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C19 20-399 – HSR&D Study

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C19 20-399
Delaying Cardiovascular Procedures to Curb the Spread of COVID-19 among Veterans: Variation in VHA Practice Patterns and Outcomes
Celina M. Yong MD MBA MSc
Palo Alto, CA
Funding Period: August 2020 - April 2022

BACKGROUND/RATIONALE:
In 2020, the rapid spread of coronavirus worldwide forced VHA hospitals across the country to start triaging the delivery of medical procedures, in efforts to flatten the curve of COVID-19 growth and its associated high mortality. On March 17, 2020, with a shelter-in-place order first deployed across a 6-county region of Northern California, and soon after, across the state of California and other regions across the country, VA hospitals started postponing all elective cardiovascular procedures, while permitting only urgent, life-threatening ones. Days later, professional societies published guidelines recommending similar rationing at scale, both to conserve resources and to prevent elderly, at-risk patients from unnecessary exposure to the highly contagious virus. There are important reasons why this approach warrants rapid evaluation: (1) COVID-19 has produced an unprecedented natural experiment to demonstrate the comparative effectiveness of a vast number of high cost procedures to guide future treatment decisions on usefulness of therapies or de-implementation, which traditional randomized controlled trials will likely never accomplish, (2) evaluation of this approach will inform how to best manage healthcare rationing responses in disaster situations, pandemics, workforce disruptions, and abrupt changes in operational capacity or funding, (3) we must determine whether vulnerable populations are disproportionately impacted by this approach to ensure that we are delivering equitable care to our Veterans at highest risk of adverse health outcomes. To achieve this, we have adapted the structure-process-outcome conceptual model to assess the impact of delays within the VHA (Fig 1, "S"= structure, "P"= process, "O"=outcome).

OBJECTIVE(S):
Specific Aim 1. To describe the impact of the COVID-19 pandemic on cardiovascular procedural volumes across the VHA nationally.

Specific Aim 2. To assess whether there were differences in procedural treatment among vulnerable populations within the VHA comparing the pre to post-COVID-19 period.

Specific Aim 3. To compare downstream outcomes in Veterans hospitalized with incident STEMI, NSTEMI, severe aortic stenosis, and AV block before and after the COVID-19 pandemic and to determine if inpatient procedure use mediates those outcomes.

METHODS:
We will assess the total number of procedures performed from Dec 2018 to present, across the spectrum of cardiovascular disease treatments (e.g. PCI, TAVR, pacemaker, atrial fibrillation ablation, etc). We will compare Mar-July 2019 to Mar-July 2020 to see differences in volumes impacted by COVID 19. We will compare across the following demographic and disease categories: race, gender, geography (less than or farther than 200 miles from tertiary care center), socioeconomic status (income quartile by zip code), education (by zip code) and age (less than or older than 65), COVID-19 positive status. We will assess inpatient mortality and LOS, with comparison over time. We will also assess complexity of procedure by MS-DRG codes.

FINDINGS/RESULTS:
TBD

IMPACT:
This work will directly translate into actionable outcomes by informing the optimal triage of cardiovascular procedures under severely resource constrained settings, identify any inequitable distribution of limited resources to vulnerable populations within the VHA, and serve as an early warning if current practices are negatively impacting Veteran health outcomes. These findings will extend to our routine prioritization of procedures when this pandemic hopefully resolves.

PUBLICATIONS:
None at this time.

DRA: Cardiovascular Disease
DRE: None at this time.
Keywords: Organizational Structure, Outcomes - Patient, Practice Patterns/Trends
MeSH Terms: None at this time.

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