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1.
PLoS One ; 16(12): e0261921, 2021.
Article in English | MEDLINE | ID: covidwho-1635925

ABSTRACT

Universal screening for suicidal ideation in primary care and mental health settings has become a key prevention tool in many healthcare systems, including the Veterans Healthcare Administration (VHA). In response to the coronavirus pandemic, healthcare providers faced a number of challenges, including how to quickly adapt screening practices. The objective of this analyses was to learn staff perspectives on how the pandemic impacted suicide risk screening in primary care and mental health settings. Forty semi-structured interviews were conducted with primary care and mental health staff between April-September 2020 across 12 VHA facilities. A multi-disciplinary team employed a qualitative thematic analysis using a hybrid inductive/deductive approach. Staff reported multiple concerns for patients during the crisis, especially regarding vulnerable populations at risk for social isolation. Lack of clear protocols at some sites on how to serve patients screening positive for suicidal ideation created confusion for staff and led some sites to temporarily stop screening. Sites had varying degrees of adaptability to virtual based care, with the biggest challenge being completion of warm hand-offs to mental health specialists. Unanticipated opportunities that emerged during this time included increased ability of patients and staff to conduct virtual care, which is expected to continue benefit post-pandemic.


Subject(s)
COVID-19/epidemiology , COVID-19/psychology , Health Personnel , Mass Screening/methods , Pandemics , SARS-CoV-2 , Suicidal Ideation , Veterans Health , Veterans/psychology , COVID-19/prevention & control , COVID-19/virology , Humans , Mental Health , Physical Distancing , Primary Health Care , Risk Assessment/methods , Telemedicine/methods
3.
BMJ Open ; 11(10): e049134, 2021 10 04.
Article in English | MEDLINE | ID: covidwho-1450602

ABSTRACT

OBJECTIVE: Early in the COVID-19 pandemic, US Veterans Health Administration (VHA) employee occupational health (EOH) providers were tasked with assuming a central role in coordinating employee COVID-19 screening and clearance for duty, representing entirely novel EOH responsibilities. In a rapid qualitative needs assessment, we aimed to identify learnings from the field to support the vastly expanding role of EOH providers in a national healthcare system. METHODS: We employed rapid qualitative analysis of key informant interviews in a maximal variation sample on the parameters of job type, rural versus urban and provider gender. We interviewed 21 VHA EOH providers between July and December 2020. This sample represents 15 facilities from diverse regions of the USA (large, medium and small facilities in the Mid-Atlantic; medium sites in the South; large facilities in the West and Pacific Northwest). RESULTS: Five interdependent needs included: (1) infrastructure to support employee population management, including tools that facilitate infection control measures such as contact tracing (eg, employee-facing electronic health records and coordinated databases); (2) mechanisms for information sharing across settings (eg, VHA listserv), especially for changing policy and protocols; (3) sufficiently resourced staffing using detailing to align EOH needs with human resource capital; (4) connected and resourced local and national leaders; and (5) strategies to support healthcare worker mental health.Our identified facilitators for EOH assuming new challenging and dynamically changing roles during COVID-19 included: (A) training or access to expertise; (B) existing mechanisms for information sharing; (C) flexible and responsive staffing; and (D) leveraging other institutional expertise not previously affiliated with EOH (eg, chaplains to support bereavement). CONCLUSIONS: Our needs assessment highlights local and system level barriers and facilitators of EOH assuming expanded roles during COVID-19. Integrating changes both within and across systems and with alignment of human capital will enable EOH preparedness for future challenges.


Subject(s)
COVID-19 , Occupational Health , Health Personnel , Humans , Needs Assessment , Pandemics , SARS-CoV-2 , Veterans Health , Workforce
5.
PLoS One ; 16(7): e0246217, 2021.
Article in English | MEDLINE | ID: covidwho-1331980

ABSTRACT

OBJECTIVE: We explored longitudinal trends in sociodemographic characteristics, reported symptoms, laboratory findings, pharmacological and non-pharmacological treatment, comorbidities, and 30-day in-hospital mortality among hospitalized patients with coronavirus disease 2019 (COVID-19). METHODS: This retrospective cohort study included patients diagnosed with COVID-19 in the United States Veterans Health Administration between 03/01/20 and 08/31/20 and followed until 09/30/20. We focused our analysis on patients that were subsequently hospitalized, and categorized them into groups based on the month of hospitalization. We summarized our findings through descriptive statistics. We used Cuzick's Trend Test to examine any differences in the distribution of our study variables across the six months. RESULTS: During our study period, we identified 43,267 patients with COVID-19. A total of 8,240 patients were hospitalized, and 13.1% (N = 1,081) died within 30 days of admission. Hospitalizations increased over time, but the proportion of patients that died consistently declined from 24.8% (N = 221/890) in March to 8.0% (N = 111/1,396) in August. Patients hospitalized in March compared to August were younger on average, mostly black, urban-dwelling, febrile and dyspneic. They also had a higher frequency of baseline comorbidities, including hypertension and diabetes, and were more likely to present with abnormal laboratory findings including low lymphocyte counts and elevated creatinine. Lastly, there was a decline from March to August in receipt of mechanical ventilation (31.4% to 13.1%) and hydroxychloroquine (55.3% to <1.0%), while treatment with dexamethasone (3.7% to 52.4%) and remdesivir (1.1% to 38.9%) increased. CONCLUSION: Among hospitalized patients with COVID-19, we observed a trend towards decreased disease severity and mortality over time.


Subject(s)
COVID-19/mortality , Veterans Health/statistics & numerical data , Adenosine Monophosphate/analogs & derivatives , Adenosine Monophosphate/therapeutic use , Aged , Aged, 80 and over , Alanine/analogs & derivatives , Alanine/therapeutic use , COVID-19/drug therapy , Comorbidity , Dexamethasone/therapeutic use , Female , Hospital Mortality , Hospitalization/statistics & numerical data , Humans , Longitudinal Studies , Lymphocyte Count , Lymphocytes/immunology , Male , Middle Aged , Respiration, Artificial/methods , Retrospective Studies , United States
6.
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
7.
PLoS One ; 16(5): e0251651, 2021.
Article in English | MEDLINE | ID: covidwho-1226903

ABSTRACT

BACKGROUND: The risk factors associated with the stages of Coronavirus Disease-2019 (COVID-19) disease progression are not well known. We aim to identify risk factors specific to each state of COVID-19 progression from SARS-CoV-2 infection through death. METHODS AND RESULTS: We included 648,202 participants from the Veteran Affairs Million Veteran Program (2011-). We identified characteristics and 1,809 ICD code-based phenotypes from the electronic health record. We used logistic regression to examine the association of age, sex, body mass index (BMI), race, and prevalent phenotypes to the stages of COVID-19 disease progression: infection, hospitalization, intensive care unit (ICU) admission, and 30-day mortality (separate models for each). Models were adjusted for age, sex, race, ethnicity, number of visit months and ICD codes, state infection rate and controlled for multiple testing using false discovery rate (≤0.1). As of August 10, 2020, 5,929 individuals were SARS-CoV-2 positive and among those, 1,463 (25%) were hospitalized, 579 (10%) were in ICU, and 398 (7%) died. We observed a lower risk in women vs. men for ICU and mortality (Odds Ratio (95% CI): 0.48 (0.30-0.76) and 0.59 (0.31-1.15), respectively) and a higher risk in Black vs. Other race patients for hospitalization and ICU (OR (95%CI): 1.53 (1.32-1.77) and 1.63 (1.32-2.02), respectively). We observed an increased risk of all COVID-19 disease states with older age and BMI ≥35 vs. 20-24 kg/m2. Renal failure, respiratory failure, morbid obesity, acid-base balance disorder, white blood cell diseases, hydronephrosis and bacterial infections were associated with an increased risk of ICU admissions; sepsis, chronic skin ulcers, acid-base balance disorder and acidosis were associated with mortality. CONCLUSIONS: Older age, higher BMI, males and patients with a history of respiratory, kidney, bacterial or metabolic comorbidities experienced greater COVID-19 severity. Future studies to investigate the underlying mechanisms associated with these phenotype clusters and COVID-19 are warranted.


Subject(s)
COVID-19/epidemiology , Veterans Health , Age Factors , Aged , Aged, 80 and over , Body Mass Index , COVID-19/mortality , Disease Progression , Female , Hospitalization , Humans , Intensive Care Units , Longitudinal Studies , Male , Middle Aged , Risk Factors , SARS-CoV-2/isolation & purification , Sex Factors , United States/epidemiology , Veterans
8.
Obesity (Silver Spring) ; 29(5): 786-787, 2021 05.
Article in English | MEDLINE | ID: covidwho-1162914
9.
Am Heart J ; 237: 1-4, 2021 07.
Article in English | MEDLINE | ID: covidwho-1141561

ABSTRACT

Patients with coronavirus disease 2019 (COVID-19) are at heightened risk of venous thromboembolic events (VTE), though there is no data examining when these events occur following a COVID-19 diagnosis. We therefore sought to characterize the incidence, timecourse of events, and outcomes of VTE during the COVID-19 pandemic in a national healthcare system using data from Veterans Affairs Administration.


Subject(s)
Anticoagulants/administration & dosage , COVID-19 , Venous Thromboembolism , Veterans Health/statistics & numerical data , Aged , COVID-19/complications , COVID-19/epidemiology , COVID-19/therapy , COVID-19 Nucleic Acid Testing , Chemoprevention/methods , Chemoprevention/statistics & numerical data , Female , Hospitalization/statistics & numerical data , Humans , Incidence , Male , Outcome Assessment, Health Care , Risk Assessment/statistics & numerical data , Risk Factors , SARS-CoV-2/isolation & purification , United States/epidemiology , Venous Thromboembolism/epidemiology , Venous Thromboembolism/etiology , Venous Thromboembolism/therapy
10.
Obesity (Silver Spring) ; 29(5): 825-828, 2021 05.
Article in English | MEDLINE | ID: covidwho-1139281

ABSTRACT

OBJECTIVE: The purpose of this study was to assess associations between BMI and severe coronavirus disease 2019 (COVID-19) outcomes: hospitalization, intensive care unit (ICU) admission, and mortality. A secondary aim was to investigate whether associations varied by age. METHODS: The cohort comprised patients in the Veterans Health Administration (VHA) who tested positive for COVID-19 (N = 9,347). For each outcome, we fit piecewise logistic regression models with restricted cubic splines (knots at BMI of 23, 30, and 39), adjusting for age, sex, comorbidities, VHA nursing home residence, and race/ethnicity. Supplemental analyses included age-by-BMI interaction terms (α = 0.05). RESULTS: We found evidence of a nonlinear J-curve association between BMI and likelihood of hospitalization and mortality. BMI was associated with increased odds for hospitalization, ICU admission, and mortality among patients with BMI 30 to 39 but decreased odds of hospitalization and mortality for patients with BMI 23 to 30. Patients under age 75 with BMI between 30 and 39 had increased odds for mortality with increasing BMI. CONCLUSIONS: Odds for severe outcomes with COVID-19 infection increased with increasing BMI for people with, but not without, obesity. This nonlinear relationship should be tested in future research. COVID-19 public health messages in VHA, and broadly, should incorporate information about risks associated with all classes of obesity, particularly for those under age 75.


Subject(s)
Body Mass Index , COVID-19/epidemiology , Veterans/statistics & numerical data , Aged , Cohort Studies , Comorbidity , Female , Hospitalization , Humans , Intensive Care Units , Logistic Models , Male , Middle Aged , Obesity/complications , Risk Factors , United States/epidemiology , Veterans Health , Veterans Health Services
13.
Diagn Microbiol Infect Dis ; 100(1): 115312, 2021 May.
Article in English | MEDLINE | ID: covidwho-1039330

ABSTRACT

Reporting of Coronavirus disease 2019 (COVID-19) co-infections with other respiratory pathogens has varied. We evaluated 825,280 molecular and/or viral culture respiratory assays within the Veterans Health Administration from September 29, 2019 to May 31, 2020. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was detected in 10,222 of 174,746 (5.8%) individuals. 30,063 (17.2%) of 174,746 individuals tested for SARS-CoV-2 had additional respiratory pathogen testing; co-infection was identified in 56 of 3757 (1.5%) individuals positive for SARS-CoV-2. Among those negative for SARS-CoV-2, 1022 of 26,306 (3.9%) were positive for at least 1 respiratory pathogen. Compared to COVID-19 mono-infection, individuals with COVID-19 co-infection had lower odds of being female. Compared to non-COVID-19 respiratory pathogen infection, individuals with COVID-19 co-infection had lower odds of being female, were hospitalized more frequently, had higher odds of death, and were younger at death. Our findings suggest COVID-19 co-infections were rare; however, not all COVID-19 patients were concurrently tested for other respiratory pathogens and seasonal decreases in other respiratory pathogens were occurring as COVID-19 emerged.


Subject(s)
COVID-19/epidemiology , Respiratory Tract Infections/epidemiology , Veterans Health/statistics & numerical data , Adolescent , Adult , Aged , Aged, 80 and over , Child , Child, Preschool , Coinfection/epidemiology , Female , Humans , Influenza, Human/epidemiology , Male , Middle Aged , Prevalence , Respiratory Tract Infections/microbiology , Respiratory Tract Infections/virology , United States/epidemiology , United States Department of Veterans Affairs , Veterans Health Services , Young Adult
14.
PLoS Med ; 18(1): e1003490, 2021 01.
Article in English | MEDLINE | ID: covidwho-1021593

ABSTRACT

BACKGROUND: The COVID-19 epidemic in the United States is widespread, with more than 200,000 deaths reported as of September 23, 2020. While ecological studies show higher burdens of COVID-19 mortality in areas with higher rates of poverty, little is known about social determinants of COVID-19 mortality at the individual level. METHODS AND FINDINGS: We estimated the proportions of COVID-19 deaths by age, sex, race/ethnicity, and comorbid conditions using their reported univariate proportions among COVID-19 deaths and correlations among these variables in the general population from the 2017-2018 National Health and Nutrition Examination Survey (NHANES). We used these proportions to randomly sample individuals from NHANES. We analyzed the distributions of COVID-19 deaths by race/ethnicity, income, education level, and veteran status. We analyzed the association of these characteristics with mortality by logistic regression. Summary demographics of deaths include mean age 71.6 years, 45.9% female, and 45.1% non-Hispanic white. We found that disproportionate deaths occurred among individuals with nonwhite race/ethnicity (54.8% of deaths, 95% CI 49.0%-59.6%, p < 0.001), individuals with income below the median (67.5%, 95% CI 63.4%-71.5%, p < 0.001), individuals with less than a high school level of education (25.6%, 95% CI 23.4% -27.9%, p < 0.001), and veterans (19.5%, 95% CI 15.8%-23.4%, p < 0.001). Except for veteran status, these characteristics are significantly associated with COVID-19 mortality in multiple logistic regression. Limitations include the lack of institutionalized people in the sample (e.g., nursing home residents and incarcerated persons), the need to use comorbidity data collected from outside the US, and the assumption of the same correlations among variables for the noninstitutionalized population and COVID-19 decedents. CONCLUSIONS: Substantial inequalities in COVID-19 mortality are likely, with disproportionate burdens falling on those who are of racial/ethnic minorities, are poor, have less education, and are veterans. Healthcare systems must ensure adequate access to these groups. Public health measures should specifically reach these groups, and data on social determinants should be systematically collected from people with COVID-19.


Subject(s)
COVID-19/mortality , Healthcare Disparities/standards , Public Health , Social Determinants of Health/statistics & numerical data , Socioeconomic Factors , Aged , Comorbidity , Female , Health Services Needs and Demand , Humans , Male , Mortality , Public Health/methods , Public Health/standards , Quality Improvement/organization & administration , SARS-CoV-2/isolation & purification , United States , Veterans Health/statistics & numerical data
16.
Ann Epidemiol ; 55: 10-14, 2021 03.
Article in English | MEDLINE | ID: covidwho-978209

ABSTRACT

PURPOSE: Veterans represent a significant proportion of the U.S. population (7%), and the impact of the coronavirus disease 2019 (COVID-19) in this group of vulnerable patients has been largely overlooked. This analysis reports COVID-19 patient demographics, infection, mortality, and case-fatality rates in the veteran population. METHODS: This is a cross-sectional analysis using the Veterans Affairs informatics and computing infrastructure tool to assess the veterans' COVID-19 infections at the Veterans Affairs facilities from March 4th to June 23rd, 2020. RESULTS: Of the 10,621,580 veterans in this analysis, 59.7% were ≥65 yo, 92.5% were men, 68.7% were white, and 14.2% were black. Veterans ≥65 yo comprised 52.1% of cases and 89.9% of deaths. The relative mortality and case-fatality rates of black veterans, when compared with white veterans, were 2.83 (CI 2.56-3.14; P < .001) and 0.75 (CI 0.68-0.82; P < .001), respectively. Among the veterans who died from COVID-19, 87.4% had a history of cardiovascular disease, 56.5% had a history of diabetes, and 33.6% were obese. CONCLUSIONS: Elderly veterans (≥65yo) and veterans with a history of cardiovascular disease represent a large proportion of the VA COVID-19 cases and deaths. Black veterans had higher mortality rates but lower case fatality rates when than white veterans.


Subject(s)
COVID-19/epidemiology , Veterans , Adolescent , Adult , Aged , Aged, 80 and over , COVID-19/mortality , Cardiovascular Diseases/epidemiology , Cross-Sectional Studies , Female , Humans , Male , Middle Aged , United States/epidemiology , United States Department of Veterans Affairs , Veterans Health , Young Adult
18.
J Psychiatr Res ; 143: 504-507, 2021 11.
Article in English | MEDLINE | ID: covidwho-939091

ABSTRACT

Posttraumatic stress disorder (PTSD) is associated with coronavirus disease 2019 (COVID-19) risk factors, such as hypertension and obesity. Associations between PTSD and COVID-19 outcomes may affect Veterans Health Administration (VA) services, as PTSD occurs at higher rates among veterans than the general population. While previous research has identified the potential for increased PTSD prevalence resulting from COVID-19 as a public health concern, no known research examines the effect of pre-existing PTSD on COVID-19 test-seeking behavior or infection. This study aimed to evaluate pre-existing PTSD as a predictor of COVID-19 testing and test positivity. The sample consisted of 6,721,407 veterans who sought VA care between March 1, 2018 and February 29, 2020. Veterans with a previous PTSD clinical diagnosis were more likely to receive COVID-19 testing than veterans without PTSD. However, among those with available COVID-19 test results (n = 168,032), veterans with a previous PTSD clinical diagnosis were less likely to test positive than veterans without PTSD. Elevated COVID-19 testing rates among veterans with PTSD may reflect increased COVID-19 health concerns and/or hypervigilance. Lower rates of COVID-19 test positivity among veterans with PTSD may reflect increased social isolation, or overrepresentation in the tested population due to higher overall use of VA services. As the COVID-19 pandemic continues, the identification of patient-level psychiatric predictors of testing and test positivity can facilitate the targeted provision of medical and mental health services to individuals in need.


Subject(s)
COVID-19 , Stress Disorders, Post-Traumatic , Veterans , COVID-19 Testing , Humans , Pandemics , SARS-CoV-2 , Stress Disorders, Post-Traumatic/diagnosis , Stress Disorders, Post-Traumatic/epidemiology , United States/epidemiology , United States Department of Veterans Affairs , Veterans Health
19.
PLoS One ; 15(11): e0241825, 2020.
Article in English | MEDLINE | ID: covidwho-919031

ABSTRACT

BACKGROUND: Available COVID-19 mortality indices are limited to acute inpatient data. Using nationwide medical administrative data available prior to SARS-CoV-2 infection from the US Veterans Health Administration (VA), we developed the VA COVID-19 (VACO) 30-day mortality index and validated the index in two independent, prospective samples. METHODS AND FINDINGS: We reviewed SARS-CoV-2 testing results within the VA between February 8 and August 18, 2020. The sample was split into a development cohort (test positive between March 2 and April 15, 2020), an early validation cohort (test positive between April 16 and May 18, 2020), and a late validation cohort (test positive between May 19 and July 19, 2020). Our logistic regression model in the development cohort considered demographics (age, sex, race/ethnicity), and pre-existing medical conditions and the Charlson Comorbidity Index (CCI) derived from ICD-10 diagnosis codes. Weights were fixed to create the VACO Index that was then validated by comparing area under receiver operating characteristic curves (AUC) in the early and late validation cohorts and among important validation cohort subgroups defined by sex, race/ethnicity, and geographic region. We also evaluated calibration curves and the range of predictions generated within age categories. 13,323 individuals tested positive for SARS-CoV-2 (median age: 63 years; 91% male; 42% non-Hispanic Black). We observed 480/3,681 (13%) deaths in development, 253/2,151 (12%) deaths in the early validation cohort, and 403/7,491 (5%) deaths in the late validation cohort. Age, multimorbidity described with CCI, and a history of myocardial infarction or peripheral vascular disease were independently associated with mortality-no other individual comorbid diagnosis provided additional information. The VACO Index discriminated mortality in development (AUC = 0.79, 95% CI: 0.77-0.81), and in early (AUC = 0.81 95% CI: 0.78-0.83) and late (AUC = 0.84, 95% CI: 0.78-0.86) validation. The VACO Index allows personalized estimates of 30-day mortality after COVID-19 infection. For example, among those aged 60-64 years, overall mortality was estimated at 9% (95% CI: 6-11%). The Index further discriminated risk in this age stratum from 4% (95% CI: 3-7%) to 21% (95% CI: 12-31%), depending on sex and comorbid disease. CONCLUSION: Prior to infection, demographics and comorbid conditions can discriminate COVID-19 mortality risk overall and within age strata. The VACO Index reproducibly identified individuals at substantial risk of COVID-19 mortality who might consider continuing social distancing, despite relaxed state and local guidelines.


Subject(s)
Coronavirus Infections/mortality , Pneumonia, Viral/mortality , Adult , Age Factors , Aged , Aged, 80 and over , Area Under Curve , Betacoronavirus/isolation & purification , COVID-19 , Comorbidity , Coronavirus Infections/pathology , Coronavirus Infections/virology , Databases, Factual , Female , Humans , Logistic Models , Male , Middle Aged , Pandemics , Pneumonia, Viral/pathology , Pneumonia, Viral/virology , ROC Curve , Risk Factors , SARS-CoV-2 , Veterans Health , Young Adult
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