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Publication Briefs
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  • 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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