychiatric distress. Distress was associated with increased odds of planning to leave the profession. Demoralizing factors (e.g., feeling unsupported by one’s workplace, being asked to take unnecessary risks) were most strongly associated with distress. Healthcare staffing shortages are in and of themselves a COVID-19 stressor, so turnover could exponentially worsen HCW’s wellbeing and professional retention.
Date: December 16, 2021
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Veterans’ Intentions and Attitudes Regarding COVID-19 Vaccines
The goal of this study was to assess Veterans’ attitudes and intentions regarding COVID-19 vaccination within the VA healthcare system, in order to inform ongoing, system-wide communication efforts to increase uptake of the vaccines. Findings showed that 71% of the Veterans in the study reported being vaccinated. The main reasons for not being vaccinated included skepticism (36% concerned about side effects from COVID-19 vaccines, 20% prefer using few medications, and 19% prefer gaining natural immunity); deliberation (22% prefer to wait because vaccine is new); and distrust (19% do not trust healthcare system). Among Veterans who were vaccinated, preventing oneself from getting sick (57%) and contributing to the end of the COVID-19 pandemic (56%) were the main reasons for getting vaccinated. The proportion of Veterans who trusted their VA healthcare provider as a source of vaccine information was higher among those unsure about vaccination compared to those who indicated they would definitely not – or probably not get vaccinated (26% vs 15%). Among Veterans reporting they would “definitely not” or “probably not” get vaccinated, their most trusted source of information (31%) was news on TV, radio, or online. Targeting Veterans’ concerns around the adverse effects and safety of COVID-19 vaccines through conversations with trusted VA providers is key to increasing vaccine acceptance.
Date: November 3, 2021
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Changes in the Association between Race and Urban Residence with COVID-19 Outcomes among Veterans
This study examined whether key sociodemographic and clinical risk factors for COVID-19 infection and mortality changed between February 2020 and March 2021 among more than 9 million Veterans enrolled in VA healthcare. Findings showed that strongly positive associations of Black race, American Indian/Alaska Native (AI/AN) race, and urban residence with COVID-19 infection, mortality, and case fatality that were observed early in the pandemic attenuated over time. The magnitude of the association between Black (vs. White) race and COVID-19 infection or mortality declined steadily from February/March 2020 to November 2020, when it was no longer significant. The association between AI/AN (vs. White) race and COVID-19 infection declined steadily over time to a negative association in March 2021. Similarly, the association between urban vs. rural location and COVID-19 infection or mortality also declined steadily over time, shifting from a positive association in February/March 2020 to a negative association in September/October 2020 and to a non-significant association in March 2021. Throughout the study period, high comorbidity burden, younger age, Hispanic ethnicity, and obesity were consistently associated with COVID-19 infection, while high comorbidity burden, older age, Hispanic ethnicity, obesity, and male sex were consistently associated with mortality. Understanding changing patterns of risk factors could be important in informing population-based approaches to prevent infection and reduce mortality by targeting those at highest risk at any given time during the course of an evolving pandemic.
Date: October 21, 2021
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Receipt of COVID-19 Vaccine is Higher among Racial/Ethnic Minorities than Whites within VA Healthcare System
VA began administering COVID-19 vaccinations shortly after the US rollout began, allowing for an examination of vaccination rates among racial/ethnic minorities in an integrated healthcare system with few barriers to access. Findings showed that in contrast to disparities reported in the general population, COVID-19 vaccine receipt in the VA healthcare system was higher among most racial/ethnic minority groups than in Whites, suggesting reduced vaccination barriers compared with non-VA care. Overall, 24% of the cohort received at least one vaccine dose as of 2/23/21. Black (29%), Hispanic (27%), and Asian (27%) Veterans were significantly more likely than White (24%) Veterans to receive a vaccination through VA, while American Indian and Alaska Native (AI/AN) Veterans were less likely. Only AI/ANs in Contract Health Service Delivery Area counties, which indicates residence in/adjacent to federally reserved tribal lands were less likely than Whites to be vaccinated. Since AI/AN Veterans were less likely to obtain COVID-19 vaccinations through VA when close to a tribal area, the Indian Health Service may provide a safety net that is effective at reaching this population despite disparities in other contexts. Influenza vaccination history was positively associated with COVID-19 vaccine uptake.
Date: October 21, 2021
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VHA In-Person Care Declined Substantially More than Community Care During Pandemic – And Has Yet to Recover
This study sought to describe how VA care patterns shifted in response to the pandemic, including all forms of care either purchased (Community Care) or provided by VA. Findings showed that overall VA healthcare use dropped precipitously in March and April of 2020, while virtual care expanded swiftly. However, VA in-person care declined substantially more than Community Care, and total encounters have yet to recover to pre-pandemic levels. The estimated total volume of missing encounters relative to the previous year (2019) was 16.5 million. Virtual care in VA increased from 6% (n=454,399) in April 2019 to 44% (n=1,894,674) in April 2020 before falling to 29% (n=1,861,922) in December 2020. As of December 2020, VA in-person care constituted just 30% of VA paid or provided care while non-acute community care accounted for 29% of all encounters. VA likely adopted a more conservative reopening strategy compared to community providers, who have different financial incentives to resume in-person care and returned close to pre-pandemic patient volume by September 2020. In the wake of concerns about access, VA has steadily increased spending on Community Care, and study results indicate existing trends pushing VA toward being a mixed payer and provider may have accelerated.
Date: October 1, 2021
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Best Practices for Equitable COVID-19 Vaccination Drive
In collaboration with HSR&D investigators, the Interdisciplinary Vaccine Team at the VA Puget Sound Healthcare System worked to develop an equitable, coordinated, and data-driven COVID-19 vaccination drive for Veterans (carried out from December 21, 2020 to May 30, 2021). As of July 28, 2021, the VA Puget Sound facility had administered 79,643 vaccinations to 41,386 Veterans, representing 42% of its total population, and including 42% of Black enrollees, 29% of American Indian/Native Alaskan enrollees, and 35% of white enrollees. Key takeaways include: develop an intentional vaccine delivery strategy in conjunction with experts in population-level barriers to vaccination; explicitly include demographic and social determinants of health data to prioritize vulnerable populations in accessing vaccination; utilize multiple communication channels to reach patients in different formats.
Date: September 15, 2021
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Routine Use of Remdesivir for COVID-19 May Increase Length of Hospital Stay without Improving Survival
This study sought to determine any associations between remdesivir treatment, survival, and length of stay among Veterans hospitalized with COVID-19 in the VA healthcare system. Findings showed that remdesivir therapy was not associated with improved 30-day survival: 12% mortality for remdesivir recipients vs. 11% for those who did not receive remdesivir. Remdesivir therapy was associated with an increase in median time to hospital discharge: 6 days for Veterans who received remdesivir compared to 3 days for matched Veterans who did not receive the drug. Examination of time to remdesivir completion and discharge suggested that clinicians may have been keeping patients in the hospital to complete 5-day remdesivir courses, contributing to a longer length of stay. Findings suggest that the routine use of remdesivir may be utilizing scarce hospital beds during a pandemic without leading to clear improvements in patient survival, and that interventions are needed to ensure that patients are not kept in the hospital solely to receive remdesivir.
Date: July 15, 2021
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Social and Behavioral Risk Factors Are Not Associated with Higher Mortality among VA Patients with COVID-19
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. Findings showed that 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.
Date: June 9, 2021
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Two Studies Show Positive Impact of COVID-19 Vaccinations on VA and Community Nursing Home Residents
U.S. nursing homes incurred more than one-third of COVID-19 fatalities in the United States and began vaccine clinics in mid-December. The first study describes the proportion of COVID-19 positive tests among 130 VA Community Living Centers (CLCs) before and after COVID-19 vaccination. Findings showed that the number of COVID-19 positive tests dropped among all CLC residents in the fourth week after vaccination, with an approximately 75% drop in the proportion of COVID-19 positive tests. The second study compared incident COVID-19 infection and 30-day hospitalization or death among residents with COVID-19 between non-VA nursing homes with earlier versus later vaccine clinics. Findings showed that one week after their initial vaccine clinics, nursing homes with earlier vaccination had 2.5 fewer new COVID-19 infections per 100 at-risk residents than expected relative to facilities with later vaccination. Cumulatively over 7 weeks, earlier vaccination facilities had 5.2 fewer infections per 100 at-risk residents and 5 fewer hospitalizations and/or deaths per 100 infected residents. These results suggest that COVID-19 vaccines accelerated the rate of decline of incident infections, morbidity, and mortality.
Date: April 16, 2021
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Veterans of Color Are More Likely to be Tested for COVID-19 at VA than White Veterans and are More Likely to Test Positive
This analysis evaluated the characteristics associated with obtaining a COVID-19 test within the VA healthcare system – and receiving a positive test result from February 8 through December 28, 2020. Findings showed that VA is testing a significantly higher proportion of traditionally disenfranchised patient groups for COVID-19 than other healthcare systems. However, Black and Hispanic/Latino Veterans have an increased risk of receiving a positive test result for COVID-19, despite receiving more tests than White and non-Hispanic/Latino Veterans. Overall, Veterans who were female, Black/African American, Hispanic/Latino, lived in urban settings, had a low income, or had a disability had an increased likelihood of obtaining a COVID-19 test, while Veterans who were Asian had a decreased likelihood. Compared with Veterans who were White, Veterans who were Black/African American were 23% more likely and Native Hawaiian/Other Pacific Islander 13% more likely to receive a positive test result. Hispanic/Latino Veterans had a 43% higher risk of receiving a positive test result than non-Hispanic/Latino Veterans. Veterans with disabilities or who were low-income were more likely to obtain a COVID-19 test but had a lower risk of receiving a positive test. Although disparities are significantly smaller at VA, the test positivity differences suggest that Veterans are not immune to the negative external effects of SDH. Results suggest that other factors (e.g., external social inequities) are driving disparities in COVID-19 prevalence.
Date: April 7, 2021
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VA Researchers Develop Model to Estimate Risk of COVID-19 Related Deaths among Veterans for Use in Prioritizing Vaccine
This study sought to develop a model to estimate the risk of COVID-19 related death in the general population to aid vaccination prioritization. In estimating the risk, COVIDVax (the model developed) used the following 10 patient characteristics: sex, age, race, ethnicity, body mass index (BMI), Charlson Comorbidity Index (CCI), diabetes, chronic kidney disease, congestive heart failure, and the Care Assessment Need (CAN) score. Using COVIDVax to prioritize vaccination was estimated to prevent 64% of deaths that would occur by the time 50% of VA enrollees are vaccinated, significantly higher than prioritizing vaccination based on age (46%) or the CDC phases of vaccine allocation (41%). Even under conditions when vaccine supply is no longer limited, the model can help target individuals who might not yet be vaccinated but are at highest risk from COVID.
Date: April 6, 2021
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Early Initiation of Prophylactic Anticoagulation for Veterans Hospitalized with COVID-19 Reduces Mortality
This study sought to determine whether early initiation of prophylactic anticoagulation compared to no anticoagulation decreased risk of death in patients hospitalized with COVID-19. Findings showed that after accounting for a large number of demographic and clinical characteristics, mortality at 30 days was 14% among Veterans who received prophylactic anticoagulation and 19% among patients who did not, resulting in a 27% decreased risk for 30-day mortality. This benefit appeared to be greater among patients not transferred to the ICU within 24 hours of admission. Similar associations were found for inpatient mortality and initiation of therapeutic anticoagulation. In a post-hoc safety analysis, the receipt of prophylactic anticoagulation was not associated with an increased risk of bleeding that required a transfusion. Findings provide strong real-world evidence to support guidelines recommending the use of prophylactic anticoagulation as initial therapy for COVID-19 patients upon hospital admission.
Date: February 11, 2021
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Review Provides Updated Guidance for Use of Remdesivir among Individuals with COVID-19
In this article, investigators updated their previous systematic review of remdesivir for adults with COVID-19 to include new meta-analyses of patients with COVID-19 – of any severity – compared with a control. Compared with controls, a 10-day course of remdesivir probably results in little to no mortality reduction but may result in a small reduction in the proportion receiving mechanical ventilation. Compared with a 10-day course of remdesivir for patients not requiring ventilation at baseline, a 5-day course may reduce mortality, the need for ventilation, and serious adverse events while increasing the percentage of patients who recovered or clinically improved. Effect on hospital length of stay or the percentage of those remaining hospitalized is mixed. Among patients already receiving invasive mechanical ventilation remdesivir may not reduce time to recovery and may increase mortality. Serious adverse events reported in trials include a combination of clinical findings resulting from COVID-19 progression (e.g., respiratory failure) and direct remdesivir toxicity. For patients not receiving ventilation, a 5-day course of remdesivir may provide greater benefits and fewer harms with lower drug costs than a 10-day course. The American College of Physicians’ Scientific Medical Policy Committee used this updated systematic review to develop a new Practice Points document to guide clinicians on the use of remdesivir.
Date: February 9, 2021
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Strains on Critical Care Capacity Associated with Increased Mortality among VA Patients Admitted to an ICU for COVID-19
This study sought to determine whether COVID-19 mortality was associated with COVID-19 Intensive Care Unit (ICU) strain. Findings showed that strains on critical care capacity due to peak COVID ICU caseload were associated with increased COVID-19 mortality. ICU patients with COVID-19 had a two-fold increased risk of death if treated during periods where COVID-19 ICU-demand was 75-100% of peak demand (“rush hour”) compared to periods below 50% of peak. No association between COVID-19 ICU-demand and mortality was observed for non-ICU patients with COVID-19. Mortality among hospitalized patients with COVID-19 declined significantly from early in the pandemic through summer 2020: March, 23%; April, 25%; May, 16%; June, 14%; July, 13%; and August, 13%. Public health officials and hospital administrators should monitor rising COVID-19 ICU case counts relative to earlier peaks to prepare for possible effects on patient outcomes and seek ways to reduce ICU strain.
Date: January 19, 2021
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Inpatient Mortality Underestimates the Health Burden of COVID-19 Hospitalizations in Veterans
This study sought to measure the rate of readmission, reasons for readmission, and rate of death after hospital discharge among Veterans with COVID-19 who used VA healthcare. Findings showed that 27% of Veterans who survived COVID-19 hospitalization were readmitted or died by 60 days post-discharge, and this rate was lower than matched survivors of pneumonia (26% vs. 32%) or heart failure (27% vs. 37%). Rates of readmission or death were higher than matched pneumonia or heart failure survivors during the first 10 days after discharge following COVID-19 hospitalization, suggesting a period of heightened risk for clinical deterioration.
Date: December 14, 2020
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Older Age Strongest Risk Factor Associated with Mechanical Ventilation and Death among Veterans with COVID-19
This study sought to identify risk factors associated with hospitalization, mechanical ventilation, and death among patients with COVID-19 infection. Findings showed that Veterans who were COVID-positive were more likely to be Black (42% vs 25%), obese (45% vs 40%), and to live in states with a high burden of COVID-19 compared to Veterans who tested negative. Veterans who tested positive for COVID-19 had a 4.2-fold risk of mechanical ventilation and a 4.4-fold risk of death compared with Veterans who tested negative. Most COVID-19 deaths among Veterans in this study were attributed to age 50 and older (64%), male sex (12%), and greater comorbidity burden (11%). Many factors previously reported to be associated with mortality in smaller studies were not confirmed, including Black race, Hispanic ethnicity, COPD, hypertension, and smoking. Other risk factors for mortality among Veterans with COVID-19 included select pre-existing comorbid conditions, such as heart failure, chronic kidney disease, and cirrhosis.
Date: September 23, 2020
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Blacks and Hispanics Twice as Likely as White Veterans to Test Positive for COVID-19
This study examined racial and ethnic disparities in patterns of COVID-19 testing (i.e., who received testing and who tested positive) and subsequent 30-day mortality for Veterans receiving VA healthcare (all testing and services in this study were provided within VA). Findings showed that Black Veterans were more likely to be tested (rate per 1,000 patients, 60.0) than Hispanic (52.7) or White Veterans (38.6). Among those tested, both Black and Hispanic Veterans were twice as likely to test positive than White Veterans, even after accounting for all adjusting variables. The disparity between Black and White Veterans in testing positive slightly decreased over the study period – and was highest in the Midwest compared to other regions. The disparity between Hispanic and White Veterans was consistent across time, geographic region, and outbreak pattern. Among those who tested positive for COVID-19, there were no other observed differences in 30-day mortality by race/ethnicity group.
Date: September 22, 2020
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Repeated Temperature Readings with Patient Baseline Increases Sensitivity for COVID-19 Detection among Elderly Veterans
The purpose of this study was to compare temperature trends and identify maximum temperatures in Community Living Center (CLC) residents 14 days prior to and following systematic testing for COVID-19. Findings showed that a single temperature screening is unlikely to accurately detect COVID-19 in nursing home residents. Only 27% of residents who tested positive for the virus met the temperature threshold (38°C or 100.4°F) during the study period. While most nursing home residents (63%) with confirmed COVID-19 experienced two or more 0.5°C elevations above their baseline temperatures, there also was a group (20%) that was persistently cooler and had no temperature deviation from baseline. Temperatures in elderly Veterans with COVID-19 began rising 7 days prior to testing for the virus – and remained elevated during the 14-day follow-up. The average maximum temperature in COVID-19 positive patients was 37.66°C (99.8°F) compared to 37.11°C (98.8°F) in patients who were COVID-19 negative. Study findings suggest that the current fever threshold for COVID-19 screening should be reconsidered. Repeated temperature measurement with a patient-derived baseline could increase sensitivity for surveillance purposes when applied to a nursing home population.
Date: June 8, 2020
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Strategy in a VA Skilled Nursing Facility Minimizes Both Asymptomatic and Pre-Symptomatic Transmission of COVID-19
Universal and serial COVID-19 testing in skilled nursing facilities can identify cases during an outbreak, and rapid isolation and cohorting can minimize ongoing transmission. This outbreak report demonstrates the utility of universal serial laboratory screening to identify cases to rapidly isolate or cohort to reduce transmission in a VA skilled nursing facility. This strategy limited potential asymptomatic and pre-symptomatic transmission of COVID-19, allowing for successful containment. The outbreak in one ward was suppressed within 1 week, the outbreak in a second ward was suppressed within 2 weeks, and no cases occurred in a third ward.
Date: May 29, 2020
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Common Drugs for Hypertension and Diabetes Not Associated with Severe COVID-19 Illness or Testing Positive for COVID-19
Originally requested by the World Health Organization (WHO), this systematic review examined the relationship between angiotensin-converting enzyme inhibitors (ACEI) or angiotensin-receptor blockers (ARB) use and COVID-19 illness. Findings showed that high-certainty evidence suggests that ACEI or ARB use is not associated with more severe COVID-19 illness, and moderate-certainty evidence suggests no association between the use of these medications and positive SARS-CoV-2 test results among symptomatic patients. Findings from this rapidly expanding literature show no indication to prophylactically stop ACEI or ARB treatment because of concerns about COVID-19. Moreover, withdrawal of long-term ACEIs or ARBs may be harmful, especially in patients with heart failure, because observational studies and trials have suggested that discontinuation of ACEI or ARB therapy is associated with worse outcomes.
Date: May 15, 2020
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Veterans Advocate Treating “Sickest First” When Discussing Limited Resources for Hepatitis C Treatment
Investigators in this study used Democratic Deliberation (DD) methods as a proof of concept for informing policy decisions related to the allocation of scarce resources for treatment of chronic hepatitis C virus in VA. Findings showed that most Veterans endorsed a sickest-first policy over a first-come-first-served policy, emphasizing the ethical and medical appropriateness of treating the sickest Veterans first. When given the option, almost two-thirds of participants insisted that all Veterans be treated without delay regardless of symptoms or degree of disease severity (note: this is currently VA policy but not common outside of VA). Only when required to choose between the two policies did a majority opt for the SF policy (86% before DD session; 93% after DD session). Veterans also suggested modifications to the “sickest first” policy: 1) need to consider additional health factors, 2) taking behavior and lifestyle into account, 3) offering education and support to overcome barriers to treatment, 4) improving access to testing/treatment, and 5) improving how allocation decisions are made. The approach of using DD to incorporate the opinions of patients may have implications for how to develop policies around allocation of limited healthcare resources during the current COVID-19 pandemic.
Date: May 1, 2020
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Possible Impact of Measures to Curb COVID-19 Spread on Suicide Prevention Efforts
Social distancing and other public health actions intended to curb the spread of COVID-19 have the potential for adverse outcomes on suicide risk. However, concerns about negative secondary outcomes of COVID-19 prevention efforts should not imply that that these public health actions should not be taken. Implementation should include a comprehensive approach that considers the public health priority of suicide prevention as well.
Date: April 10, 2020
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Practical Recommendations for the Care of Older Individuals at Highest Risk from COVID-19
The risk of COVID-19 transmission in the coming months may be high long-term care facilities, requiring focused attention and preparedness efforts. Adding to this healthcare challenge, long-term care residents often have medical conditions associated with an increased risk of morbidity and mortality from COVID-19. Appropriate preparedness includes five key elements: 1) Reduce morbidity and mortality among those infected; 2) Minimize transmission; 3) Ensure protection of healthcare workers; 4) Maintain healthcare system functioning, and 5) Maintain communication with worried residents and family members. Airborne disease protocols should be activated and put into action. Environmental services should be engaged to perform at least daily cleaning with Environmental Protection Agency (EPA) registered hospital-grade disinfectants, particularly in high-traffic areas (e.g., dining halls, treatment areas, living spaces, etc.). Training staff and visitors on how to minimize their risk for picking up COVID-19 in the community and in long-term care facilities, and transmitting it to others, will remain the most important tools to stop the spread of the virus. Executing a communication strategy that keeps residents, family members, and the public informed also will be critical during this rapidly evolving crisis.
Date: March 13, 2020
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