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Publication Briefs
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  • Changes in the Association between Race and Urban Residence with COVID-19 Outcomes among Veterans
    This study examined whether key sociodemographic and clinical risk factors for COVID-19 infection and mortality changed between February 2020 and March 2021 among more than 9 million Veterans enrolled in VA healthcare. Findings showed that strongly positive associations of Black race, American Indian/Alaska Native (AI/AN) race, and urban residence with COVID-19 infection, mortality, and case fatality that were observed early in the pandemic attenuated over time. The magnitude of the association between Black (vs. White) race and COVID-19 infection or mortality declined steadily from February/March 2020 to November 2020, when it was no longer significant. The association between AI/AN (vs. White) race and COVID-19 infection declined steadily over time to a negative association in March 2021. Similarly, the association between urban vs. rural location and COVID-19 infection or mortality also declined steadily over time, shifting from a positive association in February/March 2020 to a negative association in September/October 2020 and to a non-significant association in March 2021. Throughout the study period, high comorbidity burden, younger age, Hispanic ethnicity, and obesity were consistently associated with COVID-19 infection, while high comorbidity burden, older age, Hispanic ethnicity, obesity, and male sex were consistently associated with mortality. Understanding changing patterns of risk factors could be important in informing population-based approaches to prevent infection and reduce mortality by targeting those at highest risk at any given time during the course of an evolving pandemic.
    Date: October 21, 2021
  • VHA In-Person Care Declined Substantially More than Community Care During Pandemic – And Has Yet to Recover
    This study sought to describe how VA care patterns shifted in response to the pandemic, including all forms of care either purchased (Community Care) or provided by VA. Findings showed that overall VA healthcare use dropped precipitously in March and April of 2020, while virtual care expanded swiftly. However, VA in-person care declined substantially more than Community Care, and total encounters have yet to recover to pre-pandemic levels. The estimated total volume of missing encounters relative to the previous year (2019) was 16.5 million. Virtual care in VA increased from 6% (n=454,399) in April 2019 to 44% (n=1,894,674) in April 2020 before falling to 29% (n=1,861,922) in December 2020. As of December 2020, VA in-person care constituted just 30% of VA paid or provided care while non-acute community care accounted for 29% of all encounters. VA likely adopted a more conservative reopening strategy compared to community providers, who have different financial incentives to resume in-person care and returned close to pre-pandemic patient volume by September 2020. In the wake of concerns about access, VA has steadily increased spending on Community Care, and study results indicate existing trends pushing VA toward being a mixed payer and provider may have accelerated.
    Date: October 1, 2021
  • Best Practices for Equitable COVID-19 Vaccination Drive
    In collaboration with HSR&D investigators, the Interdisciplinary Vaccine Team at the VA Puget Sound Healthcare System worked to develop an equitable, coordinated, and data-driven COVID-19 vaccination drive for Veterans (carried out from December 21, 2020 to May 30, 2021). As of July 28, 2021, the VA Puget Sound facility had administered 79,643 vaccinations to 41,386 Veterans, representing 42% of its total population, and including 42% of Black enrollees, 29% of American Indian/Native Alaskan enrollees, and 35% of white enrollees. Key takeaways include: develop an intentional vaccine delivery strategy in conjunction with experts in population-level barriers to vaccination; explicitly include demographic and social determinants of health data to prioritize vulnerable populations in accessing vaccination; utilize multiple communication channels to reach patients in different formats.
    Date: September 15, 2021
  • Routine Use of Remdesivir for COVID-19 May Increase Length of Hospital Stay without Improving Survival
    This study sought to determine any associations between remdesivir treatment, survival, and length of stay among Veterans hospitalized with COVID-19 in the VA healthcare system. Findings showed that remdesivir therapy was not associated with improved 30-day survival: 12% mortality for remdesivir recipients vs. 11% for those who did not receive remdesivir. Remdesivir therapy was associated with an increase in median time to hospital discharge: 6 days for Veterans who received remdesivir compared to 3 days for matched Veterans who did not receive the drug. Examination of time to remdesivir completion and discharge suggested that clinicians may have been keeping patients in the hospital to complete 5-day remdesivir courses, contributing to a longer length of stay. Findings suggest that the routine use of remdesivir may be utilizing scarce hospital beds during a pandemic without leading to clear improvements in patient survival, and that interventions are needed to ensure that patients are not kept in the hospital solely to receive remdesivir.
    Date: July 15, 2021
  • Social and Behavioral Risk Factors Are Not Associated with Higher Mortality among VA Patients with COVID-19
    This study sought to determine if social and behavioral risk factors were associated with mortality from COVID-19 among Veterans, and whether the association was modified by race/ethnicity. Findings showed that despite relatively high levels of social and behavioral risk among Veterans in this study, no association with mortality from COVID-19 was found. Housing problems, financial hardship, current tobacco, alcohol, and substance use did not have statistically significant associations with mortality. Analyses by race/ethnicity did not find associations between mortality and these risk factors. Predictors of mortality in this study were consistent with other studies, including older age, Asian and American Indian or Alaska Native race, and certain comorbid conditions, such as diabetes, chronic kidney disease, dementia, and cirrhosis or hepatitis. This study highlights how integrated health systems such as VA can transcend social vulnerabilities and serve as models of support services for COVID-affected households and at-risk populations.
    Date: June 9, 2021
  • Two Studies Show Positive Impact of COVID-19 Vaccinations on VA and Community Nursing Home Residents
    U.S. nursing homes incurred more than one-third of COVID-19 fatalities in the United States and began vaccine clinics in mid-December. The first study describes the proportion of COVID-19 positive tests among 130 VA Community Living Centers (CLCs) before and after COVID-19 vaccination. Findings showed that 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. The second study compared incident COVID-19 infection and 30-day hospitalization or death among residents with COVID-19 between non-VA nursing homes with earlier versus later vaccine clinics. Findings showed that one week after their initial vaccine clinics, nursing homes with earlier vaccination had 2.5 fewer new COVID-19 infections per 100 at-risk residents than expected relative to facilities with later vaccination. 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. These results suggest that COVID-19 vaccines accelerated the rate of decline of incident infections, morbidity, and mortality.
    Date: April 16, 2021
  • Veterans of Color Are More Likely to be Tested for COVID-19 at VA than White Veterans and are More Likely to Test Positive
    This analysis evaluated the characteristics associated with obtaining a COVID-19 test within the VA healthcare system – and receiving a positive test result from February 8 through December 28, 2020. Findings showed that VA is testing a significantly higher proportion of traditionally disenfranchised patient groups for COVID-19 than other healthcare systems. However, Black and Hispanic/Latino Veterans have an increased risk of receiving a positive test result for COVID-19, despite receiving more tests than White and non-Hispanic/Latino Veterans. Overall, Veterans who were female, Black/African American, Hispanic/Latino, lived in urban settings, had a low income, or had a disability had an increased likelihood of obtaining a COVID-19 test, while Veterans who were Asian had a decreased likelihood. Compared with Veterans who were White, Veterans who were Black/African American were 23% more likely and Native Hawaiian/Other Pacific Islander 13% more likely to receive a positive test result. Hispanic/Latino Veterans had a 43% higher risk of receiving a positive test result than non-Hispanic/Latino Veterans. Veterans with disabilities or who were low-income were more likely to obtain a COVID-19 test but had a lower risk of receiving a positive test. Although disparities are significantly smaller at VA, the test positivity differences suggest that Veterans are not immune to the negative external effects of SDH. Results suggest that other factors (e.g., external social inequities) are driving disparities in COVID-19 prevalence.
    Date: April 7, 2021
  • VA Researchers Develop Model to Estimate Risk of COVID-19 Related Deaths among Veterans for Use in Prioritizing Vaccine
    This study sought to develop a model to estimate the risk of COVID-19 related death in the general population to aid vaccination prioritization. In estimating the risk, COVIDVax (the model developed) used the following 10 patient characteristics: sex, age, race, ethnicity, body mass index (BMI), Charlson Comorbidity Index (CCI), diabetes, chronic kidney disease, congestive heart failure, and the Care Assessment Need (CAN) score. Using COVIDVax to prioritize vaccination was estimated to prevent 64% of deaths that would occur by the time 50% of VA enrollees are vaccinated, significantly higher than prioritizing vaccination based on age (46%) or the CDC phases of vaccine allocation (41%). Even under conditions when vaccine supply is no longer limited, the model can help target individuals who might not yet be vaccinated but are at highest risk from COVID.
    Date: April 6, 2021
  • Early Initiation of Prophylactic Anticoagulation for Veterans Hospitalized with COVID-19 Reduces Mortality
    This study sought to determine whether early initiation of prophylactic anticoagulation compared to no anticoagulation decreased risk of death in patients hospitalized with COVID-19. Findings showed that after accounting for a large number of demographic and clinical characteristics, mortality at 30 days was 14% among Veterans who received prophylactic anticoagulation and 19% 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. Findings provide strong real-world evidence to support guidelines recommending the use of prophylactic anticoagulation as initial therapy for COVID-19 patients upon hospital admission.
    Date: February 11, 2021
  • Review Provides Updated Guidance for Use of Remdesivir among Individuals with COVID-19
    In this article, investigators updated their previous systematic review of remdesivir for adults with COVID-19 to include new meta-analyses of patients with COVID-19 – of any severity – compared with a control. Compared with controls, a 10-day course of remdesivir probably results in little to no mortality reduction but may result in a small reduction in the proportion receiving mechanical ventilation. Compared with a 10-day course of remdesivir for patients not requiring ventilation at baseline, a 5-day course may reduce mortality, the need for ventilation, and serious adverse events while increasing the percentage of patients who recovered or clinically improved. Effect on hospital length of stay or the percentage of those remaining hospitalized is mixed. Among patients already receiving invasive mechanical ventilation remdesivir may not reduce time to recovery and may increase mortality. Serious adverse events reported in trials include a combination of clinical findings resulting from COVID-19 progression (e.g., respiratory failure) and direct remdesivir toxicity. For patients not receiving ventilation, a 5-day course of remdesivir may provide greater benefits and fewer harms with lower drug costs than a 10-day course. The American College of Physicians’ Scientific Medical Policy Committee used this updated systematic review to develop a new Practice Points document to guide clinicians on the use of remdesivir.
    Date: February 9, 2021
  • Strains on Critical Care Capacity Associated with Increased Mortality among VA Patients Admitted to an ICU for COVID-19
    This study sought to determine whether COVID-19 mortality was associated with COVID-19 Intensive Care Unit (ICU) strain. Findings showed that strains on critical care capacity due to peak COVID ICU caseload were associated with increased COVID-19 mortality. ICU patients with COVID-19 had a two-fold increased risk of death if treated during periods where COVID-19 ICU-demand was 75-100% of peak demand (“rush hour”) compared to periods below 50% of peak. No association between COVID-19 ICU-demand and mortality was observed for non-ICU patients with COVID-19. Mortality among hospitalized patients with COVID-19 declined significantly from early in the pandemic through summer 2020: March, 23%; April, 25%; May, 16%; June, 14%; July, 13%; and August, 13%. Public health officials and hospital administrators should monitor rising COVID-19 ICU case counts relative to earlier peaks to prepare for possible effects on patient outcomes and seek ways to reduce ICU strain.
    Date: January 19, 2021
  • Inpatient Mortality Underestimates the Health Burden of COVID-19 Hospitalizations in Veterans
    This study sought to measure the rate of readmission, reasons for readmission, and rate of death after hospital discharge among Veterans with COVID-19 who used VA healthcare. Findings showed that 27% of Veterans who survived COVID-19 hospitalization were readmitted or died by 60 days post-discharge, and this rate was lower than matched survivors of pneumonia (26% vs. 32%) or heart failure (27% vs. 37%). Rates of readmission or death were higher than matched pneumonia or heart failure survivors during the first 10 days after discharge following COVID-19 hospitalization, suggesting a period of heightened risk for clinical deterioration.
    Date: December 14, 2020
  • Older Age Strongest Risk Factor Associated with Mechanical Ventilation and Death among Veterans with COVID-19
    This study sought to identify risk factors associated with hospitalization, mechanical ventilation, and death among patients with COVID-19 infection. Findings showed that Veterans who were COVID-positive were more likely to be Black (42% vs 25%), obese (45% vs 40%), and to live in states with a high burden of COVID-19 compared to Veterans who tested negative. Veterans who tested positive for COVID-19 had a 4.2-fold risk of mechanical ventilation and a 4.4-fold risk of death compared with Veterans who tested negative. Most COVID-19 deaths among Veterans in this study were attributed to age 50 and older (64%), male sex (12%), and greater comorbidity burden (11%). Many factors previously reported to be associated with mortality in smaller studies were not confirmed, including Black race, Hispanic ethnicity, COPD, hypertension, and smoking. Other risk factors for mortality among Veterans with COVID-19 included select pre-existing comorbid conditions, such as heart failure, chronic kidney disease, and cirrhosis.
    Date: September 23, 2020
  • Blacks and Hispanics Twice as Likely as White Veterans to Test Positive for COVID-19
    This study examined racial and ethnic disparities in patterns of COVID-19 testing (i.e., who received testing and who tested positive) and subsequent 30-day mortality for Veterans receiving VA healthcare (all testing and services in this study were provided within VA). Findings showed that Black Veterans were more likely to be tested (rate per 1,000 patients, 60.0) than Hispanic (52.7) or White Veterans (38.6). Among those tested, both Black and Hispanic Veterans were twice as likely to test positive than White Veterans, even after accounting for all adjusting variables. The disparity between Black and White Veterans in testing positive slightly decreased over the study period – and was highest in the Midwest compared to other regions. The disparity between Hispanic and White Veterans was consistent across time, geographic region, and outbreak pattern. Among those who tested positive for COVID-19, there were no other observed differences in 30-day mortality by race/ethnicity group.
    Date: September 22, 2020
  • Repeated Temperature Readings with Patient Baseline Increases Sensitivity for COVID-19 Detection among Elderly Veterans
    The purpose of this study was to compare temperature trends and identify maximum temperatures in Community Living Center (CLC) residents 14 days prior to and following systematic testing for COVID-19. Findings showed that a single temperature screening is unlikely to accurately detect COVID-19 in nursing home residents. Only 27% of residents who tested positive for the virus met the temperature threshold (38°C or 100.4°F) during the study period. While most nursing home residents (63%) with confirmed COVID-19 experienced two or more 0.5°C elevations above their baseline temperatures, there also was a group (20%) that was persistently cooler and had no temperature deviation from baseline. Temperatures in elderly Veterans with COVID-19 began rising 7 days prior to testing for the virus – and remained elevated during the 14-day follow-up. The average maximum temperature in COVID-19 positive patients was 37.66°C (99.8°F) compared to 37.11°C (98.8°F) in patients who were COVID-19 negative. Study findings suggest that the current fever threshold for COVID-19 screening should be reconsidered. Repeated temperature measurement with a patient-derived baseline could increase sensitivity for surveillance purposes when applied to a nursing home population.
    Date: June 8, 2020
  • Strategy in a VA Skilled Nursing Facility Minimizes Both Asymptomatic and Pre-Symptomatic Transmission of COVID-19
    Universal and serial COVID-19 testing in skilled nursing facilities can identify cases during an outbreak, and rapid isolation and cohorting can minimize ongoing transmission. This outbreak report demonstrates the utility of universal serial laboratory screening to identify cases to rapidly isolate or cohort to reduce transmission in a VA skilled nursing facility. This strategy limited potential asymptomatic and pre-symptomatic transmission of COVID-19, allowing for successful containment. The outbreak in one ward was suppressed within 1 week, the outbreak in a second ward was suppressed within 2 weeks, and no cases occurred in a third ward.
    Date: May 29, 2020
  • Common Drugs for Hypertension and Diabetes Not Associated with Severe COVID-19 Illness or Testing Positive for COVID-19
    Originally requested by the World Health Organization (WHO), this systematic review examined the relationship between angiotensin-converting enzyme inhibitors (ACEI) or angiotensin-receptor blockers (ARB) use and COVID-19 illness. Findings showed that high-certainty evidence suggests that ACEI or ARB use is not associated with more severe COVID-19 illness, and moderate-certainty evidence suggests no association between the use of these medications and positive SARS-CoV-2 test results among symptomatic patients. Findings from this rapidly expanding literature show no indication to prophylactically stop ACEI or ARB treatment because of concerns about COVID-19. Moreover, withdrawal of long-term ACEIs or ARBs may be harmful, especially in patients with heart failure, because observational studies and trials have suggested that discontinuation of ACEI or ARB therapy is associated with worse outcomes.
    Date: May 15, 2020
  • Veterans Advocate Treating “Sickest First” When Discussing Limited Resources for Hepatitis C Treatment
    Investigators in this study used Democratic Deliberation (DD) methods as a proof of concept for informing policy decisions related to the allocation of scarce resources for treatment of chronic hepatitis C virus in VA. Findings showed that most Veterans endorsed a sickest-first policy over a first-come-first-served policy, emphasizing the ethical and medical appropriateness of treating the sickest Veterans first. When given the option, almost two-thirds of participants insisted that all Veterans be treated without delay regardless of symptoms or degree of disease severity (note: this is currently VA policy but not common outside of VA). Only when required to choose between the two policies did a majority opt for the SF policy (86% before DD session; 93% after DD session). Veterans also suggested modifications to the “sickest first” policy: 1) need to consider additional health factors, 2) taking behavior and lifestyle into account, 3) offering education and support to overcome barriers to treatment, 4) improving access to testing/treatment, and 5) improving how allocation decisions are made. The approach of using DD to incorporate the opinions of patients may have implications for how to develop policies around allocation of limited healthcare resources during the current COVID-19 pandemic.
    Date: May 1, 2020
  • Possible Impact of Measures to Curb COVID-19 Spread on Suicide Prevention Efforts
    Social distancing and other public health actions intended to curb the spread of COVID-19 have the potential for adverse outcomes on suicide risk. However, concerns about negative secondary outcomes of COVID-19 prevention efforts should not imply that that these public health actions should not be taken. Implementation should include a comprehensive approach that considers the public health priority of suicide prevention as well.
    Date: April 10, 2020
  • Practical Recommendations for the Care of Older Individuals at Highest Risk from COVID-19
    The risk of COVID-19 transmission in the coming months may be high long-term care facilities, requiring focused attention and preparedness efforts. Adding to this healthcare challenge, long-term care residents often have medical conditions associated with an increased risk of morbidity and mortality from COVID-19. Appropriate preparedness includes five key elements: 1) Reduce morbidity and mortality among those infected; 2) Minimize transmission; 3) Ensure protection of healthcare workers; 4) Maintain healthcare system functioning, and 5) Maintain communication with worried residents and family members. Airborne disease protocols should be activated and put into action. Environmental services should be engaged to perform at least daily cleaning with Environmental Protection Agency (EPA) registered hospital-grade disinfectants, particularly in high-traffic areas (e.g., dining halls, treatment areas, living spaces, etc.). Training staff and visitors on how to minimize their risk for picking up COVID-19 in the community and in long-term care facilities, and transmitting it to others, will remain the most important tools to stop the spread of the virus. Executing a communication strategy that keeps residents, family members, and the public informed also will be critical during this rapidly evolving crisis.
    Date: March 13, 2020

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