Lead/Presenter: Karen Seal, San Francisco VA Healthcare System
All Authors: Seal KH (Integrative Health Service, San Francisco VA Health Care System and Departments of Medicine and Psychiatry, University of California, San Francisco), Manuel JK (Mental Health Service, San Francisco VA Health Care System and Department of Psychiatry, University of California, San Francisco) Pyne JM (Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System and Department of Psychiatry, University of Arkansas for Medical Sciences) Bertenthal D (Integrative Health Service, San Francisco VA Health Care System) Elwy R (VA Bedford Healthcare System; 8 Brown University School of Medicine) Esserman D (Department of Biostatistics, Yale University School of Medicine)
Objectives:
COVID-19 primary vaccination and boosters decrease COVID-related hospitalizations and deaths. Rural Veterans have lower vaccination rates than urban Veterans, but underlying reasons remain unknown. Using the Veterans Health Administration (VHA) electronic health record, rural and urban Veterans enrolled in the VHA were compared on demographic, social determinants, and health services utilization factors associated with completion of COVID-19 vaccination series and first booster.
Methods:
The VA COVID Shared Data Resource and Corporate Data Warehouse were used to construct a retrospective cohort of Veterans from December 11, 2020 (Pfizer EUA) through June 7, 2022, among those with at least one VHA outpatient visit during the ascertainment period. Descriptive statistics compared vaccination rates in rural vs. urban Veterans (based on RUCA classification) examining factors associated with completion of primary vaccination and first booster (e.g., age, sex, race/ethnicity, housing and food insecurity, distance to nearest VA facility, telehealth utilization, primary care team assignment, comorbidities, and prior COVID-19 diagnosis). Geospatial mapping (i.e., choropleths) illustrated differences in vaccination rates by rural/urban regions. Subgroup analyses using generalized linear models with predictive margins estimated adjusted rates and rate differences in vaccination.
Results:
During the study, 1.2 million (62.1%) rural Veterans and 2.6 million (69.4%) urban Veterans received primary COVID-19 vaccination; representing a 7.3% lower rate of primary vaccination among rural Veterans. Among Veterans completing primary vaccination, 577,536 (49.0%) rural Veterans and 1.3 million (53.4%) urban Veterans received their first COVID-19 booster; a 4.4% lower rate among rural Veterans. Adjusted analyses revealed that primary vaccination and booster rates were lower for rural Veterans across all subgroups, except for African American and Hispanic Veterans. Some factors were more strongly associated with lower rates among rural Veterans than urban Veterans: being White, male, younger than age 50, residing in Southern states, and having fewer primary care visits; driving time to VA primary care had less impact for rural Veterans. Among both rural and urban Veterans, rates of primary vaccination were higher among Veterans with more in-person and video telehealth visits, whereas more telephone visits predicted lower vaccination rates. Also, in both groups, Veterans with food and/or housing insecurity, higher comorbidity levels, and those with prior COVID-19 had lower rates of primary vaccination. Similar rural-urban differences were observed for completion of the first COVID-19 booster.
Implications:
Rural Veterans had lower rates of COVID-19 vaccination than their urban counterparts especially in those who were White, male, and < 50 years old, yet rates among rural Black/African American and Hispanic Veterans were similar to urban Veterans. Having more primary care visits differentially improved vaccination rates in rural Veterans. Among both rural and urban Veterans, vaccination rates were lowest in veterans who were marginally housed and who had the highest comorbidity levels and prior COVID-19; rates improved with more in-person and video (vs. telephone) visits.
Impacts:
Targeted interventions are needed in subgroups of rural Veterans and among all Veterans with greater social and clinical vulnerability. Engagement in primary care, particularly via in-person or video telehealth improves COVID-19 vaccination rates among rural Veterans enrolled in the VHA.