2023 HSR&D/QUERI National Conference

4144 — Impact of the COVID-19 Pandemic on Treatment and Outcomes of Acute Coronary Syndromes in the Veterans Health Administration

Lead/Presenter: Peter Groeneveld,  COIN - Pittsburgh/Philadelphia
All Authors: Groeneveld PW (Corporal Michael J. Crescenz VA Medical Center), Wu J (Corporal Michael J. Crescenz VA Medical Center) Nathan AS (Corporal Michael J. Crescenz VA Medical Center) Giri J (Corporal Michael J. Crescenz VA Medical Center) Julien HM (Corporal Michael J. Crescenz VA Medical Center)

The onset of the COVID-19 pandemic in March of 2020 resulted in marked declines in the number of U.S. patients seeking hospital care for acute coronary syndromes (ACS), which have high mortality rates, particularly when untreated. Black communities had higher rates of COVID infections and greater adverse economic impact from the pandemic, thus the barriers to hospital care may have been higher among Black ACS patients. This study investigated the rates of ACS hospitalization among Black and White Veterans in VA hospitals before and during the pandemic, to determine if VA rates of hospitalization, diagnostic catheterization (CATH), percutaneous coronary intervention (PCI), and mortality changed for ACS patients during the pandemic, and whether those changes disproportionately affected Black Veterans.

We combined VA health care utilization data from the VA’s Corporate Data Warehouse (CDW) from Black or White Veterans admitted to VA hospitals or observation units with an ACS diagnosis (i.e., acute myocardial infarction or unstable angina) as identified by ICD-10 coding from July 1, 2017 through September 30, 2020. Receipt of CATH or PCI was determined by linkages to procedural information in the VA’s Clinical Assessment Reporting and Tracking for Cardiac Catheterization Laboratories national registry. Thirty-day mortality was determined from the VA’s Vital Status File. Demographic and pre-admission comorbidity information was obtained from linked CDW data. Multivariable logistic regression models with hospital fixed effects were estimated for CATH, PCI, and 30-day mortality, including race, age, gender, comorbidities, an indicator for admission during the “COVID era” (i.e., Mar-Sep, 2020), and an interaction effect between race and COVID-era admission.

We identified 43,017 ACS admissions from mid-2017 to Sep, 2020. Among these, 25% of Veterans were Black. The onset of COVID was associated with a 17% decline in VA ACS admissions. COVID-era ACS admissions declined more sharply among White Veterans (-20%) than Black Veterans (-12%)(p < 0.001). During the COVID era, the ACS CATH rate increased from 46% to 52% (p < 0.001), and the PCI rate increased from 23% to 27% (p < 0.001). Multivariable models confirmed a risk-adjusted increase in both CATH (odds ratio[OR] = 1.36, p < 0.001) and PCI (OR = 1.21, p < 0.001) associated with the COVID pandemic, however there was no COVID-era-associated change in 30-day mortality (OR = 0.90, p = 0.08). Our regression models also showed no significant racial differences in the COVID-associated changes in CATH (OR for Blacks = 0.96, p = 0.46), PCI (OR = 1.00, p = 0.98), or mortality (OR = 1.02, p = 0.91).

The VA served proportionally more Black patients with ACS during the COVID pandemic than immediately prior, and the pandemic was not associated with additional disadvantages to Black Veterans with ACS in either the receipt of advanced therapies or in their likelihood of survival.

Despite a pandemic that disproportionately affected Black communities, the VA maintained equitable access, delivery of advanced cardiac care, and outcomes to patients with acute coronary syndromes. This experience can inform and encourage VA’s plans for future national health emergencies.