Racial, Ethnic, and Rural Disparities in US Veteran COVID-19 Vaccine Rates

Background Race, ethnicity, and rurality-related disparities in coronavirus disease 2019 (COVID-19) vaccine uptake have been documented in the United States (US). Objective We determined whether these disparities existed among patients at the Department of Veterans Affairs (VA), the largest healthcare system in the US. Design, Settings, Participants, Measurements Using VA Corporate Data Warehouse data, we included 5,871,438 patients (9.4% women) with at least one primary care visit in 2019 in a retrospective cohort study. Each patient was assigned a single race/ethnicity, which were mutually exclusive, self-reported categories. Rurality was based on 2019 home address at the zip code level. Our primary outcome was time-to-first COVID-19 vaccination between December 15, 2020-June 15, 2021. Additional covariates included age (in years), sex, geographic region (North Atlantic, Midwest, Southeast, Pacific, Continental), smoking status (current, former, never), Charlson Comorbidity Index (based on ≥1 inpatient or two outpatient ICD codes), service connection (any/none, using standardized VA-cutoffs for disability compensation), and influenza vaccination in 2019-2020 (yes/no). Results Compared with unvaccinated patients, those vaccinated (n=3,238,532;55.2%) were older (mean age in years vaccinated=66.3, (standard deviation=14.4) vs. unvaccinated=57.7, (18.0), p<.0001)). They were more likely to identify as Black (18.2% vs. 16.1%, p<.0001), Hispanic (7.0% vs. 6.6% p<.0001), or Asian American/Pacific Islander (AA/PI) (2.0% vs. 1.7%, P<.0001). In addition, they were more likely to reside in urban settings (68.0% vs. 62.8, p<.0001). Relative to non-Hispanic White urban Veterans, the reference group for race/ethnicity-urban/rural hazard ratios reported, all urban race/ethnicity groups were associated with increased likelihood for vaccination except American Indian/Alaskan Native (AI/AN) groups. Urban Black groups were 12% more likely (Hazard Ratio (HR)=1.12 [CI 1.12-1.13]) and rural Black groups were 6% more likely to receive a first vaccination (HR=1.06 [1.05-1.06]) relative to white urban groups. Urban Hispanic, AA/PI and Mixed groups were more likely to receive vaccination while rural members of these groups were less likely (Hispanic: Urban HR=1.17 [1.16-1.18], Rural HR=0.98 [0.97-0.99];AA/PI: Urban HR=1.22 [1.21-1.23], Rural HR=0.86 [0.84-0.88]). Rural White Veterans were 21% less likely to receive an initial vaccine compared with urban White Veterans (HR=0.79 [0.78-0.79]). AI/AN groups were less likely to receive vaccination regardless of rurality: Urban HR=0.93 [0.91-0.95];AI/AN-Rural HR=0.76 [0.74-0.78]. Conclusions Urban Black, Hispanic, and AA/PI Veterans were more likely than their urban White counterparts to receive a first vaccination;all rural race/ethnicity groups except Black patients had lower likelihood for vaccination compared with urban White patients. A better understanding of disparities and rural outreach will inform equitable vaccine distribution. Graphical Image, graphical

Usability Testing of the Kidney Score Platform to Enhance Communication About Kidney Disease in Primary Care Settings: Qualitative Think-Aloud Study.

BACKGROUND: Patient awareness of chronic kidney disease (CKD) is low in part due to suboptimal testing for CKD among those at risk and lack of discussions about kidney disease between patients and clinicians. To bridge these gaps, the National Kidney Foundation developed the Kidney Score Platform, which is a web-based series of tools that includes resources for health care professionals as well as an interactive, dynamic patient-facing component that includes a brief questionnaire about risk factors for kidney disease, individualized assessment of risk for developing CKD, and self-management tools to manage one's kidney disease. OBJECTIVE: The aim of this study is to perform usability testing of the patient component of the Kidney Score platform among veterans with and at risk for kidney disease and among clinicians working as primary care providers in Veterans Affairs administration. METHODS: Think-aloud exercises were conducted, during which participants (veterans and clinicians) engaged with the platform while verbalizing their thoughts and making their perceptions, reasonings, and decision points explicit. A usability facilitator observed participants' behaviors and probed selectively to clarify their comprehension of the tool's instructions, content, and overall functionality. Thematic analysis on the audio-recording transcripts was performed, focusing on positive attributes, negative comments, and areas that required facilitator involvement. RESULTS: Veterans (N=18) were 78% (14/18) male with a mean age of 58.1 years. Two-thirds (12/18) were of non-White race/ethnicity, 28% (5/18) had laboratory evidence of CKD without a formal diagnosis, and 50% (9/18) carried a diagnosis of hypertension or diabetes. Clinicians (N=19) were 29% (5/17) male, 30% (5/17) of non-White race/ethnicity, and had a mean of 17 (range 4-32) years of experience. Veterans and clinicians easily navigated the online tool and appreciated the personalized results page as well as the inclusion of infographics to deliver key educational messages. Three major themes related to content and communication about risk for CKD emerged from the think-aloud exercises: (1) tension between lay and medical terminology when discussing kidney disease and diagnostic tests, (2) importance of linking general information to concrete self-management actions, and (3) usefulness of the tool as an adjunct to the office visit to prepare for patient-clinician communication. Importantly, these themes were consistent among interviews involving both veterans and clinicians. CONCLUSIONS: Veterans and clinicians both thought that the Kidney Score Platform would successfully promote communication and discussion about kidney disease in primary care settings. Tension between using medical terminology that is used regularly by clinicians versus lay terminology to promote CKD awareness was a key challenge, and knowledge of this can inform the development of future CKD educational materials.

Addressing COVID-19 Vaccine Acceptance Within a Large Healthcare System: a Population Health Model.

BACKGROUND: The COVID-19 pandemic, and vaccine hesitancy, pose a significant public health threat. The Veterans Health Administration system is uniquely situated to provide insights into the implementation of a population health approach to vaccine acceptance. AIM: We describe the VA Connecticut Healthcare System's (VACHS) quality improvement project to improve rates of vaccine uptake. SETTING AND PARTICIPANTS: VACHS consists of eight primary care sites with 80 primary care providers delivering care to 47,000 enrolled veterans. PROGRAM DESCRIPTION: Our program involved identification of a local champion, education sessions, development of vaccine acceptance tools (including the templated "COVID-19 Prevention Letter" and the "COVID-19 Prevention Telephone Note"), and application of a population health approach (use of a prioritization scheme and playbook) by primary care patient-aligned care (PACT) medical home teams. PROGRAM EVALUATION: We found increased rates of vaccination at VACT compared to the surrounding region 6 months after implementation (65.16% vs 61.89%). Use of vaccine acceptance tools were associated with a statistically significant increase in vaccination (24.1% vs 13.6%, P = 0.036) in unvaccinated veterans. DISCUSSION: A population health approach to vaccine acceptance using EHR-based tools can impact vaccination rates, and this approach may be of practical utility to other large healthcare systems with EHR.

Virtual Respiratory Urgent Clinics for COVID-19 Symptoms.

BACKGROUND: The COVID-19 pandemic has forced a shift from in-person to virtual care to reduce exposure risks to patients and health care workers. This report aims to describe a large primary care system's implementation of virtual respiratory urgent care clinics (VRUCs). METHODS: The VA Connecticut Healthcare System (VACHS) delivers care to more than 58,000 veterans in at 8 primary care sites. VRUCs were established as part of the VACHS primary care rapid transition to virtual care model. Retrospective analysis and qualitative chart reviews were performed from February 2020 through May 2020 to describe characteristics of patients who received care through the VRUCs. RESULTS: VRUCs were used by > 445 patients, 51% received COVID-19 testing, 10% tested positive, 5% were admitted to the hospital, and 18% had ≥ 1 subsequent emergency department visits. Chart documentation rates of discussion of isolation precautions, high occupational risk, and goals of care were 71%, 25%, and 14%, respectively. CONCLUSIONS: Average wait time for health care provider evaluation was 104 minutes, suggesting VRUCs are an expedient means to provide assessment of COVID-19 symptoms. Use of templated notes may ensure routine counseling about isolation, occupation, and goals of care.

HIV care using differentiated service delivery during the COVID-19 pandemic: a nationwide cohort study in the US Department of Veterans Affairs.

INTRODUCTION: The Department of Veterans Affairs (VA) is the largest provider of HIV care in the United States. Changes in healthcare delivery became necessary with the COVID-19 pandemic. We compared HIV healthcare delivery during the first year of the COVID-19 pandemic to a prior similar calendar period. METHODS: We included 27,674 people with HIV (PWH) enrolled in the Veterans Aging Cohort Study prior to 1 March 2019, with ≥1 healthcare encounter from 1 March 2019 to 29 February 2020 (2019) and/or 1 March 2020 to 28 February 2021 (2020). We counted monthly general medicine/infectious disease (GM/ID) clinic visits and HIV-1 RNA viral load (VL) tests. We determined the percentage with ≥1 clinic visit (in-person vs. telephone/video [virtual]) and ≥1 VL test (detectable vs. suppressed) for 2019 and 2020. Using pharmacy records, we summarized antiretroviral (ARV) medication refill length (<90 vs. ≥90 days) and monthly ARV coverage. RESULTS: Most patients had ≥1 GM/ID visit in 2019 (96%) and 2020 (95%). For 2019, 27% of visits were virtual compared to 64% in 2020. In 2019, 82% had VL measured compared to 74% in 2020. Of those with VL measured, 92% and 91% had suppressed VL in 2019 and 2020. ARV refills for ≥90 days increased from 39% in 2019 to 51% in 2020. ARV coverage was similar for all months of 2019 and 2020 ranging from 76% to 80% except for March 2019 (72%). Women were less likely than men to be on ARVs or to have a VL test in both years. CONCLUSIONS: During the COVID-19 pandemic, the VA increased the use of virtual visits and longer ARV refills, while maintaining a high percentage of patients with suppressed VL among those with VL measured. Despite decreased in-person services during the pandemic, access to ARVs was not disrupted. More follow-up time is needed to determine whether overall health was impacted by the use of differentiated service delivery and to evaluate whether a long-term shift to increased virtual healthcare could be beneficial, particularly for PWH in rural areas or with transportation barriers. Programmes to increase ARV use and VL testing for women are needed.

SARS-CoV-2 detection in setting of viral swabs scarcity: Are MRSA swabs and viral swabs equivalent?

BACKGROUND: The global pandemic of Severe Acute Respiratory Syndrome-Related Coronavirus 2 (SARS-CoV2) has resulted in unprecedented challenges for healthcare systems. One barrier to widespread testing has been a paucity of traditional respiratory viral swab collection kits relative to the demand. Whether other sample collection kits, such as widely available MRSA nasal swabs can be used to detect SARS-CoV-2 is unknown. METHODS: We compared simultaneous nasal MRSA swabs (COPAN ESwabs ® 480C flocked nasal swab in 1mL of liquid Amies medium) and virals wabs (BD H192(07) flexible mini-tip flocked nasopharyngeal swabs in 3mL Universal Transport Medium) for SARS-CoV-2 PCR testing using Simplexa COVID-19 Direct assay on patients over a 4-day period. When the results were discordant, the viral swab sample was run again on the Cepheid Xpert Xpress ® SARS-CoV-2 assay. RESULTS: Of the 81 included samples, there were 19 positives and 62 negatives in viral media and 18 positives and 63 negative in the MRSA swabs. Amongst all included samples, there was concordance between the COPAN ESwabs ® 480C and the viral swabs in 78 (96.3%). CONCLUSION: We found a high rate of concordance in test results between COPAN ESwabs ® 480C in Amies solution and BD H192(07) nasopharyngeal swabs in in 3 mL of Universal Viral Transport medium viral media. Clinicians and laboratories should feel better informed and assured using COPAN ESwabs ® 480C to help in the diagnosis of COVID-19.

A Model for Rapid Transition to Virtual Care, VA Connecticut Primary Care Response to COVID-19.

INTRODUCTION: Traditionally, health care delivery in the USA has been structured around in-person visits. The COVID-19 pandemic has forced a shift to virtual care models in order to reduce patient exposure to high-risk environments and to preserve valuable health care resources. This report describes one large primary care system's model for rapid transition to virtual care (RTVC). SETTING AND PARTICIPANTS: A RTVC model was implemented at the VA Connecticut Health Care System (VACHS), which delivers care to over 58,000 veterans. PROGRAM DESCRIPTION: The RTVC model included immediate virtual care conversion, telework expansion, implementation of virtual respiratory urgent care clinics, and development of standardized note templates. PROGRAM EVALUATION: Outcomes include the rates of primary encounter types, staff teleworking, and utilization of virtual respiratory urgent care clinics. In under 2 weeks, most encounters were transitioned from in-person to virtual care, enabling telework for over half of the medical staff. The majority of virtual visits were telephone encounters, though rates of video visits increased nearly 18-fold. DISCUSSION: The RTVC model demonstrates expeditious and sustained transition to virtual care during the COVID-19 pandemic. Our experiences help inform institutions still reliant on traditional in-person visits, and future pandemic response.