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Publication Briefs

Study Suggests Substantial Health Risks Remain for Veterans Two Years after Hospitalization for COVID-19

Much evidence suggests that COVID-19 can lead to post-acute sequelae in multiple organ systems, which can increase the risk of various disorders (i.e., cardiovascular, neurologic and mental health, metabolic, kidney, and gastrointestinal disorders). 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. Using VA electronic health record data, investigators created a cohort of 138,818 Veterans who had been infected with COVID-19 before December 31, 2020 and 5,985,227 Veterans who had not been infected. These two cohorts were followed for two years to estimate the risks of death, hospitalization, and 80 pre-specified post-acute sequelae of COVID-19 (PASC), such as: depressive disorder, heart failure, GERD, myopathy, fatigue, memory problems, and joint pain. Veterans’ outcomes also were assessed cumulatively at two years in mutually exclusive groups according to care setting during the acute phase of the disease (non-hospitalized and hospitalized), as well as in the overall cohort.


  • 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
  • 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.
  • Cumulatively at two years, PASC contributed 80.4 and 642.8 disability-adjusted-life-years (DALYs) per 1,000 persons among non-hospitalized and hospitalized individuals; 25% and 21% of the cumulative two-year DALYs in those non-hospitalized and hospitalized were from the second year.


  • 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.
  • Reducing the risk of infection and transmission with updated vaccines may be a critical strategic avenue to reducing the risk of long-term health loss in populations.


  • The cohort with COVID-19 did not include those with a SARS-CoV-2 infection who had not been tested; inclusion of these Veterans in the control group, if their true risk of adverse health outcomes was higher than the non-infected, might have resulted in an under-estimation of risks.
  • While investigators pre-specified 80 sequelae, their analyses did not capture all possible known and yet to be characterized sequelae, particularly in regard to ongoing COVID variants.
  • Because all cases were infected in the first year of COVID before COVID-19 vaccines were available, results may not apply to patients infected more recently.

This study was supported by HSR&D. Drs. Bowe, Xie, and Al-Aly (Chief of Research and Development) are part of VA St. Louis Health Care.

Bowe B, Xie Y, and Al-Aly Z. Post-acute Sequelae of COVID-19 at 2 Years. Nature Medicine. August 21, 2023;online ahead of print.

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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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