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2.
PLoS Med ; 18(10): e1003807, 2021 10.
Article in English | MEDLINE | ID: covidwho-1484840

ABSTRACT

BACKGROUND: We examined whether key sociodemographic and clinical risk factors for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection and mortality changed over time in a population-based cohort study. METHODS AND FINDINGS: In a cohort of 9,127,673 persons enrolled in the United States Veterans Affairs (VA) healthcare system, we evaluated the independent associations of sociodemographic and clinical characteristics with SARS-CoV-2 infection (n = 216,046), SARS-CoV-2-related mortality (n = 10,230), and case fatality at monthly intervals between February 1, 2020 and March 31, 2021. VA enrollees had a mean age of 61 years (SD 17.7) and were predominantly male (90.9%) and White (64.5%), with 14.6% of Black race and 6.3% of Hispanic ethnicity. Black (versus White) race was strongly associated with SARS-CoV-2 infection (adjusted odds ratio [AOR] 5.10, [95% CI 4.65 to 5.59], p-value <0.001), mortality (AOR 3.85 [95% CI 3.30 to 4.50], p-value < 0.001), and case fatality (AOR 2.56, 95% CI 2.23 to 2.93, p-value < 0.001) in February to March 2020, but these associations were attenuated and not statistically significant by November 2020 for infection (AOR 1.03 [95% CI 1.00 to 1.07] p-value = 0.05) and mortality (AOR 1.08 [95% CI 0.96 to 1.20], p-value = 0.21) and were reversed for case fatality (AOR 0.86, 95% CI 0.78 to 0.95, p-value = 0.005). American Indian/Alaska Native (AI/AN versus White) race was associated with higher risk of SARS-CoV-2 infection in April and May 2020; this association declined over time and reversed by March 2021 (AOR 0.66 [95% CI 0.51 to 0.85] p-value = 0.004). Hispanic (versus non-Hispanic) ethnicity was associated with higher risk of SARS-CoV-2 infection and mortality during almost every time period, with no evidence of attenuation over time. Urban (versus rural) residence was associated with higher risk of infection (AOR 2.02, [95% CI 1.83 to 2.22], p-value < 0.001), mortality (AOR 2.48 [95% CI 2.08 to 2.96], p-value < 0.001), and case fatality (AOR 2.24, 95% CI 1.93 to 2.60, p-value < 0.001) in February to April 2020, but these associations attenuated over time and reversed by September 2020 (AOR 0.85, 95% CI 0.81 to 0.89, p-value < 0.001 for infection, AOR 0.72, 95% CI 0.62 to 0.83, p-value < 0.001 for mortality and AOR 0.81, 95% CI 0.71 to 0.93, p-value = 0.006 for case fatality). Throughout the observation period, high comorbidity burden, younger age, and obesity were consistently associated with infection, while high comorbidity burden, older age, and male sex were consistently associated with mortality. Limitations of the study include that changes over time in the associations of some risk factors may be affected by changes in the likelihood of testing for SARS-CoV-2 according to those risk factors; also, study results apply directly to VA enrollees who are predominantly male and have comprehensive healthcare and need to be confirmed in other populations. CONCLUSIONS: In this study, we found that strongly positive associations of Black and AI/AN (versus White) race and urban (versus rural) residence with SARS-CoV-2 infection, mortality, and case fatality observed early in the pandemic were ameliorated or reversed by March 2021.


Subject(s)
COVID-19/mortality , Continental Population Groups , Population Surveillance , Rural Population/trends , United States Department of Veterans Affairs/trends , Urban Population/trends , Aged , COVID-19/diagnosis , COVID-19/economics , Cohort Studies , Female , Humans , Male , Middle Aged , Mortality/trends , Population Surveillance/methods , Risk Factors , Socioeconomic Factors , United States/epidemiology
3.
JAMA Netw Open ; 4(10): e2128391, 2021 10 01.
Article in English | MEDLINE | ID: covidwho-1453501

ABSTRACT

Importance: Effectiveness of mRNA vaccinations in a diverse older population with high comorbidity is unknown. Objectives: To describe the scope of the COVID-19 vaccination rollout among US veterans, and to estimate mRNA COVID-19 vaccine effectiveness (VE) as measured by rates of SARS-CoV-2 infection. Design, Setting, and Participants: This matched test-negative case-control study was conducted using SARS-CoV-2 test results at Veterans Health Administration sites from December 14, 2020, to March 14, 2021. Vaccine coverage was estimated for all veterans. VE against SARS-CoV-2 infection and COVID-19-related hospitalization and death were estimated using electronic health records from veterans who routinely sought care at a VHA facility and had a test result positive for SARS-CoV-2 (cases) or negative for SARS-CoV-2 (controls). Cases and controls were matched on time of test and geographic region. Data were analyzed from May to July 2021. Exposures: Vaccination status, defined as unvaccinated, partially vaccinated (≥14 days after first dose until second dose), or fully vaccinated (≥14 days after second dose), at time of test. Main Outcomes and Measures: The main outcome of interest was a positive result for SARS-CoV-2 on a polymerase chain reaction or antigen test. Secondary outcomes included COVID-19-related hospitalization and death, defined by discharge data and proximity of event to positive test result. VE was estimated from odds ratios for SARS-CoV-2 infection with 95% CIs. Results: Among 6 647 733 veterans included (3 350 373 veterans [50%] aged ≥65 years; 6 014 798 [90%] men and 632 935 [10%] women; 461 645 Hispanic veterans of any race [7%], 1 102 471 non-Hispanic Black veterans [17%], and 4 361 621 non-Hispanic White veterans [66%]), 1 363 180 (21%) received at least 1 COVID-19 vaccination by March 7, 2021. In this period, during which the share of SARS-CoV-2 variants Alpha, Epsilon, and Iota had started to increase in the US, estimates of COVID-19 VE against infection, regardless of symptoms, was 95% (95% CI, 93%-96%) for full vaccination and 64% (95% CI, 59%-68%) for partial vaccination. Estimated VE against COVID-19-related hospitalization for full vaccination was 91% (95% CI 83%-95%); there were no deaths among veterans who were fully vaccinated. VE against infection was similar across subpopulations (non-Hispanic Black, 94% [95% CI, 88%-97%]; Hispanic [any race], 83% [95% CI, 45%-95%]; non-Hispanic White, 92% [95% CI 88%-94%]; rural, 94% [95% CI, 89%-96%]; urban, 93% 95% CI, 89%-95%]). Conclusions and Relevance: For veterans of all racial and ethnic subgroups living in urban or rural areas, mRNA vaccination was associated with substantially decreased risk of COVID-19 infection and hospitalization, with no deaths among fully vaccinated veterans.


Subject(s)
COVID-19 Vaccines , COVID-19/prevention & control , RNA, Messenger , Vaccination Coverage , Veterans , African Americans , Aged , Aged, 80 and over , Case-Control Studies , European Continental Ancestry Group , Female , Hispanic Americans , Hospitalization , Humans , Male , Odds Ratio , Pandemics , SARS-CoV-2 , Treatment Outcome , United States , United States Department of Veterans Affairs
4.
Int J Environ Res Public Health ; 18(19)2021 Sep 23.
Article in English | MEDLINE | ID: covidwho-1438597

ABSTRACT

The current study assessed performance of the new Veterans Affairs (VA) women cardiovascular disease (CVD) risk score in predicting women veterans' 60-day CVD event risk using VA COVID-19 shared cohort data. The study data included 17,264 women veterans-9658 White, 6088 African American, and 1518 Hispanic women veterans-ever treated at US VA hospitals and clinics between 24 February and 25 November 2020. The VA women CVD risk score discriminated patients with CVD events at 60 days from those without CVD events with accuracy (area under the curve) of 78%, 50%, and 83% for White, African American, and Hispanic women veterans, respectively. The VA women CVD risk score itself showed good accuracy in predicting CVD events at 60 days for White and Hispanic women veterans, while it performed poorly for African American women veterans. The future studies are needed to identify non-traditional factors and biomarkers associated with increased CVD risk specific to African American women and incorporate them to the CVD risk assessment.


Subject(s)
COVID-19 , Cardiovascular Diseases , Veterans , Cardiovascular Diseases/epidemiology , Female , Heart Disease Risk Factors , Humans , Incidence , Information Dissemination , Risk Factors , SARS-CoV-2 , United States/epidemiology , United States Department of Veterans Affairs
5.
MMWR Morb Mortal Wkly Rep ; 70(37): 1294-1299, 2021 Sep 17.
Article in English | MEDLINE | ID: covidwho-1417367

ABSTRACT

COVID-19 mRNA vaccines (Pfizer-BioNTech and Moderna) have been shown to be highly protective against COVID-19-associated hospitalizations (1-3). Data are limited on the level of protection against hospitalization among disproportionately affected populations in the United States, particularly during periods in which the B.1.617.2 (Delta) variant of SARS-CoV-2, the virus that causes COVID-19, predominates (2). U.S. veterans are older, more racially diverse, and have higher prevalences of underlying medical conditions than persons in the general U.S. population (2,4). CDC assessed the effectiveness of mRNA vaccines against COVID-19-associated hospitalization among 1,175 U.S. veterans aged ≥18 years hospitalized at five Veterans Affairs Medical Centers (VAMCs) during February 1-August 6, 2021. Among these hospitalized persons, 1,093 (93.0%) were men, the median age was 68 years, 574 (48.9%) were non-Hispanic Black (Black), 475 were non-Hispanic White (White), and 522 (44.4%) had a Charlson comorbidity index score of ≥3 (5). Overall adjusted vaccine effectiveness against COVID-19-associated hospitalization was 86.8% (95% confidence interval [CI] = 80.4%-91.1%) and was similar before (February 1-June 30) and during (July 1-August 6) SARS-CoV-2 Delta variant predominance (84.1% versus 89.3%, respectively). Vaccine effectiveness was 79.8% (95% CI = 67.7%-87.4%) among adults aged ≥65 years and 95.1% (95% CI = 89.1%-97.8%) among those aged 18-64 years. COVID-19 mRNA vaccines are highly effective in preventing COVID-19-associated hospitalization in this older, racially diverse population of predominately male U.S. veterans. Additional evaluations of vaccine effectiveness among various age groups are warranted. To prevent COVID-19-related hospitalizations, all eligible persons should receive COVID-19 vaccination.


Subject(s)
COVID-19 Vaccines/administration & dosage , COVID-19/prevention & control , Hospitalization/statistics & numerical data , Veterans/statistics & numerical data , Adolescent , Adult , Aged , COVID-19/epidemiology , COVID-19/therapy , Female , Hospitals, Veterans , Humans , Male , Middle Aged , United States/epidemiology , United States Department of Veterans Affairs , Vaccines, Synthetic , Young Adult
7.
Am Heart J ; 240: 46-57, 2021 10.
Article in English | MEDLINE | ID: covidwho-1316364

ABSTRACT

BACKGROUND: Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) are known to impact the functional receptor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The association between chronic therapy with these medications and infection risk remains unclear. OBJECTIVES: The objective was to determine the association between prior ACEI or ARB therapy and SARS-CoV-2 infection among patients with hypertension in the U.S. Veteran's Affairs health system. METHODS: We compared the odds of SARS-CoV-2 infection among three groups: patients treated with ACEI, treated with ARB, or treated with alternate first-line anti-hypertensives without ACEI/ARB. We excluded patients with alternate indications for ACEI or ARB therapy. We performed an augmented inverse propensity weighted analysis with adjustment for demographics, region, comorbidities, vitals, and laboratory values. RESULTS: Among 1,724,723 patients with treated hypertension, 659,180 were treated with ACEI, 310,651 with ARB, and 754,892 with neither. Before weighting, patients treated with ACEI or ARB were more likely to be diabetic and use more anti-hypertensives. There were 13,278 SARS-CoV-2 infections (0.8%) between February 12, 2020 and August 19, 2020. Patients treated with ACEI had lower odds of SARS-CoV-2 infection (odds ratio [OR] 0.93; 95% CI: 0.89-0.97) while those treated with ARB had similar odds (OR 1.02; 95% CI: 0.96-1.07) compared with patients treated with alternate first-line anti-hypertensives without ACEI/ARB. In falsification analyses, patients on ACEI did not have a difference in their odds of unrelated outcomes. CONCLUSIONS: Our results suggest the safety of continuing ACEI and ARB therapy. The association between ACEI therapy and lower odds of SARS-CoV-2 infection requires further investigation.


Subject(s)
Angiotensin Receptor Antagonists/therapeutic use , Angiotensin-Converting Enzyme Inhibitors/therapeutic use , Antihypertensive Agents/therapeutic use , COVID-19/epidemiology , Hypertension/drug therapy , Renin-Angiotensin System/drug effects , Adrenergic beta-Antagonists/therapeutic use , Aged , Angiotensin II Type 2 Receptor Blockers , Calcium Channel Blockers/therapeutic use , Case-Control Studies , Comorbidity , Confidence Intervals , Diabetes Mellitus/epidemiology , Female , Humans , Male , Middle Aged , Odds Ratio , Propensity Score , Receptors, Virus , SARS-CoV-2 , Sodium Chloride Symporter Inhibitors/therapeutic use , United States/epidemiology , United States Department of Veterans Affairs , Veterans/statistics & numerical data
8.
J Community Psychol ; 49(7): 2532-2547, 2021 09.
Article in English | MEDLINE | ID: covidwho-1305130

ABSTRACT

People experiencing homelessness during the 2017-2018 California wildfires faced significant risks of disruption. Homeless service organizations (HSOs) are an essential safety net for this population. To learn about how HSOs performed during the wildfires, this study interviewed U.S. Department of Veterans Affairs (VA) staff overseeing HSOs providing transitional housing under the VA's Grant and Per Diem (GPD) program to Veterans experiencing homelessness. We employed a comparative case study approach exploring GPD organizations' disaster response actions, including evacuating Veterans from wildfire-affected areas or taking in disaster-displaced Veterans. This article presents three themes in the GPD organizations' disaster response: (1) Organizations benefitted from close collaboration and communication with the VA during the disaster, creating a safety net to ensure Veterans' well-being and enact rapid re-housing to prevent homelessness; (2) Organization staff performed heroically under stressful disaster conditions; and (3) Organizations benefitted from the written disaster plans that VA requires them to create, but were not as well-prepared for wildfires as they had been for earthquakes. As emergent threats such as the COVID-19 pandemic, wildfires, and a very active 2020 hurricane season amplify the importance of mitigating risks, comprehensive disaster planning is needed to ensure the safety and support of people experiencing homelessness.


Subject(s)
Disasters , Fires , Homeless Persons , California , Disaster Planning , Emergency Shelter , Humans , United States , United States Department of Veterans Affairs , Veterans
9.
Med Care ; 59(7): 646-652, 2021 07 01.
Article in English | MEDLINE | ID: covidwho-1276272

ABSTRACT

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has led to a dramatic increase in virtual care (VC) across outpatient specialties, but little is known regarding provider acceptance of VC. OBJECTIVE: The objective of this study was to assess provider perceptions of the quality, efficiency, and challenges of VC versus in-person care with masks. DESIGN: This was a voluntary survey. PARTICIPANTS: Mental health (MH), primary care, medical specialty, and surgical specialty providers across the 8 VA New England Healthcare System medical centers. MEASURES: Provider ratings of: (1) quality and efficiency of VC (phone and video telehealth) compared with in-person care with masks; (2) challenges of VC; and (3) percentage of patients that providers are comfortable seeing via VC in the future. RESULTS: The sample included 998 respondents (49.8% MH, 20.6% primary care, 20.4% medical specialty, 9.1% surgical specialty; 61% response rate). Most providers rated VC as equivalent to or higher in quality and efficiency compared with in-person care with masks. Quality ratings were significantly higher for video versus phone (χ2=61.4, P<0.0001), but efficiency ratings did not differ significantly. Ratings varied across specialties (highest in MH, lowest in SS; all χ2s>24.1, Ps<0.001). Inability to conduct a physical examination and patient technical difficulties were significant challenges. MH providers were comfortable seeing a larger proportion of patients virtually compared with the other specialties (all χ2s>12.2, Ps<0.01). CONCLUSIONS: Broad provider support for VC was stratified across specialties, with the highest ratings in MH and lowest ratings in SS. Findings will inform the improvement of VC processes and the planning of health care delivery during the COVID-19 pandemic and beyond.


Subject(s)
Attitude of Health Personnel , Telemedicine , COVID-19/psychology , Humans , Mental Health , Primary Health Care , SARS-CoV-2 , Specialties, Surgical , Surveys and Questionnaires , United States , United States Department of Veterans Affairs
10.
Nature ; 594(7862): 259-264, 2021 06.
Article in English | MEDLINE | ID: covidwho-1275936

ABSTRACT

The acute clinical manifestations of COVID-19 have been well characterized1,2, but the post-acute sequelae of this disease have not been comprehensively described. Here we use the national healthcare databases of the US Department of Veterans Affairs to systematically and comprehensively identify 6-month incident sequelae-including diagnoses, medication use and laboratory abnormalities-in patients with COVID-19 who survived for at least 30 days after diagnosis. We show that beyond the first 30 days of illness, people with COVID-19 exhibit a higher risk of death and use of health resources. Our high-dimensional approach identifies incident sequelae in the respiratory system, as well as several other sequelae that include nervous system and neurocognitive disorders, mental health disorders, metabolic disorders, cardiovascular disorders, gastrointestinal disorders, malaise, fatigue, musculoskeletal pain and anaemia. We show increased incident use of several therapeutic agents-including pain medications (opioids and non-opioids) as well as antidepressant, anxiolytic, antihypertensive and oral hypoglycaemic agents-as well as evidence of laboratory abnormalities in several organ systems. Our analysis of an array of prespecified outcomes reveals a risk gradient that increases according to the severity of the acute COVID-19 infection (that is, whether patients were not hospitalized, hospitalized or admitted to intensive care). Our findings show that a substantial burden of health loss that spans pulmonary and several extrapulmonary organ systems is experienced by patients who survive after the acute phase of COVID-19. These results will help to inform health system planning and the development of multidisciplinary care strategies to reduce chronic health loss among individuals with COVID-19.


Subject(s)
COVID-19/complications , SARS-CoV-2/pathogenicity , COVID-19/diagnosis , COVID-19/drug therapy , COVID-19/physiopathology , COVID-19/psychology , Cohort Studies , Databases, Factual , Datasets as Topic , Electronic Health Records , Female , Hospitalization/statistics & numerical data , Humans , Influenza, Human/diagnosis , Influenza, Human/drug therapy , Influenza, Human/physiopathology , Male , Outpatients/psychology , Outpatients/statistics & numerical data , Risk , Time Factors , United States , United States Department of Veterans Affairs
11.
Jt Comm J Qual Patient Saf ; 47(8): 469-480, 2021 08.
Article in English | MEDLINE | ID: covidwho-1275440

ABSTRACT

BACKGROUND: The United States is in the midst of an opioid epidemic within the COVID-19 pandemic, and veterans are twice as likely to die from accidental overdose compared to non-veterans. This article describes the Veterans Health Administration (VHA) Rapid Naloxone Initiative, which aims to prevent opioid overdose deaths among veterans through (1) opioid overdose education and naloxone distribution (OEND) to VHA patients at risk for opioid overdose, (2) VA Police naloxone, and (3) select automated external defibrillator (AED) cabinet naloxone. METHODS: VHA has taken a multifaceted, theory-based approach to ensuring the rapid availability of naloxone to prevent opioid overdose deaths. Strategies targeted at multiple levels (for example, patient, provider, health care system) have enabled synergies to speed diffusion of this lifesaving practice. RESULTS: As of April 2021, 285,279 VHA patients had received naloxone from 31,730 unique prescribers, with 1,880 reported opioid overdose reversals with naloxone; 129 VHA facilities had equipped 3,552 VA Police officers with naloxone, with 136 reported opioid overdose reversals with VA Police naloxone; and 77 VHA facilities had equipped 1,095 AED cabinets with naloxone, with 10 reported opioid overdose reversals with AED cabinet naloxone. Remarkably, the COVID-19 pandemic had minimal impact on naloxone dispensing to VHA patients. CONCLUSION: The VHA Rapid Naloxone Initiative saves lives. VHA is sharing many of the tools and resources it has developed to support uptake across other health care systems. Health care systems need to work together to combat this horrific epidemic within a pandemic and prevent a leading cause of accidental death (opioid overdose).


Subject(s)
COVID-19 , Drug Overdose , Drug Overdose/drug therapy , Drug Overdose/prevention & control , Humans , Naloxone/therapeutic use , Pandemics , SARS-CoV-2 , United States , United States Department of Veterans Affairs , Veterans Health
12.
BMJ Health Care Inform ; 28(1)2021 Jun.
Article in English | MEDLINE | ID: covidwho-1263921

ABSTRACT

Using administrative data on all Veterans who enter Department of Veterans Affairs (VA) medical centres throughout the USA, this paper uses artificial intelligence (AI) to predict mortality rates for patients with COVID-19 between March and August 2020. First, using comprehensive data on over 10 000 Veterans' medical history, demographics and lab results, we estimate five AI models. Our XGBoost model performs the best, producing an area under the receive operator characteristics curve (AUROC) and area under the precision-recall curve of 0.87 and 0.41, respectively. We show how focusing on the performance of the AUROC alone can lead to unreliable models. Second, through a unique collaboration with the Washington D.C. VA medical centre, we develop a dashboard that incorporates these risk factors and the contributing sources of risk, which we deploy across local VA medical centres throughout the country. Our results provide a concrete example of how AI recommendations can be made explainable and practical for clinicians and their interactions with patients.


Subject(s)
Artificial Intelligence , COVID-19/mortality , Models, Statistical , Veterans , Data Display , Humans , Risk Factors , United States , United States Department of Veterans Affairs
13.
JAMA Netw Open ; 4(6): e2113031, 2021 06 01.
Article in English | MEDLINE | ID: covidwho-1261749

ABSTRACT

Importance: The US Department of Veterans Affairs (VA) offers programs that reduce barriers to care for veterans and those with housing instability, poverty, and substance use disorder. In this setting, however, the role that social and behavioral risk factors play in COVID-19 outcomes is unclear. Objective: To examine whether social and behavioral risk factors were associated with mortality among US veterans with COVID-19 and whether this association might be modified by race/ethnicity. Design, Setting, and Participants: This cohort study obtained data from the VA Corporate Data Warehouse to form a cohort of veterans who received a positive COVID-19 test result between March 2 and September 30, 2020, in a VA health care facility. All veterans who met the inclusion criteria were eligible to participate in the study, and participants were followed up for 30 days after the first SARS-CoV-2 or COVID-19 diagnosis. The final follow-up date was October 31, 2020. Exposures: Social risk factors included housing problems and financial hardship. Behavioral risk factors included current tobacco use, alcohol use, and substance use. Main Outcomes and Measures: The primary outcome was all-cause mortality in the 30-day period after the SARS-CoV-2 or COVID-19 diagnosis date. Multivariable logistic regression was used to estimate odds ratios, clustering for health care facilities and adjusting for age, sex, race, ethnicity, marital status, clinical factors, and month of COVID-19 diagnosis. Results: Among 27 640 veterans with COVID-19 who were included in the analysis, 24 496 were men (88.6%) and the mean (SD) age was 57.2 (16.6) years. A total of 3090 veterans (11.2%) had housing problems, 4450 (16.1%) had financial hardship, 5358 (19.4%) used alcohol, and 3569 (12.9%) reported substance use. Hospitalization occurred in 7663 veterans (27.7%), and 1230 veterans (4.5%) died. Housing problems (adjusted odds ratio [AOR], 0.96; 95% CI, 0.77-1.19; P = .70), financial hardship (AOR, 1.13; 95% CI, 0.97-1.31; P = .11), alcohol use (AOR, 0.82; 95% CI, 0.68-1.01; P = .06), current tobacco use (AOR, 0.85; 95% CI, 0.68-1.06; P = .14), and substance use (AOR, 0.90; 95% CI, 0.71-1.15; P = .41) were not associated with higher mortality. Interaction analyses by race/ethnicity did not find associations between mortality and social and behavioral risk factors. Conclusions and Relevance: Results of this study showed that, in an integrated health system such as the VA, social and behavioral risk factors were not associated with mortality from COVID-19. Further research is needed to substantiate the potential of an integrated health system to be a model of support services for households with COVID-19 and populations who are at risk for the disease.


Subject(s)
COVID-19/mortality , Housing , Pandemics , Poverty , Substance-Related Disorders , Veterans , Adult , Aged , Alcohol Drinking , COVID-19/ethnology , Cohort Studies , Continental Population Groups , Ethnic Groups , Female , Homeless Persons , Humans , Logistic Models , Male , Middle Aged , Odds Ratio , Risk Factors , SARS-CoV-2 , Tobacco Use , United States/epidemiology , United States Department of Veterans Affairs
14.
J Gen Intern Med ; 36(8): 2274-2282, 2021 08.
Article in English | MEDLINE | ID: covidwho-1240057

ABSTRACT

BACKGROUND: Veterans experiencing homelessness face substantial barriers to accessing health and social services. In 2016, the Veterans Affairs (VA) healthcare system launched a unique program to distribute video-enabled tablets to Veterans with access barriers. OBJECTIVE: Evaluate the use of VA-issued video telehealth tablets among Veterans experiencing homelessness in the VA system. DESIGN: Guided by the RE-AIM framework, we first evaluated the adoption of tablets among Veterans experiencing homelessness and housed Veterans. We then analyzed health record and tablet utilization data to compare characteristics of both subpopulations, and used multivariable logistic regression to identify factors associated with tablet use among Veterans experiencing homelessness. PATIENTS: In total, 12,148 VA patients receiving tablets between October 2017 and March 2019, focusing on the 1470 VA Veterans experiencing homelessness receiving tablets (12.1%). MAIN MEASURES: Tablet use within 6 months of receipt for mental health, primary or specialty care. KEY RESULTS: Nearly half (45.9%) of Veterans experiencing homelessness who received a tablet had a video visit within 6 months of receipt, most frequently for telemental health. Tablet use was more common among Veterans experiencing homelessness who were younger (AOR = 2.77; P <.001); middle-aged (AOR = 2.28; P <.001); in rural settings (AOR = 1.46; P =.005); and those with post-traumatic stress disorder (AOR = 1.64; P <.001), and less common among those who were Black (AOR = 0.43; P <.001) and those with a substance use disorder (AOR = 0.59; P <.001) or persistent housing instability (AOR = 0.75; P = .023). CONCLUSIONS: Telehealth care and connection for vulnerable populations are particularly salient during the COVID-19 pandemic but also beyond. VA's distribution of video telehealth tablets offers healthcare access to Veterans experiencing homelessness; however, barriers remain for subpopulations. Tailored training and support for these patients may be needed to optimize telehealth tablet use and effectiveness.


Subject(s)
COVID-19 , Homeless Persons , Telemedicine , Veterans , Health Services Accessibility , Humans , Middle Aged , Pandemics , SARS-CoV-2 , United States , United States Department of Veterans Affairs
16.
J Nerv Ment Dis ; 209(8): 543-546, 2021 08 01.
Article in English | MEDLINE | ID: covidwho-1234178

ABSTRACT

ABSTRACT: Social distancing due to COVID-19 may adversely impact treatment of adults with serious mental illness, especially those receiving intensive forms of community-based care, in part through weakening of the therapeutic alliance. Veterans and staff at a Veterans Affair (VA) medical center were surveyed 3 months after social distancing disrupted usual service delivery in intensive community-based treatment programs. Veterans (n = 105) and staff (n = 112) gave similar multi-item ratings of service delivery after social distancing, which involved far less face-to-face contact and more telephone contact than usual and rated their therapeutic alliances and clinical status similarly as "not as good" on average than before social distancing. Self-reported decline in therapeutic alliance was associated with parallel decline in clinical status indicators. Both veterans and staff indicated clear preference for return to face-to-face service delivery after the pandemic with some telehealth included.


Subject(s)
Attitude of Health Personnel , COVID-19 , Case Management/standards , Community Mental Health Services/standards , Delivery of Health Care/standards , Patient Preference , Physical Distancing , Telemedicine/standards , Therapeutic Alliance , Adult , COVID-19/prevention & control , Female , Humans , Male , Middle Aged , United States , United States Department of Veterans Affairs , Veterans
17.
Med Care ; 59(Suppl 3): S259-S269, 2021 06 01.
Article in English | MEDLINE | ID: covidwho-1225638

ABSTRACT

BACKGROUND: In the unique context of rural Veterans' health care needs, expansion of US Department of Veterans Affairs and Community Care programs under the MISSION Act, and the uncertainties of coronavirus disease 2019 (COVID-19), it is critical to understand what may support effective interorganizational care coordination for increased access to high-quality care. OBJECTIVES: We conducted a systematic review to examine the interorganizational care coordination initiatives that Veterans Affairs (VA) and community partners have pursued in caring for rural Veterans, including challenges and opportunities, organizational domains shaping care coordination, and among these, initiatives that improve or impede health care outcomes. RESEARCH DESIGN: We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to search 2 electronic databases (PubMed and Embase) for peer-reviewed articles published between January 2009 and May 2020. Building on prior research, we conducted a systematic review. RESULTS: Sixteen articles met our criteria. Each captured a unique health care focus while examining common challenges. Four organizational domains emerged: policy and administration, culture, mechanisms, and relational practices. Exemplars highlight how initiatives improve or impede rural health care delivery. CONCLUSIONS: This is the first systematic review, to our knowledge, examining interorganizational care coordination of rural Veterans by VA and Community Care programs. Results provide exemplars of interorganizational care coordination domains and program effectiveness. It suggests that partners' efforts to align their coordination domains can improve health care, with rurality serving as a critical contextual factor. Findings are important for policies, practices, and research of VA and Community Care partners committed to improving access and health care for rural Veterans.


Subject(s)
Continuity of Patient Care/organization & administration , Health Services Accessibility , Quality of Health Care , Rural Health Services/organization & administration , Veterans Health Services/organization & administration , Humans , Organizational Culture , Organizational Policy , Program Evaluation , United States , United States Department of Veterans Affairs/legislation & jurisprudence
19.
Am J Health Syst Pharm ; 78(13): 1216-1222, 2021 06 23.
Article in English | MEDLINE | ID: covidwho-1182989

ABSTRACT

PURPOSE: The potentially vast supply of unused opioids in Americans' homes has long been a public health concern. We conducted a needs assessment of how Veterans Affairs (VA) facilities address and manage disposal of unused opioid medications to identify opportunities for improvement. METHODS: We used rapid qualitative content analysis methods with team consensus to synthesize findings. Data were collected in 2 waves: (1) semistructured interviews with 19 providers in October 2019 and (2) structured questions to 21 providers in March to April of 2020 addressing how coronavirus disease 2019 (COVID-19) changed disposal priorities. RESULTS: While many diverse strategies have been tried in the VA, we found limited standardization of advice on opioid disposal and practices nationally. Providers offered the following recommendations: target specific patient scenarios for enhanced disposal efforts, emphasize mail-back envelopes, keep recommendations to providers and patients consistent and reinforce existing guidance, explore virtual modalities to monitor disposal activity, prioritize access to viable disposal strategies, and transition from pull to push communication. These themes were identified in the fall of 2019 and remained salient in the context of the COVID-19 pandemic. CONCLUSION: A centralized VA national approach could include proactive communication with patients and providers, interventions tailored to specific settings and populations, and facilitated access to disposal options. All of the above strategies are feasible in the context of an extended period of social distancing.


Subject(s)
Analgesics, Opioid , COVID-19/drug therapy , Medical Waste Disposal/methods , Medical Waste Disposal/standards , Quality Improvement , United States Department of Veterans Affairs , Humans , Interviews as Topic , Qualitative Research , SARS-CoV-2 , United States
20.
J Am Med Dir Assoc ; 22(3): 682-688, 2021 03.
Article in English | MEDLINE | ID: covidwho-761756

ABSTRACT

OBJECTIVE: This study aimed to further knowledge of older Veterans' experiences with transitioning to the community from Veterans Affairs nursing homes (Community Living Centers or CLCs) with emphasis on social functioning. DESIGN: A qualitative study design was used in addition to administration of standardized depression and mental status screens. SETTING AND PARTICIPANTS: Veterans (n = 18) and caregivers (n = 14) were purposively sampled and recruited from 2 rural CLCs in Upstate New York. METHODS: Semistructured interviews were completed with Veterans in the CLC prior to discharge (to explore experiences during the CLC stay and expectations regarding discharge and returning home) and in the home 2-4 weeks postdischarge (to explore daily routines and perceptions of overall health, mental health, and social functioning). Caregivers participated in 1 interview, completed postdischarge. The 9-item Patient Health Questionnaire and the Brief Interview for Mental Status were administered postdischarge. RESULTS: Thematic analysis of verbatim transcriptions revealed 3 inter-related themes: (1) Veterans may experience improved social connectedness in CLCs by nature of the unique care environment (predominantly male, shared military experience); (2) Experiences of social engagement and connectedness varied after discharge and could be discordant with Veterans' expectations for recovery prior to discharge; and (3) Veterans may or may not describe themselves as "lonely" after discharge, when physically isolated. Veterans lacked moderate to severe cognitive impairment (Brief Interview for Mental Status: range = 14-15); however, they reported a wide range in depressive symptom severity postdischarge (9-item Patient Health Questionnaire: mean = 4.9, SD = 6.1, median/mode = 3, range = 0-23). CONCLUSIONS AND IMPLICATIONS: This study identified a potential for increased social isolation and disengagement after discharge from Veterans Affairs nursing homes. Nursing homes should integrate social functioning assessment for their residents, while extending care planning and transitional care to address patient-centered social functioning goals.


Subject(s)
Veterans , Aftercare , Humans , Male , New York , Nursing Homes , Patient Discharge , Patient Transfer , United States , United States Department of Veterans Affairs
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