SeroNet Pooling Project of immunocompromised populations

Introduction: COVID-19 vaccination substantially reduces morbidity and mortality associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and severe illness. However, despite effective COVID-19 vaccines many questions remain about the efficacy of vaccines and the durability and robustness of immune responses, especially in immunocompromised persons. The NCI-funded Serological Sciences Network (SeroNet) is a coordinated effort including 11 sites to advance research on the immune response to SARS-CoV-2 infection and COVID-19 vaccination among diverse and vulnerable populations. The goals of the Pooling Project are: (1) to conduct real-world data (RWD) analyses using electronic medical records (EMR) data from four health care systems (Kaiser Permanente Northern California, Northwell Health, Veterans Affairs-Case Western, and Cedars-Sinai) to determine vaccine effectiveness in (a) cancer patients;(b) autoimmune diseases and (c) solid organ transplant recipients (SOTR);(2) to conduct meta-analyses of prospective cohort studies from eight SeroNet institutions (Cedars-Sinai, Johns Hopkins, Northwell Health, Emory University, University of Minnesota, Mount Sinai, Yale University) to determine post-vaccine immune responses in (a) lung cancer patients;(b) hematologic cancers/hematopoietic stem cell transplant (HSCT) recipients;(c) SOTR;(d) lupus. Method(s): For our RWD analyses, data is extracted from EMR using standardized algorithms using ICD-10 codes to identify immunocompromised persons (hematologic and solid organ malignancy;SOTR;autoimmune disease, including inflammatory bowel disease, rheumatoid arthritis, and SLE). We use common case definitions to extract data on demographic, laboratory values, clinical co morbidity, COVID-19 vaccination, SARS-CoV-2 infection and severe COVID-19, and diseasespecific variables. In addition, we pool individual-level data from prospective cohorts enrolling patients with cancer and other immunosuppressed conditions from across network. Surveys and biospecimens from serology and immune profiling are collected at pre-specified timepoints across longitudinal cohorts. Result(s): Currently, we have EMR data extracted from 4 health systems including >715,000 cancer patients, >9,500 SOTR and >180,000 with autoimmune conditions. Prospective cohorts across the network have longitudinal data on >450 patients with lung cancer, >1,200 patients with hematologic malignancies, >400 SOTR and >400 patients with lupus. We will report results examining vaccine effectiveness for prevention of SARS-CoV-2 infection, severe COVID-19 and post-acute sequelae of COVID-19 (PAS-C or long COVID) in cancer patients compared to other immunocompromised conditions. Conclusion(s): Our goal is to inform public health guidelines on COVID-19 vaccine and boosters to reduce SARS-CoV-2 infection and severe illness in immunocompromised populations.

Comprehensive medication management services provided via telehealth or hybrid models: A scoping review

Comprehensive medication management (CMM) is increasingly provided by health care teams through telehealth or hybrid modalities. The purpose of this scoping literature review was to assess the published literature and examine the economic, clinical, and humanistic outcomes of CMM services provided by pharmacists via telehealth or hybrid modalities. This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews. Randomized controlled trials (RCTs) and observational studies were included if they: reported on economic, clinical, or humanistic outcomes;were conducted via telehealth or hybrid modalities;included a pharmacist on their interprofessional team;and evaluated CMM services. The search was conducted between January 1, 2000, and September 28, 2021. The search strategy was adapted for use in Medline (PubMed);Embase;Cochrane;Cumulative Index to Nursing and Allied Health Literature;PsychINFO;International Pharmaceutical s;Scopus;and grey literature. Four reviewers extracted data using a screening tool developed for this study and reviewed for risk of bias. Authors screened 3500 articles, from which 11 studies met the inclusion criteria (9 observational studies, 2 RCTs). In seven studies, clinical outcomes improved with telehealth CMM interventions compared to either usual care, face-to-face CMM, or educational controls, as shown by the statistically significant changes in chronic disease clinical outcomes. Two studies evaluated and found increased patient and provider satisfaction. One study described a source of revenue for a telehealth CMM service. Overall, study results indicate that telehealth CMM services, in select cases, may be associated with improved clinical outcomes, but the methods of the included studies were not homogenous enough to conclude that telehealth or hybrid modalities were superior to in-person CMM. To understand the full impact on the Quadruple Aim, additional research is needed to investigate the financial outcomes of CMM conducted using telehealth or hybrid technologies.Copyright © 2022 Pharmacotherapy Publications, Inc.

Uptake and Equity in Influenza Vaccination Among Veterans with VA Coverage, Veterans Without VA Coverage, and Non-Veterans in the USA, 2019-2020.

BACKGROUND: Vaccination is a primary method of reducing the burden of influenza, yet uptake is neither optimal nor equitable. Single-tier, primary care-oriented health systems may have an advantage in the efficiency and equity of vaccination. OBJECTIVE: To assess the association of Veterans' Health Administration (VA) coverage with influenza vaccine uptake and disparities. DESIGN: Cross-sectional. PARTICIPANTS: Adult respondents to the 2019-2020 National Health Interview Survey. MAIN MEASURES: We examined influenza vaccination rates, and racial/ethnic and income-based vaccination disparities, among veterans with VA coverage, veterans without VA coverage, and adult non-veterans. We performed multivariable logistic regressions adjusted for demographics and self-reported health, with interaction terms to examine differential effects by race/ethnicity and income. KEY RESULTS: Our sample included n=2,277 veterans with VA coverage, n=2,821 veterans without VA coverage, and n=46,456 non-veterans. Veterans were more often White and male; among veterans, those with VA coverage had worse health and lower incomes. Veterans with VA coverage had a higher unadjusted vaccination rate (63.0%) than veterans without VA coverage (59.1%) and non-veterans (46.5%) (p<0.05 for each comparison). In our adjusted model, non-veterans were 11.4 percentage points (95% CI -14.3, -8.5) less likely than veterans with VA coverage to be vaccinated, and veterans without VA coverage were 6.7 percentage points (95% CI -10.3, -3.0) less likely to be vaccinated than those with VA coverage. VA coverage, compared with non-veteran status, was also associated with reduced racial/ethnic and income disparities in vaccination. CONCLUSIONS: VA coverage is associated with higher and more equitable influenza vaccination rates. A single-tier health system that emphasizes primary care may improve the uptake and equity of vaccination for influenza, and possibly other pathogens, like SARS-CoV2.

Antecedents to COVID-19 vaccine uptake among patients and employees in the Veterans Health Administration.

The present study sought to understand the antecedents to COVID-19 vaccination among those reporting a change in vaccine intention in order to improve COVID-19 vaccine uptake in the United States. We employed semi-structured interviews and one focus group discussion with vaccinated and unvaccinated Veterans Health Administration (VHA) employees and Veterans at three Veterans' Affairs medical centers between January and June 2021. A subset of these participants (n=21) self-reported a change in COVID-19 vaccine intention and were selected for additional analysis. We combined thematic analysis using the 5C scale (confidence, collective responsibility, complacency, calculation, constraints) as our theoretical framework with a constant comparative method from codes based on the SAGE Working Group on Vaccine Hesitancy. We generated 13 themes distributed across the 5C constructs that appeared to be associated with a change in COVID-19 vaccine intention. Themes included a trusted family member, friend or colleague in a healthcare field, a trusted healthcare professional, distrust of government or politics (confidence); duty to family and protection of others (collective responsibility); perceived health status and normative beliefs (complacency); perceived vaccine safety, perceived risk-benefit, and orientation towards deliberation (calculation); and ease of process (constraints). Key factors in promoting vaccine uptake included a desire to protect family; and conversations with as key factors in promoting vaccine uptake. Constructs from the 5C scale are useful in understanding intrapersonal changes in vaccine intentions over time, which may help public health practitioners improve future vaccine uptake.

In this study of the Veteran and VA employee population, we aimed to understand what factors led to a decision to receive a COVID-19 vaccine. As part of a quality improvement project, we interviewed individuals at three Veterans' Affairs sites in the first six months of 2021. We then used a smaller sample of 21 participants who reported a change in their intentions to receive a COVID-19 vaccine to analyze for this study. This analysis utilizes constructs from the 5C scale, which was developed to understand the conditions required for an individual to decide to receive a vaccine (confidence, collective responsibility, complacency, calculation, constraints). The coding process revealed a number of recurring themes across the interviews falling under each of the five constructs, but concepts relating to vaccine confidence (i.e., level of trust in those developing and disseminating the vaccine) were most common, and constraints (i.e., psychological and structural barriers that stand in the way of vaccination) appeared least frequently in our interviews. We found that significant motivators to receive the vaccine included a desire to protect family and conversations with trusted clinicians, particularly mental healthcare providers. Our study was unique in using the 5Cs to understand changes in vaccine changes over time. Findings show that change in vaccine attitudes is possible even in the presence of concerns and shed light on approaches that public health providers could use to improve vaccine and booster rates.

Success and failures in MRSA infection control during the COVID-19 pandemic.

Private sector facilities in the United States have experienced a resurgence of Methicillin-resistant Staphylococcus aureus (MRSA) hospital-onset infections during the COVID-19 pandemic, which eliminated all gains that were achieved over the last decade. The third quarter of 2021, the Standardized Infection Ratio for hospital onset MRSA bloodstream infections was 1.17, well above the baseline value of 1.0. In contrast, the Veterans Health Administration (VHA) has been able to maintain its mitigation efforts and low rates of MRSA hospital-onset infections through the second quarter of fiscal year 2022 (Mar. 31, 2022), the most recent available data. The difference may be explained not only by the VHA's use of uniform mitigating policies which rely on active surveillance and contact precautions, but also on the VAH's ability to maintain adequate staffing during the pandemic. Future research into MRSA mitigation is warranted and this data supports the need for healthcare system transformation.

Effects of VHA Policy Directive 1163 on Acceptance and Employment Rates for Veterans with Substance Use Disorders Referred to VHA Vocational Rehabilitation.

Introduction: Research has shown that Veterans with Substance/Alcohol Use Disorders (SUDs/AUDs) are at a greater risk for employment-related issues (eg, lower labor force participation rates), and interventions such as Vocational Rehabilitation (VR) have been used as a tool to reduce employment obtainment and maintenance. The purpose of the current study was to evaluate acceptance rates and employment rates at closure for Veterans with SUDs/AUDs prior to the implementation of VHA Policy Directive 1163 (mandated that Veterans are not refused services based on prior or current SUD/AUDs). SUD/AUDs were coded to reflect DSM 5-TR criteria of active use and in-remission. Methods: Data from a VHA Vocational Rehabilitation program in the Veterans Integrated Service Network 12 network were obtained for the purpose of the current study. Results: Findings showed that Veterans with AUDs were less likely to be accepted for VR services prior and after implementation of VHA Policy Directive 1163. Conclusions: When examining active and inactive SUDs/AUDs, findings showed that implementation of VHA Policy Directive 1163 was not effective for Veterans with AUDs. One factor that was not explored but could explain disparities in program acceptance rates is duration of program entry. If a Veteran has a consult placed for VHA Vocational Rehabilitation services, and their program entry date (date accepted) is a significant duration, then perhaps Veterans with active AUDs start drinking again given that they are waiting for vocational assistance. Thus, it would be important to assist Veterans with active AUDs into services in a timely manner (perhaps prior them being discharged from SUD treatment).

Comparing mental and physical health of U.S. veterans by VA healthcare use: implications for generalizability of research in the VA electronic health records.

OBJECTIVE: The Department of Veterans Affairs' (VA) electronic health records (EHR) offer a rich source of big data to study medical and health care questions, but patient eligibility and preferences may limit generalizability of findings. We therefore examined the representativeness of VA veterans by comparing veterans using VA healthcare services to those who do not. METHODS: We analyzed data on 3051 veteran participants age ≥ 18 years in the 2019 National Health Interview Survey. Weighted logistic regression was used to model participant characteristics, health conditions, pain, and self-reported health by past year VA healthcare use and generate predicted marginal prevalences, which were used to calculate Cohen's d of group differences in absolute risk by past-year VA healthcare use. RESULTS: Among veterans, 30.4% had past-year VA healthcare use. Veterans with lower income and members of racial/ethnic minority groups were more likely to report past-year VA healthcare use. Health conditions overrepresented in past-year VA healthcare users included chronic medical conditions (80.6% vs. 69.4%, d = 0.36), pain (78.9% vs. 65.9%; d = 0.35), mental distress (11.6% vs. 5.9%; d = 0.47), anxiety (10.8% vs. 4.1%; d = 0.67), and fair/poor self-reported health (27.9% vs. 18.0%; d = 0.40). CONCLUSIONS: Heterogeneity in veteran sociodemographic and health characteristics was observed by past-year VA healthcare use. Researchers working with VA EHR data should consider how the patient selection process may relate to the exposures and outcomes under study. Statistical reweighting may be needed to generalize risk estimates from the VA EHR data to the overall veteran population.

A survey on self-medication for the prevention or treatment of COVID-19 and distrust in healthcare of veterans in a primary care setting in the United States.

Background: The SARS-CoV-2 (COVID-19) pandemic brought the public overwhelming and conflicting information. Rates of trust in healthcare professionals have been declining among laypersons over the past five decades. In this setting, we sought to evaluate the use of medications, both with or without a prescription, to prevent and treat SARS-CoV-2 as well as trust in healthcare among patients in a primary care clinic. Design: We surveyed 150 veterans in primary care clinic waiting rooms at a large southwestern tertiary care Veterans Affairs hospital. This survey was performed in March-November 2021. Methods: The survey asked about respondents' demographics, use of medications, nutritional supplements, and other remedies for the prevention and treatment of COVID-19, perceived access to care using Agency for Healthcare Research and Quality (AHRQ) Consumer Assessment of Healthcare Providers and System (CAHPS), overall health status, and barriers to medical appointments in the last 12 months. Distrust was measured using the Revised Health Care Distrust scale. We used univariate and multivariate linear regression analyses to study predictors of distrust to healthcare. Results: Forty-two (28%) of 150 respondents reported taking an agent for the prevention of COVID-19, while 4% reported storing antibiotics for the treatment of COVID-19, if diagnosed. Medications were obtained from medical providers, US stores or markets, the Internet, home stockpiles, and other countries. Medications with potentially harmful effects taken for the prevention and treatment of COVID-19 included hydroxychloroquine, pseudoephedrine, and antibiotics. Among those surveyed, the mean (SD) on the health system distrust score was 2.2 (0.6) on a scale of 1-5, with 5 indicating higher distrust. Younger age, self-reported poor health, lack of a regular physician, and self-reported poor access to care were independently associated with distrust in healthcare. Conclusion: Self-medication to prevent COVID-19 infection with unproven therapies was common among respondents, as was some level of distrust in the healthcare system. Access to care was one of the modifiable factors associated with distrust. Future studies may explore whether improving trust may moderate self-treatment behavior and storage of potentially harmful medications. Plain Language Summary: Self-Medication Habits and Trust in Healthcare Among Patients in a Primary Care Setting in the United States The public has received information from many different sources on COVID-19. Trust in healthcare leadership has also been impacted. We studied self-medication habits to prevent or treat COVID-19 among a group of primary care patients in a large hospital system in the Southwest United States. We also explored these patients' trust in their healthcare system.We asked people waiting in primary care clinic waiting rooms whether they had taken any medications, nutritional supplements, or other remedies to prevent or treat COVID-19. We also asked people whether they stored medications in the event that they were diagnosed with COVID. The survey explored patients' trust in the healthcare system through a validated trust survey tool. The survey also assessed basic demographic information, health literacy, access to care, and self-reported health status. These survey answers were analyzed to see whether there was an association between trust in healthcare and other factors including self-medication habits, access to care, demographics, or perceived health.This study found that over 25% of the 150 people surveyed had taken a medication, nutritional supplement, or remedy in an attempt to prevent COVID. We found that some people were taking potentially harmful medications, including hydroxychloroquine, pseudoephedrine, and antibiotics. We found that patients' distrust score was 2.2 on a scale of 1-5 (5 is associated with higher distrust). Self-medication for the prevention or treatment of COVID was not associated with distrust; however, younger age, self-perceived lack of access to healthcare, self-perceived poor overall health, and not having a regular doctor were predictors for lower trust. This information provides a basis to further study self-medication habits as well as ways to improve trust in the healthcare system.

The US Department of Veterans Affairs Science and Health Initiative to Combat Infectious and Emerging Life-Threatening Diseases (VA SHIELD): A Biorepository Addressing National Health Threats.

Background: The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has demonstrated the need to share data and biospecimens broadly to optimize clinical outcomes for US military Veterans. Methods: In response, the Veterans Health Administration established VA SHIELD (Science and Health Initiative to Combat Infectious and Emerging Life-threatening Diseases), a comprehensive biorepository of specimens and clinical data from affected Veterans to advance research and public health surveillance and to improve diagnostic and therapeutic capabilities. Results: VA SHIELD now comprises 12 sites collecting de-identified biospecimens from US Veterans affected by SARS-CoV-2. In addition, 2 biorepository sites, a data processing center, and a coordinating center have been established under the direction of the Veterans Affairs Office of Research and Development. Phase 1 of VA SHIELD comprises 34 157 samples. Of these, 83.8% had positive tests for SARS-CoV-2, with the remainder serving as contemporaneous controls. The samples include nasopharyngeal swabs (57.9%), plasma (27.9%), and sera (12.5%). The associated clinical and demographic information available permits the evaluation of biological data in the context of patient demographics, clinical experience and management, vaccinations, and comorbidities. Conclusions: VA SHIELD is representative of US national diversity with a significant potential to impact national healthcare. VA SHIELD will support future projects designed to better understand SARS-CoV-2 and other emergent healthcare crises. To the extent possible, VA SHIELD will facilitate the discovery of diagnostics and therapeutics intended to diminish COVID-19 morbidity and mortality and to reduce the impact of new emerging threats to the health of US Veterans and populations worldwide.

Associations Between Gastrointestinal Symptoms and COVID-19 Severity Outcomes Based on a Propensity Score-Weighted Analysis of a Nationwide Cohort.

Background and Aims: Gastrointestinal (GI) symptoms are well-recognized manifestations of coronavirus disease 2019 (COVID-19). Our primary objective was to evaluate the association between GI symptoms and COVID-19 severity. Methods: In this nationwide cohort of US veterans, we evaluated GI symptoms (nausea/vomiting/diarrhea) reported 30 days before and including the date of positive SARS-CoV-2 testing (March 1, 2020, to February 20, 2021). All patients had ≥1 year of prior baseline data and ≥60 days follow-up relative to the test date. We used propensity score (PS)-weighting to balance covariates in patients with vs without GI symptoms. The primary composite outcome was severe COVID-19, defined as hospital admission, intensive care unit admission, mechanical ventilation, or death within 60 days of positive testing. Results: Of 218,045 SARS-CoV-2 positive patients, 29,257 (13.4%) had GI symptoms. After PS weighting, all covariates were balanced. In the PS-weighted cohort, patients with vs without GI symptoms had severe COVID-19 more often (29.0% vs 17.1%; P < .001). When restricted to hospitalized patients (14.9%; n=32,430), patients with GI symptoms had similar frequencies of intensive care unit admission and mechanical ventilation compared with patients without symptoms. There was a significant age interaction; among hospitalized patients aged ≥70 years, lower COVID-19-associated mortality was observed in patients with vs without GI symptoms, even after accounting for COVID-19-specific medical treatments. Conclusion: In the largest integrated US health care system, SARS-CoV-2-positive patients with GI symptoms experienced severe COVID-19 outcomes more often than those without symptoms. Additional research on COVID-19-associated GI symptoms may inform preventive efforts and interventions to reduce severe COVID-19.

The impact of COVID-19 and rapid policy exemptions expanding on access to medication for opioid use disorder (MOUD): A nationwide Veterans Health Administration cohort study.

BACKGROUND: In March 2020, Veterans Health Administration (VHA) enacted policies to expand treatment for Veterans with opioid use disorder (OUD) during COVID-19. In this study, we evaluate whether COVID-19 and subsequent OUD treatment policies impacted receipt of therapy/counseling and medication for OUD (MOUD). METHODS: Using VHA's nationwide electronic health record data, we compared outcomes between a comparison cohort derived using data from prior to COVID-19 (October 2017-December 2019) and a pandemic-exposed cohort (January 2019-March 2021). Primary outcomes included receipt of therapy/counseling or any MOUD (any/none); secondary outcomes included the number of therapy/counseling sessions attended, and the average percentage of days covered (PDC) by, and months prescribed, each MOUD in a year. RESULTS: Veterans were less likely to receive therapy/counseling over time, especially post-pandemic onset, and despite substantial increases in teletherapy. The likelihood of receiving buprenorphine, methadone, and naltrexone was reduced post-pandemic onset. PDC on MOUD generally decreased over time, especially methadone PDC post-pandemic onset, whereas buprenorphine PDC was less impacted during COVID-19. The number of months prescribed methadone and buprenorphine represented relative improvements compared to prior years. We observed important disparities across Veteran demographics. CONCLUSION: Receipt of treatment was negatively impacted during the pandemic. However, there was some evidence that coverage on methadone and buprenorphine may have improved among some veterans who received them. These medication effects are consistent with expected COVID-19 treatment disruptions, while improvements regarding access to therapy/counseling via telehealth, as well as coverage on MOUD during the pandemic, are consistent with the aims of MOUD policy exemptions.

IMPACT OF HISPANIC ETHNICITY ON MORTALITY AMONG HOSPITALIZED PATIENTS WITH COVID-19 DIAGNOSIS

SESSION TITLE: What Lessons Will We Take From the Pandemic? SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Ethnic and racial disparities have been found to be influential drivers for poor outcomes in COVID-19 patients. Hispanic ethnic group has been recognized to have disproportionately higher COVID-19 infections and associated hospitalizations and deaths, which have been attributed to differences in socioeconomic and health factors, including high burden of comorbidities. However, studies specifically addressing the risk of death related to ethnicity alone are lacking. Therefore, we evaluated the association between Hispanic ethnicity and 30-day mortality in patients without comorbidities hospitalized with a COVID-19 diagnosis. METHODS: We included hospitalized patients with a COVID-19 diagnosis (based on the ICD-10 code U07.1) in an observational cohort study at the South Texas Veterans Health Care System (STVHCS) from April 1st, 2020 until December 31st, 2021. Additionally, we selected patients with no comorbidity burden based on a Charlson Comorbidity Index (excluding age) equal to zero. The index date was considered at the first documentation of COVID-19 diagnosis. We compared two independent groups: Hispanic vs. non-Hispanics. Our outcome of interest was 30-day all-cause mortality. Continuous variables were expressed as medians with interquartile ranges (IQR) and categorical variables were reported as absolute frequencies and percentages. A priori multivariable analysis was set to adjust for age, gender, and the probability of death at 30-days according to the validated Veterans Health Administration COVID-19 Index (VACO score). RESULTS: We identified 219 hospitalized COVID-19 patients with no comorbidities, stratified into Hispanics (n=87 [39.7%]) and non-Hispanics (n=132 [60.3%]). Demographic characteristics for Hispanics and non-Hispanics were comparable for median (IQR) age (48 [39-58] years vs. 51 [40-61] years), while there was a greater proportion of male gender in the Hispanic group (n=80 [92.0%] vs. n=110 [83.3%]). Hispanics had a lower probability of death according to the VACO score compared to non-Hispanics (0.22% [0.22%-2.95%] vs. 1.97% (0.22%-4.96%). Both groups had similar 30-day all-cause mortality, n=4 (4.6%) for Hispanics and n=4 (3.0%) for non-Hispanics with p-value=0.72. Due to the low number of deaths between the two groups, we were unable to perform a multivariate analysis. CONCLUSIONS: In this cohort of hospitalized COVID-19 patients without comorbidities, Hispanic ethnicity was not associated with an increased 30-day all-cause mortality. CLINICAL IMPLICATIONS: Our study demonstrates Hispanic ethnicity alone does not account for differences in outcomes of COVID-19 patients. Other factors, such as social determinants of health and comorbidity burden, have been shown to play significant roles and should be the focus of efforts to mitigate morbidity and mortality in COVID-19. DISCLOSURES: No relevant relationships by Liwayway Andrade No relevant relationships by Nicholas Hodgeman No relevant relationships by Michael Mader No relevant relationships by Marcos Restrepo No relevant relationships by Sandra Sanchez-Reilly

MORTALITY AMONG HISPANICS AND NON-HISPANICS WITH COMPARABLE COMORBIDITY BURDEN HOSPITALIZED FOR COVID-19

SESSION TITLE: Impact of Health Disparities and Differences SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: The COVID-19 pandemic resulted in an unexpected increase in mortality primarily among patients with preexisting comorbidities. San Antonio Texas and the surrounding areas are home to a proportionally larger Hispanic population relative to the remainder of the state and country. It has been well documented that patients with pre-existing comorbidities have increased mortality when admitted for COVID-19, but limited data are available regarding the Hispanic minority ethnic group. We determined whether Hispanic ethnicity contributed to 30-day mortality when compared to non-Hispanics among hospitalized COVID-19 patients with similar comorbidity burden. METHODS: We performed an observational cohort study among hospitalized patients that were enrolled at the South Texas Veterans Health Care System (STVHCS) from April 1, 2020 until December 31, 2021 and diagnosed with COVID-19 disease. The index data was defined as the day of COVID-19 diagnosis according to the ICD-10 code U07.1. Our independent variable was stratified according to the Hispanic ethnic group. We included COVID-19 patients with similar comorbidity burden, defined by a Charlson Comorbidity Index (CCI) of greater than or equal to 1. A priori adjustment was performed for variables that influence clinical outcome such as age, gender, and CCI, respectively. The primary outcome was 30-day all-cause mortality. Descriptive and multivariate analysis were performed using the IBM SPSS statistics software. RESULTS: Of the 1257 hospitalized patients during the study period, 1038 met inclusion criteria. There were 372 (35.8%) Hispanics and 666 (64.2%) non-Hispanics. Hispanic patients had similar demographic characteristics to non-Hispanic patients, regarding median age in years (68 [56-73] vs. 68 [58-74], male gender (n=354 [95.2%] vs. n=610 [91.6%]) and median CCI (4.0 [2.0-6.8] vs. 4.0 [2.0-7.0]), respectively. The 30-day all-cause mortality was 13.8% (n=50) in the Hispanic group compared to 14.0% (n=93) in the non-Hispanic group (p=0.81). After adjusting for age, gender and CCI, Hispanics had a similar 30-day all-cause mortality to the non-Hispanic group of COVID-19 hospitalized (AOR 0.98, 95% CI 0.66-1.43, p=0.97). CONCLUSIONS: Hispanic ethnicity was not associated with an increased 30-day all-cause mortality in a population of hospitalized COVID-19 patients with similar comorbidity burden. CLINICAL IMPLICATIONS: Hispanic ethnicity does not appear to be an independent risk factor for increased mortality related to COVID-19 DISCLOSURES: No relevant relationships by Liwayway Andrade No relevant relationships by Nicholas Hodgeman No relevant relationships by Marcos Restrepo

IMPACT OF DEMENTIA AS AN EARLY MORTALITY RISK FACTOR AMONG DECEASED PATIENTS WITH COVID-19

SESSION TITLE: COVID-19: Other Considerations in Management SESSION TYPE: Original Investigations PRESENTED ON: 10/18/2022 02:45 pm - 03:45 pm PURPOSE: In the context of COVID-19, dementia is a well-established risk factor for COVID-19 mortality compared to patients without dementia. To the date, however, there is limited understanding on how a preexisting dementia diagnosis may impact time to death following COVID-19 infection. Of note, identification of risk factors for earlier versus later mortality has the potential to influence treatment and hospice care decisions. Therefore, our aim was to investigate if Veterans with preexisting dementia experienced a longer time from COVID-19 diagnosis to death (all-cause mortality) compared to those without dementia who died of COVID-19. METHODS: We conducted a retrospective, cross-sectional chart review study utilizing data collected at the South Texas Veteran Health Care System from April 2020 to December 2021. Participants comprised deceased Veterans from all-cause mortality following COVID-19 infection, both with and without a preexisting dementia diagnosis in the 5 years prior to COVID-19 diagnosis. We conducted a univariate analysis of covariance, controlling for patient age, to investigate if days from COVID-19 diagnosis to death differed between patients with and without a preexisting dementia diagnosis. RESULTS: A total of N= 382 deceased subjects from all-cause mortality infected with COVID-19 were found in our data base, with a mean age of 73.74 years (SD = 12.33). The majority (64.65%;n = 247) did not have dementia, while 35 % (n = 135) had a preexisting dementia diagnosis in their medical record. Results indicated that number of days from COVID-19 diagnosis to death did not differ (F(1, 379) = 0.02, p = ns) between deceased subjects with dementia (M = 74.6 days, SD = 81.0) and without dementia (M = 75.6, SD = 93.6), controlling for patient age. Patient age was nonsignificant in the model (F(1,379) = 0.44, p = ns). CONCLUSIONS: Among patients deceased for all-cause mortality with COVID-19 infection, results did not indicate a significant difference in time to death following COVID-19 diagnosis between patients with preexisting dementia or without, controlling for age. Although dementia is an established risk factor for COVID-19 related death, it is likely one piece of a complex puzzle in terms of predicting earlier versus later mortality. Future research is needed to identify potential moderators of illness trajectory prior to death among patients following a COVID-19 diagnosis. CLINICAL IMPLICATIONS: Further studies are needed on this field. Limitations of our study were abscense of subgroups for different severity dementia classification, the diagnosis of COVD-19 for our data base was made based on the day an ICD code was entered on the subject’s chart, rather than physician diagnosis, patient’s symptoms starting day, or previous outside COVID-19 tests. Moreover, we didn’t account for other comorbidities, and most patients were male. DISCLOSURES: No relevant relationships by Lisa Kilpela No relevant relationships by Michael Mader No relevant relationships by Onachi Ofoma No relevant relationships by Carlos Perez Ruiz No relevant relationships by Marcos Restrepo No relevant relationships by Sandra Sanchez-Reilly

LONG-TERM MORTALITY IN HOSPITALIZED PATIENTS WITH COVID-19 AND PREEXISTING ASTHMA

SESSION TITLE: Post-COVID-19 Outcomes SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Asthma can be exacerbated by various triggers, including infections. One of the most frequent causes of exacerbations is respiratory viral infections. Therefore, asthmatics were expected to have worse outcomes during the COVID-19 pandemic. While mortality has often been measured in the first 30 days of diagnosis, there is paucity of data regarding the impact of pre-existing asthma in the long-term mortality after a hospitalization for COVID19. We investigated the association between pre-existing asthma and long-term all-cause mortality rate among hospitalized COVID-19 patients. METHODS: This is a retrospective cohort study from the South Texas Veterans Health Care System between April 1, 2020 and December 31, 2020 that included adults hospitalized with COVID-19. The cohort was stratified into two groups: pre-existing asthma vs. non-asthmatics patients. The patients were followed up to 365 post-index date of the COVID-19 diagnosis. The primary outcome was all-cause mortality within 365 days. Continuous variables were expressed as medians with interquartile ranges (IR) and categorical variables were reported as absolute frequencies and percentages. Multivariable analysis, including the Charlson Comorbidity Index was used to adjust for the comorbidity burden excluding asthma. RESULTS: We included 604 patients that required admission with a diagnosis of COVID-19. Pre-existing asthma occurred in 11% (n=66) of hospitalized patients with COVID-19. Asthmatic patients were younger with a median age of 64 years old (IQR 52-71) and less likely to be men (79%) compared to non-asthmatics with a median age of 68 (IQR 54-74) and 94% men, respectively. The Charlson Comorbidity Index was similar between asthmatics (median score of 3 [IQR of 2-7]) and non-asthmatic (median score of 3 [IQR 1-6]) COVID-19 hospitalized patients. The mortality rate within 365 days was numerically lower among asthmatics was 13.6% (n=9/66) when compared to non-asthmatics 21.6% (n=116/538) (p=0.13). Five of the 9 asthmatic patients died within the first 30 days post-COVID-19 diagnosis. In the multivariate analysis adjusted by Charlson Comorbidity Index, asthmatics had no statistically significant difference in mortality when compared to non-asthmatics COVID-19 patients (aOR=1.80;95%IC 0.84-3.87;p=0.13). CONCLUSIONS: There was no association between pre-existing asthma and all-cause mortality rate measured within 365 days after diagnosis of COVID-19 in hospitalized patients. CLINICAL IMPLICATIONS: Further assessment of asthma disease severity and specific therapies may assist clinicians on the potential protective effect seen in COVID-19 patients. DISCLOSURES: No relevant relationships by FRANKLIN ARGUETA No relevant relationships by Michael Mader Consultant relationship with GSK Please note: $5001 - $20000 by Diego Maselli Caceres, value=Consulting fee Consultant relationship with AstraZeneca Please note: $5001 - $20000 by Diego Maselli Caceres, value=Consulting fee Consultant relationship with Sanofi/Regeneron Please note: $5001 - $20000 by Diego Maselli Caceres, value=Consulting fee Speaker/Speaker's Bureau relationship with GSK Please note: 1 year by Diego Maselli Caceres, value=Consulting fee Speaker/Speaker's Bureau relationship with AstraZeneca Please note: 1 year by Diego Maselli Caceres, value=Honoraria Speaker/Speaker's Bureau relationship with Sanofi/Regeneron Please note: 1 year by Diego Maselli Caceres, value=Honoraria Consultant relationship with Amgen Please note: 10/1/2021 Added 04/04/2022 by Diego Maselli Caceres, value=Consulting fee No relevant relationships by Marcos Restrepo No relevant relationships by Sandra Sanchez-Reilly No relevant relationships by Kara Zabelny

EFFECT OF A MULTIDISCIPLINARY FOLLOW-UP PROGRAM ON LONG-TERM, ALL-CAUSE MORTALITY IN VETERAN SURVIVORS OF COVID-19

SESSION TITLE: Medications and Pulmonary Rehabilitation in COVID-19 Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Millions of people have survived COVID 19 infection and are living with post-acute sequelae of COVID (PASC). Multi-disciplinary programs have been established to provide follow-up to these patients. Currently, there are limited data regarding the effectiveness of these programs and it is uncertain if there is a mortality benefit. Here, we explore if the enrollment of Veterans into a multi-disciplinary COVID-19 follow-up program influences long term all-cause mortality. METHODS: We designed a retrospective cohort study at the South Texas Veteran Health Care system (STVHCS) from April 1, 2020, to December 31, 2020. Participants in the study were Veterans who survived a COVID 19 infection after 30 days and were eligible for enrollment in the STVHCS Convalescence Program (“The Program”), which conducts multi-disciplinary follow up care. Patients who died <30 days after COVID 19 diagnosis were not eligible. The primary outcome of long term all-cause mortality was defined as mortality within 31-365 days after the diagnosis of a COVID 19 infection. Demographic differences and primary outcome between the two groups (enrolled versus non-enrolled in The Program) were analyzed using Chi square for categorical variables. Continuous variables were analyzed using Student’s t-test. RESULTS: In total 2253 patients were eligible for enrollment, of which 557 were enrolled and 1696 were not enrolled. Long term all-cause mortality between the groups was 6/557 (1.07%) in the enrolled group compared to 78/1696 (4.59%) in the non-enrolled group with a p value of <0.001. There was no statistical difference between the groups based on the average Charlson comorbidity index score, 2.12 vs 2.09 respectively, with a p value = 0.85. CONCLUSIONS: Enrollment of Veterans in a COVID 19 multidisciplinary follow-up program is associated with a significant decrease in long term all-cause mortality. These differences could not be explained by inherent differences between groups. CLINICAL IMPLICATIONS: Our study shows the potential effectiveness of COVID-19 multidisciplinary follow-up programs to reduce long term all cause mortality in survivors of COVID. In addition there may be other benefits not yet explored such as reduction in symptom burden from COVID and decreased psychosocial distress. The generalizability of this study is limited by its observational study design, the voluntary nature of enrollment in the program and lack of non veterans in the population. DISCLOSURES: No relevant relationships by Ye Aung No relevant relationships by Ryan Choudhury No relevant relationships by Michael Mader No relevant relationships by Marcos Restrepo No relevant relationships by Sandra Sanchez-Reilly No relevant relationships by Monica Serra No relevant relationships by Ana Lucia Siu Chang No relevant relationships by Hanh Trinh

Impact of COVID-19 Pandemic on Teleretinal Screening using Optical Coherence Tomography at the Veterans Health Administration

Purpose : In 2019, a novel teleretinal imaging program was implemented at the Veteran Affairs (VA) Greater Los Angeles Healthcare System providing remote OCT evaluation with prompt retinal specialist evaluation. The purpose of this study was to determine how the COVID-19 pandemic affected the tele-OCT screening program in its second year of implementation. Methods : Retrospective chart review study of patients evaluated by a retina specialist through asynchronous tele-OCT evaluation in 2019 and 2020. Electronic medical records were used to obtain patients' demographic and clinical characteristics, tele-OCT consult results, and patient adherence to tele-OCT follow-up plans. Results : There were 108 tele-OCT consults in 2020 compared to 158 tele-OCT consults in 2019, a 32% decrease. There was no significant difference in overall patient adherence to follow-up between the two years. In 2020, patients who had diagnosed anxiety were less likely to be adherent compared to 2019 (37.5% v. 71.4%, p=0.023). In 2020, the retinal diagnosis was less likely to be changed after teleretinal consultation compared to 2019 (12.96% v. 29.1%, p<0.01). Conclusions : The decrease in tele-OCT use reflects the decrease in patients presenting to referring clinics that utilized the consult mechanism during the COVID-19 pandemic. Patient anxiety should be considered when addressing compliance. The teleretinal program is providing an education benefit to referring providers.

The Impact of COVID-19 on Periocular NonMelanoma Skin Cancer in the Veteran Population

Purpose : Despite an increasing incidence of skin cancer over the last decade, studies have reported a decline in the diagnosis and treatment of skin cancer during the COVID19 pandemic. We performed a retrospective cohort study using a large population-based cohort from the Veterans Health Administration (VHA) to determine how the pandemic has affected tumor size and morbidity in veterans with periocular non-melanoma skin cancer. Methods : Electronic health records from all VHA sites were accessed through the VA Informatics and Computing Infrastructure (VINCI). Data were stored in the Observational Medical Outcomes Partnership (OMOP) model and queried via SQL Server. ICD-10 and current procedural terminology codes were used to identify patients who received Mohs surgery for periocular basal cell carcinoma (BCC) or squamous cell carcinoma (SCC) between 08/01/2018 and 09/10/2021. A combination of structured algorithms and manual review were used to extract patient demographics, lesion characteristics, and surgical outcome at three time points, ie. pre-COVID, early, and late COVID. Unpaired t-tests were used to assess statistical significance. Results : Patient characteristics were similar between pre- and post-COVID cohorts in terms of gender, age, race, and tumor type. The average number of Mohs periocular surgeries performed per week were 23.1% (7.31 vs 5.62) and 13.1% (7.49 vs 6.51) lower in the early and later pandemic, respectively, compared to similar pre-COVID timeframes by month (Figure 1). Mean lesion size (maximum diameter) was 1.35 cm larger post-COVID compared to pre-COVID (95% CI 0.19 2.51, P=0.022);however, the defect size remained similar (Figure 2). Stratifying by tumor type, the same trends were noted in BCC, particularly early in the pandemic. However, mean SCC lesion and defect sizes did not vary over time. Conclusions : Periocular Mohs surgery rates declined in the COVID pandemic across VHA. Lesions were larger particularly in the earlier phase of the pandemic for BCC. Future analyses using this cohort will attempt to determine if telehealth and travel time were associated with distinct outcomes.

Complete Telehealth for Multidisciplinary Preoperative Workup Does Not Delay Time to Metabolic and Bariatric Surgery: a Pilot Study.

PURPOSE: The COVID-19 pandemic accelerated implementation of telehealth throughout the US healthcare system. At our institution, we converted a fully integrated multidisciplinary bariatric clinic from face-to-face visits to entirely telehealth video/telephone visits. We hypothesized telehealth would increase the number of provider/patient encounters and therefore delay time to surgery. METHODS: This is a retrospective review of consecutive patients who underwent total telehealth preoperative workup. Demographics, comorbidities, and surgical characteristics were compared to the same number of consecutive patients who underwent a face-to-face approach 12 months prior, using a Wilcoxon test for continuous variables and chi-square or Fisher's exact test for categorical variables. Differences between time and surgery were compared using inverse probability of treatment-weighted estimates and number of preoperative visits using Poisson regression with distance to hospital as a confounder. Noninferiority margin for time to surgery was set to 60 days, and the number of visits was set to 2 visits. RESULTS: Between March of 2020 and December of 2021, 36 patients had total telehealth workup, and were compared to 36 patients in the traditional group. Age, sex, body mass index, and comorbidities did not differ between groups. The average number of days to surgery was 121.1 days shorter in the telehealth group (90% bootstrap CI [- 160.4, - 81.8]). Estimated shift in the total number of visits was additional .76 visits in the traditional group (90% CI [.64, .91). CONCLUSIONS: The total telehealth approach to preoperative bariatric multidisciplinary workup did not delay surgery and decreased number of total outpatient visits and time to surgery.

Experiences of researchers fulfilling VHA's “fourth mission” during the COVID-19 pandemic

Background: As the largest integrated healthcare system in the US, the Veterans Health Administration (VHA) is chartered “to serve as the primary backup for any health care services needed.in the event of war or national emergency” according to a 1982 Congressional Act. This mission was invoked during the COVID 19 pandemic to divert clinical and research resources, resulting in dramatic changes in the activities of investigators and research staff. This study uses established behavioral change frameworks to examine the experience of VHA cancer researchers during the pandemic. Methods: We conducted a mixed methods study on the effects of the pandemic on VHA researchers. We used an electronic questionnaire composed of Likert scale statements and open-ended questions, which was constructed using the 14 domains of the Theoretical Domains Framework (TDF) and the Capability, Opportunity, and Motivation (COM-B) model for behavior change. Likert scale statements were quantified and content analysis was performed on open ended responses. Results: The questionnaire was distributed electronically to 118 researchers participating in national VHA collaborations, with 42 responses (36%). Several significant themes and findings emerged. Only 36% of respondents did not feel that their research focus changed during the pandemic. (TDF: professional role and identity maps to COM-B Motivation). And 81% of respondents reported a diverse range of research interests (COM-B: M). Only 11 of 42 respondents (26%) reported prior experience with infectious disease research (TDF: skills maps to COMB: C), and 31 of 42 (74%) agreed that they gained new research skills during the pandemic (COM-B: C). When asked to describe support structures helpful during the pandemic, 29% mentioned local supervisors, mentors and research staff (COM-B: C, M), 15% cited larger VHA organizations (COM-B: C) and 18% mentioned remote work abilities or telehealth (COM-B: O). Lack of timely communication from supervisors and remote work, particularly for individuals with caregiving responsibilities, were seen as limiting factors for research during the pandemic (COM-B: O). Although 83% of respondents agreed that they will be prepared to respond to future crises after COVID (COM-B: C), fewer than half (40%) of respondents felt professionally rewarded for pursuing research related to COVID, with 50% feeling neutral (COM-B: M). Conclusions: This study demonstrated the tremendous effects of the COVID 19 pandemic on research activities of VHA investigators. We identified perceptions of insufficient recognition and lack of professional advancement related to pandemic era research. Improving the structure of remote work and team communication represent high yield areas for improvement. It is essential to understand barriers and facilitators of crisis redeployment in the VHA, to make the transition effective and fulfilling for those carrying out the mission.