Mortality Among US Veterans Admitted to Community vs Veterans Health Administration Hospitals for COVID-19.

Importance: Veterans Health Administration (VHA) enrollees receive care for COVID-19 in both VHA and non-VHA (ie, community) hospitals, but little is known about the frequency or outcomes of care for veterans with COVID-19 in VHA vs community hospitals. Objective: To compare outcomes among veterans admitted for COVID-19 in VHA vs community hospitals. Design, Setting, and Participants: This retrospective cohort study used VHA and Medicare data from March 1, 2020, to December 31, 2021, on hospitalizations for COVID-19 in 121 VHA and 4369 community hospitals in the US among a national cohort of veterans (aged ≥65 years) enrolled in both the VHA and Medicare with VHA care in the year prior to hospitalization for COVID-19 based on the primary diagnosis code. Exposure: Admission to VHA vs community hospitals. Main Outcomes and Measures: The main outcomes were 30-day mortality and 30-day readmission. Inverse probability of treatment weighting was used to balance observable patient characteristics (eg, demographic characteristics, comorbidity, mechanical ventilation on admission, area-level social vulnerability, distance to VHA vs community hospitals, and date of admission) between VHA and community hospitals. Results: The cohort included 64 856 veterans (mean [SD] age, 77.6 [8.0] years; 63 562 men [98.0%]) dually enrolled in the VHA and Medicare who were hospitalized for COVID-19. Most (47 821 [73.7%]) were admitted to community hospitals (36 362 [56.1%] admitted to community hospitals via Medicare, 11 459 [17.7%] admitted to community hospitals reimbursed via VHA's Care in the Community program, and 17 035 [26.3%] admitted to VHA hospitals). Admission to community hospitals was associated with higher unadjusted and risk-adjusted 30-day mortality compared with admission to VHA hospitals (crude mortality, 12 951 of 47 821 [27.1%] vs 3021 of 17 035 [17.7%]; P < .001; risk-adjusted odds ratio, 1.37 [95% CI, 1.21-1.55]; P < .001). Readmission within 30 days was less common after admission to community compared with VHA hospitals (4898 of 38 576 [12.7%] vs 2006 of 14 357 [14.0%]; risk-adjusted hazard ratio, 0.89 [95% CI, 0.86-0.92]; P < .001). Conclusions and Relevance: This study found that most hospitalizations for COVID-19 among VHA enrollees aged 65 years or older were in community hospitals and that veterans experienced higher mortality in community hospitals than in VHA hospitals. The VHA must understand the sources of the mortality difference to plan care for VHA enrollees during future COVID-19 surges and the next pandemic.

Sexually Transmitted Infection Testing in the National Veterans Health Administration Patient Cohort During the Coronavirus Disease 2019 Pandemic.

Background: We performed a retrospective study of chlamydia, gonorrhea, syphilis, and human immunodeficiency virus (HIV) testing in the Veterans Health Administration (VHA) during 2019-2021. Methods: We determined the annual number of chlamydia, gonorrhea, syphilis, and HIV tests from 2019 through 2021 using electronic health record data. We calculated rates by age, birth sex, race, census region, rurality, HIV status, and use of preexposure prophylaxis. Results: The VHA system experienced a 24% drop in chlamydia/gonorrhea testing, a 25% drop in syphilis testing, and a 29% drop in HIV testing in 2020 versus 2019. By the conclusion of 2021, testing rates had recovered to 90% of baseline for chlamydia/gonorrhea, 91% for syphilis, and 88% for HIV. Declines and subsequent improvements in sexually transmitted infection (STI) testing occurred unequally across age, sex, race, and geographic groups. Testing for all 4 STIs in 2021 remained below baseline in rural Veterans. Excluding those aged <25 years, women experienced a steeper decline and slower recovery in chlamydia/gonorrhea testing relative to men, but quicker recovery in HIV testing. Asian Americans and Hawaiian/Pacific Islanders had a steeper decline and a slower recovery in testing for chlamydia/gonorrhea. Black and White Veterans had slower recovery in HIV testing compared with other race groups. People living with HIV experienced a smaller drop in testing for syphilis compared with people without HIV, followed by a near-total recovery of testing by 2021. Conclusions: After dramatic reductions from 2019 to 2020, STI testing rates returned to near-baseline in 2021. Testing recovery lagged in rural, female, Asian American, Hawaiian/Pacific Islander, and Black Veterans.

Sexually transmitted infection testing in the national Veterans Health Administration patient cohort during the COVID-19 pandemic

Objectives We performed a retrospective study of chlamydia, gonorrhea, syphilis, and HIV testing in the Veterans Health Administration (VHA) during 2019-2021. Methods We determined the annual number of chlamydia, gonorrhea, syphilis, and HIV tests from 2019-2021 using electronic health record data. We calculated rates by age, birth sex, race, census region, rurality, HIV status, and use of PrEP. Results The VHA system experienced a 24% drop in chlamydia/gonorrhea testing, a 25% drop in syphilis testing, and a 29% drop in HIV testing in 2020 versus 2019. By the conclusion of 2021, testing rates had recovered to 90% of baseline for chlamydia/gonorrhea, 91% for syphilis, and 88% for HIV. Declines and subsequent improvements in STI testing occurred unequally across age, sex, race, and geographic groups. Testing for all four STIs in 2021 remained below baseline in rural Veterans. Excluding those <25, women experienced a steeper decline and slower recovery in chlamydia/gonorrhea testing relative to men, but quicker recovery in HIV testing. Asian Americans and Hawaiian/Pacific Islanders had a steeper decline and a slower recovery in testing for chlamydia/gonorrhea. Black and White Veterans had slower recovery in HIV testing compared with other race groups. People living with HIV experienced a smaller drop in testing for syphilis compared with people without HIV, followed by a near-total recovery of testing by 2021. Conclusion After dramatic reductions from 2019-2020, STI testing rates returned to near-baseline in 2021. Testing recovery lagged in rural, women, Asian American, Hawaiian/Pacific Islander, and Black Veterans.

Dexamethasone in hospitalised COVID-19 patients not on intensive respiratory support.

BACKGROUND: Dexamethasone decreases mortality in coronavirus disease 2019 (COVID-19) patients on intensive respiratory support (IRS) but is of uncertain benefit if less severely ill. We determined whether early (within 48 h) dexamethasone was associated with mortality in patients hospitalised with COVID-19 not on IRS. METHODS: We included patients admitted to US Veterans Affairs hospitals between 7 June 2020 and 31 May 2021 within 14 days after a positive test for severe acute respiratory syndrome coronavirus 2. Exclusions included recent prior corticosteroids and IRS within 48 h. We used inverse probability of treatment weighting (IPTW) to balance exposed and unexposed groups, and Cox proportional hazards models to determine 90-day all-cause mortality. RESULTS: Of 19 973 total patients (95% men, median age 71 years, 27% black), 15 404 (77%) were without IRS within 48 h. Of these, 3514 out of 9450 (34%) patients on no oxygen received dexamethasone and 1042 (11%) died; 4472 out of 5954 (75%) patients on low-flow nasal cannula (NC) only received dexamethasone and 857 (14%) died. In IPTW stratified models, patients on no oxygen who received dexamethasone experienced 76% increased risk for 90-day mortality (hazard ratio (HR) 1.76, 95% CI 1.47-2.12); there was no association with mortality among patients on NC only (HR 1.08, 95% CI 0.86-1.36). CONCLUSIONS: In patients hospitalised with COVID-19, early initiation of dexamethasone was common and was associated with no mortality benefit among those on no oxygen or NC only in the first 48 h; instead, we found evidence of potential harm. These real-world findings do not support the use of early dexamethasone in hospitalised COVID-19 patients without IRS.

Bringing Iowa TelePrEP to Scale: A Qualitative Evaluation.

INTRODUCTION: Regional partnerships between public health organizations and telehealth programs have the potential to expand access to HIV pre-exposure prophylaxis in rural and small urban areas. However, little is known about the best practices for such partnerships. Iowa TelePrEP, a regional public health‒partnered telehealth model created by the Iowa Department of Public Health and the University of Iowa, expanded statewide between 2017 and 2019. This qualitative evaluation assessed the barriers and facilitators to statewide expansion and the lessons learned. METHODS: Key informants from public health partners across Iowa participated in a focus group and interviews between May 2019 and November 2020. Public health partners included local health departments and disease intervention specialist/partner services programs. Qualitative data were transcribed and thematically coded. Program documents and routinely collected reporting data were reviewed to provide the context for qualitative findings. Data were analyzed in 2020. RESULTS: TelePrEP expanded in 4 phases through partnerships with 12 public health partners. Public health partners referred 708 clients with pre-exposure prophylaxis indications to telenavigation; of these, 258 were navigated to TelePrEP, and 167 initiated pre-exposure prophylaxis. The facilitators of expansion included early public health partner engagement, model acceptability and inclusion of a navigator, and adaptability to local public health partner settings. The barriers included the need to adapt communication and processes to varying public health partners, difficulty in engaging underserved populations, the COVID-19 pandemic, and perceived gaps in understanding client outcomes. CONCLUSIONS: Partnerships between regional telehealth programs and local health departments can expand to the state level and increase the capacity to implement pre-exposure prophylaxis in rural and small urban settings. Partnerships should consider how to balance program adaptability to local public health partners with standardization and scalability.

Association of Remdesivir Treatment With Survival and Length of Hospital Stay Among US Veterans Hospitalized With COVID-19.

Importance: Randomized clinical trials have yielded conflicting results about the effects of remdesivir therapy on survival and length of hospital stay among people with COVID-19. Objective: To examine associations between remdesivir treatment and survival and length of hospital stay among people hospitalized with COVID-19 in routine care settings. Design, Setting, and Participants: This retrospective cohort study used data from the Veterans Health Administration (VHA) to identify adult patients in 123 VHA hospitals who had a first hospitalization with laboratory-confirmed COVID-19 from May 1 to October 8, 2020. Propensity score matching of patients initiating remdesivir treatment to control patients who had not initiated remdesivir treatment by the same hospital day was used to create the analytic cohort. Exposures: Remdesivir treatment. Main Outcomes and Measures: Time to death within 30 days of remdesivir treatment initiation (or corresponding hospital day for matched control individuals) and time to hospital discharge with time to death as a competing event. Associations between remdesivir treatment and these outcomes were assessed using Cox proportional hazards regression in the matched cohort. Results: The initial cohort included 5898 patients admitted to 123 hospitals, 2374 (40.3%) of whom received remdesivir treatment (2238 men [94.3%]; mean [SD] age, 67.8 [12.8] years) and 3524 (59.7%) of whom never received remdesivir treatment (3302 men [93.7%]; mean [SD] age, 67.0 [14.4] years). After propensity score matching, the analysis included 1172 remdesivir recipients and 1172 controls, for a final matched cohort of 2344 individuals. Remdesivir recipients and matched controls were similar with regard to age (mean [SD], 66.6 [14.2] years vs 67.5 [14.1] years), sex (1101 men [93.9%] vs 1101 men [93.9%]), dexamethasone use (559 [47.7%] vs 559 [47.7%]), admission to the intensive care unit (242 [20.7%] vs 234 [19.1%]), and mechanical ventilation use (69 [5.9%] vs 45 [3.8%]). Standardized differences were less than 10% for all measures. Remdesivir treatment was not associated with 30-day mortality (143 remdesivir recipients [12.2%] vs 124 controls [10.6%]; log rank P = .26; adjusted hazard ratio [HR], 1.06; 95% CI, 0.83-1.36). Results were similar for people receiving vs not receiving dexamethasone at remdesivir initiation (dexamethasone recipients: adjusted HR, 0.93; 95% CI, 0.64-1.35; nonrecipients: adjusted HR, 1.19; 95% CI, 0.84-1.69). Remdesivir recipients had a longer median time to hospital discharge compared with matched controls (6 days [interquartile range, 4-12 days] vs 3 days [interquartile range, 1-7 days]; P < .001). Conclusions and Relevance: In this cohort study of US veterans hospitalized with COVID-19, remdesivir treatment was not associated with improved survival but was associated with longer hospital stays. Routine use of remdesivir may be associated with increased use of hospital beds while not being associated with improvements in survival.