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2023 HSR&D/QUERI National Conference Abstract

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1065 — Excess Mortality at State Veterans Homes During COVID-19.

Lead/Presenter: Yevgeniy Feyman,  PEPReC (Boston)
All Authors: Strombotne KL (Partnered Evidence-Based Policy Resource Center, Boston; Boston University School of Public Health), Sadej I (Partnered Evidence-Based Policy Resource Center, Boston; Boston University School of Public Health) Feyman Y (Partnered Evidence-Based Policy Resource Center, Boston; Boston University School of Public Health) Legler A (Partnered Evidence-Based Policy Resource Center, Boston) Pizer, SD (Partnered Evidence-Based Policy Resource Center, Boston; Boston University School of Public Health) Griffith KN (Partnered Evidence-Based Policy Resource Center, Boston; Vanderbilt University Medical Center)

The COVID-19 pandemic has resulted in significant excess mortality among both the general U.S. population and at the Veterans Health Administration (VHA). However, media reports and anecdotal evidence have suggested that the coronavirus pandemic was especially lethal for Veterans living in state-run Veterans Homes. The objective of this study was to quantify excess mortality among VHA-enrolled veterans living at state Veterans homes during the COVID-19 pandemic.

We obtained data from the VHA’s Corporate Data Warehouse for 53,625 unique Veterans who were actively enrolled in the VHA and resided at one of 165 State Veterans’ Homes between 2015 and 2021. We used data from January 2015 through February 2020 to estimate a mortality risk prediction model using ten-fold cross-validation and Poisson quasi-likelihood regression. Potential predictors of mortality included individual-level demographics, priority group (an eligibility determination which reflects disability related to military service or economic hardship), and major comorbidities. We used the resulting model to predict expected mortality for two time periods: March-December 2020, and January-December 2021. Lastly, we estimated excess mortality and observed versus expected (O/E) mortality ratios for veterans residing at each facility within those time periods. Our unit of analysis was the patient-quarter.

Veterans residing at State Veteran Homes experienced 1,281 excess deaths out of 5,031 observed deaths during March-December 2020, which corresponds to an O/E ratio of 1.34 (95% CI 1.10, 1.72). Excess mortality declined in 2021: there were 1,473 excess deaths out of 8,073 observed deaths (O/E ratio 1.22, 95% CI 1.0, 2.57). There was wide variation in excess all-cause mortality across individual State Veteran Homes. Results were robust to multiple model specifications and functional forms.

The 34% excess mortality rate in Veteran deaths in State Veterans’ Homes during 2020 is well above previously-published estimates for all VHA enrollees (16%) and the U.S. general population (20%). Declining excess mortality in 2021 may be attributable to survivorship bias and a declining resident population at State Veteran Homes.

Our work provides valuable insights not only for performance management and institutional learning at State Veterans Homes, but also serves as a framework to identify changes in mortality at long-term care facilities during a public health emergency. In response to high excess mortality rates, states might consider practice reforms to mitigate against future waves of the pandemic such as increasing minimum staffing levels, collecting timely data on COVID cases and deaths, and augmenting infection control practices.