FORUM, Spring 2021
June 29, 2021
During the COVID-19 pandemic, research
teams across VA pivoted to address
numerous questions surrounding this novel
pathogen. This issue highlights just a few of VA's major research and implementation efforts and accomplishments.
Two Studies Show Positive Impact of COVID-19 Vaccinations on Nursing Home Residents
April 26, 2021
Takeaway: Findings from the two studies below indicate that COVID-19 vaccinations can decrease the pandemic-related isolation of Veterans living in VA community living centers, supporting efforts to begin resuming family visitation and to lessen other restrictions in nursing homes.
U.S. nursing homes incurred more than one-third of COVID-19 fatalities in the United States and began vaccine clinics in mid-December. Partly funded by HSR&D and led by James Rudolph, MD, Director of HSR&D’s Center of Innovation in Long-Term Services and Supports (LTSS-COIN), a retrospective analysis conducted from October 1, 2020 to February 14, 2021 describes the proportion of COVID-19 positive tests among 130 VA Community Living Centers (CLCs are VA-funded nursing homes) before and after COVID-19 vaccination. Using weekly CLC data, COVID-19 testing and vaccination results were summarized at the CLC level. For a reference on community prevalence, non-VA nursing home data reported by CMS were included for counties with CLCs. Findings show that more than half of CLC residents received their first vaccination by December 20, 2020. As of January 21, 2021, 82% of CLC residents had begun or completed the vaccination process, 13% refused the vaccination, and 5% were contraindicated. 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. Non-VA nursing home COVID-19 test positive data identified a higher proportion of COVID-19 positive tests and a similar decline in COVID-19 positive tests after vaccine availability.
In another study led by Vincent Mor, PhD, also with LTSS-COIN, investigators compared incident COVID-19 infection and 30-day hospitalization or death among residents with COVID-19 between nursing homes with earlier versus later vaccine clinics. Among 280 (non-VA) nursing homes in 21 states, early clinics vaccinated between December 18, 2020, and January 2, 2021 and later clinics between January 3, 2021, and January 18, 2021. Findings show that one week after their initial vaccine clinics, nursing homes with earlier vaccination (12,157 residents at 136 facilities) had 2.5 fewer new COVID-19 infections per 100 at-risk residents than expected relative to later vaccination (13,221 residents at 144 facilities). 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.
Results of the study by Rudolph and colleagues indicate that by reducing infection, COVID-19 vaccinations hold promise as a mechanism to decrease the pandemic-related isolation of nursing home residents. In addition, findings from the study by Mor and colleagues suggest that COVID-19 vaccines accelerated the rate of decline of incident infections, morbidity, and mortality in this large multi-state nursing home population. This evidence further supports efforts to begin resuming family visitation and to lessen other restrictions in nursing homes.
Rudolph J, et al. Proportion of SARS-CoV-2 Positive Tests and Vaccination in VA Community Living Centers. JAGS. April 16, 2021; Epub ahead of print.
Mor V, et al. Short-term Impact of Nursing Home SARS-CoV-2 Vaccinations on New Infections, Hospitalizations, and Deaths. Journal of the American Geriatrics Society. April 16, 2021; Epub ahead of print.
COVID-19 Vaccine Hesitancy
March 19, 2021
Three QUERI program Rapid Response Teams (RRT-3), representing teams from the Bridge QUERI, CARRIAGE QUERI and Function QUERI, are partnering with the National Center for Health Promotion and Disease Prevention (NCP) to carry out three separate 6-month, rapid quality improvement projects to address the following questions:
- What are Veteran and VA employees attitudes toward COVID-19 vaccines?
- What factors are associated with vaccine hesitancy?
- How do attitudes, beliefs and perceptions about COVID-19 vaccines change over time?
Using a range of methodologies (surveys, interviews and focus groups), the RRT-3 are providing real-time updates to NCP on the state of COVID-19 vaccine hesitancy across VHA. Data from these projects are being used to inform communication and implementation strategies to increase the uptake of COVID-19 vaccines among VA employees and Veterans. Projects will be completed by June 30, 2021.
Updates can be accessed on the intranet at: vaww.hsrd.research.va.gov/queri-rrt/default.cfm
Veterans with Spinal Cord Injury and Disorder at Increased Risk of Death from COVID-19
March 5, 2021
Takeaway: Veterans with spinal cord injury and disorder (SCI/D) and COVID-19 were 2.5 times more likely to die than those with COVID-19 but without SCI/D. Individuals with SCI/D should be strongly encouraged to take actions to minimize their chance of acquiring COVID-19. This work has been cited in the latest VA guidance for prioritization of COVID-19 vaccinations for outpatient SCI Veterans.
Veterans with SCI/D have unique medical concerns that can increase their risk of mortality from COVID-19 infection. VA’s SCI/D National Program Office oversees healthcare services received by more than 24,000 Veterans with SCI/D at 170 medical centers and more than 1,000 outpatient care sites. To support outreach and prevention activities in response to the current COVID-19 pandemic, the National Program Office developed operational reports showing COVID-19 infection status among Veterans with SCI/D. Additional data (i.e., demographics, comorbidities, and geographic setting) were used to determine an infection risk category and severity risk category for each SCI/D Veteran. These reports were developed in March 2020 and made available to VA SCI/D Centers on April 7, 2020. Using these reports, investigators conducting this retrospective comparative analysis sought to describe case fatality of COVID-19 infection among Veterans with SCI/D.
Findings showed that between March 9, 2020 and June 30, 2020, COVID-19 was identified in 140 of 17,452 Veterans with SCI/D. During that same period, the case fatality rate for Veterans with SCI/D was 19% compared to 8% for Veterans without SCI/D. Thus, Veterans with SCI/D and COVID-19 were 2.5 times more likely to die than those with COVID-19 without SCI/D.
This work has been cited in the latest VA guidance for prioritization of COVID-19 vaccinations for outpatient SCI Veterans. The VA SCI/D population includes a considerable number of older Veterans with multiple medical conditions which increase their risk of severe COVID-19 infection. These findings provide preliminary evidence that individuals with SCI/D in all settings, including institutional settings, should be strongly encouraged to take actions to minimize their chance of acquiring COVID-19.
This project was a joint effort between VA clinical staff in the spinal cord injury/disorder (SCI/D) units at the Puget Sound and St. Louis VA Medical Centers, HSR&D’s Center of Innovation for Complex Chronic Healthcare (CINCCH), and VA’s SCI/D National Program Office.
Burns S, Eberhart A, Sippel J, Wilson G, and Evans C. Case-fatality with coronavirus disease 2019 (COVID-19) in United States Veterans with spinal cord injuries and disorders. Spinal Cord. September 2020;58(9):1040-1041.
Prophylactic Anticoagulation for Patients Hospitalized with COVID-19 Reduces Mortality
February 12, 2021
Takeaway: New research in The British Medical Journal (BMJ) provides strong real-world evidence to support guidelines recommending the use of prophylactic anticoagulation as initial therapy for COVID-19 patients upon hospital admission.
Deaths among individuals with COVID-19 have been partially attributed to venus thromboembolism (deep vein thrombosis) and arterial thromboses (blood clot in the arteries). In response, several expert organizations recommend using prophylactic anticoagulation for patients admitted with COVID-19, who do not have a contraindication to this therapy. While evaluations of the efficacy of prophylactic anticoagulation in patients with COVID-19 in randomized clinical trials are underway, they have not yet been reported. Further, previous observational studies have been limited in sample size or used relatively small healthcare systems.
"Previous research using real-world data has not comprehensively accounted for all the reasons why people are given, or not given, anticoagulation. We designed our study to emulate a clinical trial around the specific question of whether prophylactic doses of anticoagulation given at the time of hospital admission prevented deaths from COVID-19 in patients who were eligible to receive it." Christopher Rentsch, PhD, MPH, Co-lead author*.
This observational study sought to determine whether early initiation of prophylactic anticoagulation compared to no anticoagulation decreased risk of death in patients hospitalized with COVID-19. Using VA data, investigators included all Veterans hospitalized between March 1 and July 31, 2020, who were confirmed to have COVID-19 on or within 14 days of hospital admission. The final cohort included 4,297 Veterans; 3,627 (84%) of whom received prophylactic anticoagulation within 24 hours of hospital admission. The main outcome measure was 30-day mortality. Findings show:
- After accounting for a large number of demographic and clinical characteristics, mortality at 30 days was 14.3% among Veterans who received prophylactic anticoagulation and 18.7% 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.
- Results were unchanged in several sensitivity analyses, suggesting that they withstand scrutiny. However, the researchers acknowledge that due to the observational nature of the study, a degree of uncertainty persists that can only be addressed through randomized trials.
Turning Research Findings into Practice
Investigators have reported these findings to VA Central Office, Washington, DC, and Chief Medical Officers who have taken steps to implement these findings into VA clinical care. They also have made several presentations, including one to the VA-DOE, HHS COVID-19 Insights Partnership – an initiative to coordinate and share health data, as well as research and expertise to aid in the fight against COVID-19. In addition, the findings have been published in The BMJ, prompting several press releases.
“We believe the evidence is becoming clear that initiating prophylactic anticoagulation in earlier stages of severe COVID-19 provides greater benefit than initiating prophylactic or full-dose anticoagulation when critically ill. We eagerly await the full reporting of ongoing clinical trials, particularly those investigating whether this therapy should be given to non-hospitalized people newly diagnosed with COVID-19.” - Christopher Rentsch
About the Investigators
Christopher Rentsch, PhD, MPH
Funded by VA/HSR&D and the National Institutes of Health (NIH), this study was conducted by several HSR&D investigators, including co-lead author Christopher Rentsch, PhD, who is part of part of HSR&D’s Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center in West Haven, CT. Dr. Rentsch is an epidemiologist specializing in the use of electronic health records (EHRs), with a focus on creating real-world evidence for the safety and effectiveness of medications. He is an active member of EHR Research Groups at VA and the London School of Hygiene & Tropical Medicine (LSHTM). During the coronavirus pandemic, his research has focused on investigating potential pharmacotherapies for the prevention and treatment of COVID-19, identifying racial and ethnic disparities in COVID-19 from testing to mortality, and quantifying excess risks for long-term outcomes among COVID-19 survivors.
Other HSR&D researchers on this study include: Drs. Joseph King Jr., Janet Tate, and Amy Justice are part of HSR&D’s Pain Research, Informatics, Multi-morbidities, and Education (PRIME) Center in West Haven, CT. Dr. Walid Gellad is with HSR&D’s Center for Health Equity, Research and Promotion (CHERP) in Pittsburgh and Philadelphia, PA. Dr. Paul Heidenreich is with HSR&D’s Center for Innovation to Implementation (Ci2i) in Palo Alto, CA. Dr. David Atkins is Director of HSR&D in Washington, DC. And Dr. Matthew Freiberg is part of the Tennessee Valley Healthcare System.
*Rentsch C, Beckman J, Tomlinson L, Gellad W, Alcorn C, Kidwai-Kahn F, Skanderson M, Brittain E, King Jr. J, Ho Y-L, Eden S, Kundu S, Lann M, Greevy Jr. R, Ho PM, Heidenreich P, Jacobson D, Douglas I, Tate J, Evans S, Atkins D, Justice A, and Freiberg M. Early initiation of prophylactic anticoagulation for prevention of coronavirus disease 2019 mortality in patients admitted to hospital in the United States: Cohort study. The British Medical Journal. February 11, 2021. DOI: 10.1136/bmj.n311