Spotlight on COVID-19

October 2022

COVID-19 upended daily life and created significant implications for the health and well-being of people around the world. As the virus continues to spread—so far, it has infected more than 91 million people in the U.S., according to the Centers for Disease Control and Prevention—HSR&D has continued to support research that explores the many facets of COVID-19 and other infectious diseases, from prevention to identification and management of long-term physical and mental symptoms.

HSR&D’s Evidence Synthesis Program (ESP), for example, works to synthesize evidence to identify best practices, and has developed a catalog of COVID-19 evidence reviews from around the world. Additionally, three of HSR&D’s Quality Enhancement Research Initiative (QUERI) Rapid Response Teams have partnered with the National Center for Health Promotion and Disease Prevention to carry out quality improvement projects related to vaccine hesitancy.

The following are some recent VA studies on COVID-19 and its repercussions:

• Increased Risk for Cardiovascular Conditions among Veterans Up to One Year Following COVID-19 Infection
• Use of VA Telehealth Services at VA GLA during the COVID-19 Pandemic
• Impacts of Telemental Healthcare for High-Risk Veterans with Opioid Use Disorder During COVID-19
• Impact of COVID-19 and Social Distancing on Mental Health and Suicide Risk in Veterans

Increased Risk for Cardiovascular Conditions among Veterans Up to One Year Following COVID-19 Infection

The aftereffects of COVID-19 can involve pulmonary and several other organs, including the cardiovascular system. Although cardiovascular complications during the acute phase of COVID-19 have been well described, the post-acute cardiovascular manifestations of COVID-19 have not been comprehensively assessed. Studies of post-acute COVID-19 conditions across the spectrum of care settings of acute infection (non-hospitalized, hospitalized, and admitted to intensive care) are also lacking. Addressing this knowledge gap will inform post-acute COVID-19 care strategies.

About this study

This study examined associations between COVID-19 and incident cardiovascular disease in the post-acute phase of COVID-19. Investigators estimated the risks and 12-month burdens of cardiovascular outcomes among 153,760 Veterans who survived the first 30 days of COVID, compared to 5,637,647 VA healthcare users with no COVID and 5,859,411 Veterans who used VA healthcare prior to the COVID pandemic. Investigators assessed patient demographics and health characteristics (e.g., obesity, smoking, hypertension). Cardiovascular conditions examined included: cerebrovascular disorders, dysrhythmia, inflammatory heart disease, and other cardiac disorders and thrombotic disorders.

Findings

• The risks and associated burdens of incident cardiovascular disease extended well beyond the acute phase of COVID-19 and were evident among those who were not hospitalized during the acute phase of COVID-19.
• The risks and associated burdens exhibited a graded increase across the severity spectrum of the acute phase of COVID-19, from non-hospitalized to hospitalized to those admitted to intensive care.
• The risks were evident regardless of age, race, and other cardiovascular risk factors. They were also evident in people without any cardiovascular disease before exposure to COVID-19, providing evidence that these risks might manifest even in people at low risk of cardiovascular disease.

Implications

• This study highlights the serious long-term cardiovascular consequences of COVID-19 and emphasizes the importance of vaccination to help prevent heart damage.
• Care strategies for people who survive the acute phase of COVID-19 should include attention to cardiovascular health and disease.
• Governments and health systems around the world should be prepared to deal with the likely significant contribution of the COVID-19 pandemic to a rise in the burden of cardiovascular diseases and the long-lasting consequences for patients, health systems, economic productivity, and life expectancy.

Principal investigator

Ziyad Al-Aly, MD, is the chief of research and development at the VA St. Louis Health Care System in St. Louis, MO.

Publications

Al-Aly Z, Bowe B, Xie Y. Long COVID after breakthrough SARS-CoV-2 infection. Nature Medicine. July 2022;28(7):1461–1467.

Xie Y, Al-Aly Z. Risks and burdens of incident diabetes in long COVID: a cohort study. The Lancet Diabetes & Endocrinology. May 1, 2022;10(5):311–321.

Xie Y, Xu E, Bowe B, and Al-Aly Z. Long-term cardiovascular outcomes of COVID-19. Nature Medicine. March 2022;28(3):583–590.

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Use of VA Telehealth Services at VA GLA during the COVID-19 Pandemic

The movement to integrate telehealth into clinical practice has been growing for several years, but there have been significant barriers to its widespread adoption. The COVID-19 pandemic forced rapid expansion of telehealth services. Exploring the adoption of telehealth within a single VA medical center provided the opportunity to understand the varied barriers and facilitators at different clinics and care providers, each with distinct needs and priorities.

About this study

Even though VA was an early adopter of telehealth, the vast majority of VA outpatient care continued to be face-to-face through February 2020. Because VA telehealth programs vary by clinic, this study examined how telehealth services were used at three types of outpatient clinics—primary care (PC), cardiology, and home-based primary care (HBPC)—within the VA Greater Los Angeles Healthcare System (GLA). To illustrate the use of telemedicine at each of the three clinics, researchers used VA data to:

• Examine the rate and use patterns of synchronous tele-visits (e.g., telephone, video) at each clinic 12 months before and after the onset of COVID-19.
• Identify characteristics of telehealth users at each clinic by analyzing sociodemographic data (e.g., age, race, ethnicity, marital status) and health risk scores.
• Evaluate barriers and facilitators of achieving rapid implementation of telemedicine delivery by conducting interviews with 34 key stakeholders and informants, including providers, administrators, and staff at the three clinics.

Findings

• Before the onset of COVID-19, at all three clinics, telehealth (telephone and video) use varied (PC: 16%–20%; cardiology: 7%–16%; HBPC: 16%–27%) and consisted mostly of telephone encounters.
• At the onset of COVID, telehealth use increased substantially (PC: 44%, cardiology: 45%, HBPC: 41%).
• After the onset of COVID, use of telehealth services continued to increase, reaching a peak for PC at 80% in April 2020. For cardiology and HBPC, the peak was 70% and 79%, respectively, in May 2020.
• Starting in June 2020, use of telehealth services at all three clinics began to decline slightly, but never reached pre-COVID-19 levels. However, most respondents cited the desire to continue virtual care in some form even after the pandemic is under control.
• The successful transition to telehealth largely depended on the level of communication between the scheduling clerk and the provider in each clinic.
• Providers reported that most patients preferred to use the telephone for telehealth appointments, as many did not have the equipment necessary for a video visit or found the technology difficult to navigate.
  • VA’s Video Connect (VVC) platform was described as confusing for both patients and providers.

Implications

• VVC should be reviewed and updated for easier use.
• Telehealth initiatives should consider patients’ varying degrees of equipment access and technological knowledge.
• Clear communication between each clinic’s clerk and provider helped pave the way for successful transition to telehealth appointments.
• To provide appropriate resources for successful implementation of telehealth services, it is necessary to understand individual clinic processes and workflows.

Principal investigator

Claudia Der-Martirosian, PhD, is a core investigator at HSR&D’s Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System.

Publications

Der-Martirosian C, Chu K, Steers W, et al. Examining telehealth use among primary care patients, providers, and clinics during the COVID-19 pandemic. BMC Primary Care. June 18, 2022;23(155).

Balut M, Wyte-Lake T, Steers W, and Der-Martirosian C. Expansion of telemedicine during COVID-19 at a VA specialty clinic. Healthcare. March 1, 2022;10(1):100599.

Der-Martirosian C, Wyte-Lake T, Balut M, et al. Implementation of telehealth services at the U.S. Department of Veterans Affairs during the COVID-19 pandemic. JMIR Formative Research. September 23, 2021;5(9):e29429.

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Impacts of Telemental Healthcare for High-Risk Veterans with Opioid Use Disorder During COVID-19

The COVID-19 pandemic significantly decreased Veterans’ access to healthcare and left some of the most high-risk Veterans—those with opioid use disorder (OUD)—vulnerable to worse health outcomes. Individuals with an OUD are at a significantly high risk of overdose, unintentional death, and a wide range of negative health related consequences. Evidence-based medications for OUD exist, but providers must undergo training to be certified to prescribe these types of medications, which has resulted in inadequate numbers of providers, particularly in rural areas.

Telehealth is a potentially effective service delivery method to mitigate this access to care problem, but the Ryan Haight Act of 2008 mandates that the first visit with a prescriber of schedule II–IV controlled substances be done in person. However, due to the COVID pandemic, the Act was temporarily waived. This created potential for treatment retention for high-risk Veterans with OUD and presented an opportunity to understand the impact of VA's preexisting telehealth structure for the treatment of OUD as well as the costs and benefits of the Ryan Haight Act.

About this study

The primary objectives of this study were to assess the impact of COVID-19 and related changes in policy and service design on access to care and medication management for Veterans with OUD, and to examine temporal trends during the COVID-19 window (for this study, from 3/16/20 to 6/30/20) in schedule II–IV narcotic prescription rates for Veterans who would normally fall under the parameters of the Ryan Haight Act. Researchers aimed to:

• Conduct qualitative interviews with providers and key local stakeholders to understand a) modes of patient interaction used (e.g., in-person, telephone, video conferencing), b) documentation patterns for these visits, and c) perceived facilitators and barriers to the rapid expansion of telehealth for OUD.
• Assess changes in prescribing behavior potentially attributable to the waiver of the Ryan Haight Act.
• Determine differences in the effect of the intervention by the patient’s rurality, age, gender, and/or race and ethnicity.

Preliminary findings

• Providers new to video telehealth were receptive to providing mental healthcare via video telehealth, but the perceived burden of the extra logistical steps required to provide care via telehealth deterred its use. Providers also reported anxiety about ensuring the safety of high-risk patients and/or about handling clinical emergencies over video telehealth.
• Most of the virtual care (46%) within VA was delivered by telephone during the study window, with an average of only 28% of visits provided via video.
• Examination of prescription information for 42,579 Veterans diagnosed with OUD during the 12-month period suggests that while telehealth is a legal option for prescribing controlled substances, it was not used in a way that replicated in-person care.

Implications

• As the Ryan Haight Act waiver does not acknowledge a telephone contact as adequate for new-patient schedule II–IV prescriptions, new Veterans with OUD—particularly those who reside in rural areas with few available providers—were at risk for delays in care and/or suboptimal care.
• Findings from this rapid pilot will be immediately relevant for VA operations partners, including VA Analytics and Business Intelligence, VA Office of Mental Health and Suicide Prevention, and VA Office of Connected Care.

Principal investigator

Ursula Myers, PhD, MS, is an investigator at HSR&D’s Health Equity and Rural Outreach Innovation Center (HEROIC) in Charleston, SC.

Publications

Myers U, Birks A, Grubaugh A, and Axon R. Flattening the curve by getting ahead of it: How the VA Healthcare System is leveraging telehealth to provide continued access to care for rural Veterans. The Journal of Rural Health. January 1, 2021;37(1):194–186.

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Impact of COVID-19 and Social Distancing on Mental Health and Suicide Risk in Veterans

Although the COVID-19 pandemic has created sweeping changes in people’s lives, due to the newness of this lethal virus, limited research has been conducted on its effect on mental health. Mandatory quarantines, for example, can have immediate and long-term effects on social engagement and isolation, potentially disrupting and eroding support, dependence, and trust in social networks, which in turn can harm overall well-being. Prior to the COVID-19 pandemic, Veteran suicide rates were already alarming, with 17 Veterans dying per day. Although social distancing is importantly designed to flatten the trajectory of COVID-19, it can have unintentional negative outcomes on Veterans' social networks, overall well-being, and suicide risk.

About this study

This study assessed Veterans’ experiences during the COVID-19 pandemic, changes in their social networks due to social distancing, and modifiable treatment factors to inform intervention development. Using VA data, researchers identified Veterans with a COVID-19 diagnosis and PTSD, mood disorder, or other psychiatric disorder, as psychiatric disorders raise suicide risk. Study participants (n=233) completed a one-time, 90-minute survey via their mobile device, tablet, or computer. Investigators measured hostile attributional bias, a form of social cognition that feeds a tendency to view others’ behavior as hostile or aggressive even when the behavior is benign or ambiguous. A personal-level social network analysis was conducted, and a composite adverse social connectedness measure was created based on a combination of social network measures, perceptions of social support relationships, and perceived overall level of social support.

Findings

• Overall, social connectedness worsened and dependency on a support network increased during the pandemic.
• The quality of relationships deteriorated over the course of the pandemic, and poor-quality relationships were directly related to hostile attributional bias.
• Most Veterans (87%) who indicated they had pressing healthcare needs did not have a person or organization in their support network that helped with those needs.
• Most Veterans (57%) did not have people or organizations in their identified support networks that they perceived to be coordinating their care or helping them with needs such as finances and transportation.
• Individuals with a COVID-19 diagnosis had moderate depressive symptoms; individuals with no COVID-19 diagnosis had mild depressive symptoms.

Implications

• Interventions such as social cognitive treatments that target hostile attributional bias may help improve relationships, and as a result alleviate PTSD and depressive symptoms, and thoughts of suicide.
• VA may play a critical role in helping Veterans connect with the health, emergency, and other resources they need, and in ensuring coordination and communication among providers, Veterans, and their family members.
• Inquiring about pressing needs related to social determinants of health is essential to providing Veterans the best treatment plans and care, particularly as the country emerges from the pandemic.

Principal investigator

Bryann R. DeBeer, PhD, is an investigator with HSR&D’s Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care and is director of the VA Patient Safety Center of Inquiry—Suicide Prevention Collaboration at the Rocky Mountain MIRECC for VA Suicide Prevention.

Dr. DeBeer discussed this study on a recent HSR&D podcast.

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