Racial and ethnic disparities in excess mortality among U.S. veterans during the COVID-19 pandemic.

OBJECTIVE: The COVID-19 pandemic disproportionately affected racial and ethnic minorities among the general population in the United States; however, little is known regarding its impact on U.S. military Veterans. In this study, our objectives were to identify the extent to which Veterans experienced increased all-cause mortality during the COVID-19 pandemic, stratified by race and ethnicity. DATA SOURCES: Administrative data from the Veterans Health Administration's Corporate Data Warehouse. STUDY DESIGN: We use pre-pandemic data to estimate mortality risk models using five-fold cross-validation and quasi-Poisson regression. Models were stratified by a combined race-ethnicity variable and included controls for major comorbidities, demographic characteristics, and county fixed effects. DATA COLLECTION: We queried data for all Veterans residing in the 50 states plus Washington D.C. during 2016-2020. Veterans were excluded from analyses if they were missing county of residence or race-ethnicity data. Data were then aggregated to the county-year level and stratified by race-ethnicity. PRINCIPAL FINDINGS: Overall, Veterans' mortality rates were 16% above normal during March-December 2020 which equates to 42,348 excess deaths. However, there was substantial variation by racial and ethnic group. Non-Hispanic White Veterans experienced the smallest relative increase in mortality (17%, 95% CI 11%-24%), while Native American Veterans had the highest increase (40%, 95% CI 17%-73%). Black Veterans (32%, 95% CI 27%-39%) and Hispanic Veterans (26%, 95% CI 17%-36%) had somewhat lower excess mortality, although these changes were significantly higher compared to White Veterans. Disparities were smaller than in the general population. CONCLUSIONS: Minoritized Veterans experienced higher rates excess of mortality during the COVID-19 pandemic compared to White Veterans, though with smaller differences than the general population. This is likely due in part to the long-standing history of structural racism in the United States that has negatively affected the health of minoritized communities via several pathways including health care access, economic, and occupational inequities.

Aligning quality improvement efforts and policy goals in a national integrated health system.

OBJECTIVE: To describe the design and impact of a systematic, enterprise-wide process for engaging US Department of Veterans Affairs (VA) leadership in prioritizing scarce implementation and evaluation resources. DATA SOURCES: From 2017 to 2021, the VA Quality Enhancement Research Initiative (QUERI) identified priorities from local, regional, and national leaders through qualitative discussions and a national survey and tracked impacts via reports generated from competitively funded initiatives addressing these priorities. STUDY DESIGN: Guided by the Learning Health System framework and QUERI Implementation Roadmap, QUERI engaged stakeholders to nominate and rank-order priorities, peer-reviewed and funded initiatives to scale up and spread evidence-based practices (EBPs) using theory-based implementation strategies, and evaluated the impact of these initiatives using the QUERI Impact Framework. DATA COLLECTION/EXTRACTION METHODS: QUERI collected priority nominations through qualitative discussions and a web-based survey, and live voting was used to rank-order priorities. QUERI-funded teams regularly submitted progress reports describing the key activities, findings, and impacts of the quality improvement (QI) initiatives using a standardized form created in the VA Research Electronic Data Capture (REDCap). PRINCIPAL FINDINGS: QUERI launched five QI initiatives to address priorities selected by VA leadership. In partnership with 28 health system leaders, these initiatives are implementing 10 EBPs across 53 sites, supporting 1055 VA employees in delivering evidence-based care. The success of these initiatives led to an expansion of QUERI's process to address 2021 VA leadership priorities: virtual care, health disparities, delayed or suppressed care due to COVID-19, employee burnout, long-term and home care options, and quality and cost of community care. CONCLUSIONS: QUERI, a unique program embedded in a national integrated health system, deployed a novel approach to inform policy making and enhance the real-world impact of research through prioritization of limited resources, rigorous peer-review, and assessment of impacts on the health system, employees, and Veterans.