Excess mortality in the general population versus Veterans Healthcare System during the first year of the COVID-19 pandemic in the United States (preprint)

Importance The COVID-19 pandemic had a substantial impact on the overall rate of death in the United States during the first year. It is unclear whether access to comprehensive medical care, such as through the VA healthcare system, altered death rates compared to the US population. Objective: Quantify the increase in death rates during the first year of the COVID-19 pandemic in the general US population and among individuals who receive comprehensive medical care through the Department of Veterans Affairs (VA). Design: Analysis of changes in all-cause death rates by quarter, stratified by age, sex race/ethnicity, and region, based on individual-level data. Hierarchical regression models were fit in a Bayesian setting. Standardized rates were used for comparison between populations. Setting and participants: General population of the United States, enrollees in the VA, and active users of VA healthcare. Exposure and main outcome: Changes in rates of death from any cause during the COVID-19 pandemic in 2020 compared to previous years. Results Sharp increases were apparent across all of the adult age groups (25 years and older) in both the general US population and the VA populations. Across all of 2020, the relative increase in death rates was similar in the general US population (RR: 1.20 (95% CI: 1.17, 1.22)), VA enrollees (RR: 1.20 (95% CI: 1.14, 1.29)), and VA active users (RR: 1.19 (95% CI: 1.14, 1.26)). Because the pre-pandemic standardized mortality rates were higher in the VA populations prior to the pandemic, the absolute rates of excess mortality were higher in the VA populations. Conclusions and Relevance: Despite access to comprehensive medical care, active users of the VA had similar relative mortality increases from all causes compared with the general US population. Factors that influenced baseline rates of death and that mitigated viral transmission in the community are more likely to have influenced the impact of the pandemic.

Encounters after Appointments Cancelled Due to COVID-19 in the Veterans Affairs Health Care System (preprint)

This statistical brief examines subsequent encounters after a cancellation due to COVID-19 in the Veterans Affairs System. We find that he vast majority of VA patients that had appointments cancelled in mid-March to mid-April of 2020 had another encounter within 180 days. The most common next encounter was a virtual visit with a VA provider on the same day of the original appointment. We also find that patients that saw a provider through VA community care had a lower median time to next encounter.

The COVID-19 pandemic shifted the Veterans Affairs System toward being a payer and virtual care provider: is it sustainable? (preprint)

Objective: To examine how VA shifted care delivery methods one year into the pandemic. Study Setting: All encounters paid or provided by VA between January 1, 2019 and February 27, 2021. Study Design: We aggregated all VA paid or provided encounters and classified them into community (non-VA) acute and non-acute visits, VA acute and non-acute visits, and VA virtual visits. We then compared the number of encounters by week over time to pre-pandemic levels. Data Extraction Methods: Aggregation of administrative VA claims and health records. Principal Findings: VA has experienced a dramatic and persistent shift to providing virtual care and purchasing care from non-VA providers. Before the pandemic, a majority (63%) of VA care was provided in-person at a VA facility. One year into the pandemic, in-person care at VA's constituted just 33% of all visits. Most of the difference made up by large expansions of virtual care; total VA provided visits (in person and virtual) declined (4.9 million to 4.2 million) while total visits of all types declined only 3.5%. Community provided visits exceeded prepandemic levels (2.3 million to 2.9 million, +26%). Conclusion: Unlike private health care, VA has resumed in-person care slowly at its own facilities, and more rapidly in purchased care with different financial incentives a likely driver. The very large expansion of virtual care nearly made up the difference. With a widespread physical presence across the U.S., this has important implications for access to care and future allocation of medical personnel, facilities, and resources.

The Association Between Alpha-1 Adrenergic Receptor Antagonists and In-Hospital Mortality from COVID-19 (preprint)

Effective therapies for coronavirus disease 2019 (COVID-19) are urgently needed, and preclinical data suggest alpha-1 adrenergic receptor antagonists (1-AR antagonists) may be effective in reducing mortality related to hyperinflammation independent of etiology. Using a retrospective cohort design with patients in the Department of Veterans Affairs healthcare system, we use doubly robust regression and matching to estimate the association between baseline use of 1-AR antagonists and likelihood of death due to COVID-19 during hospitalization. Having an active prescription for any 1-AR antagonist (tamsulosin, silodosin, prazosin, terazosin, doxazosin, or alfuzosin) at the time of admission had a significant negative association with in-hospital mortality (relative risk reduction 18%; odds ratio 0.73; 95% CI 0.63 to 0.85; p [≤] 0.001) and death within 28 days of admission (relative risk reduction 17%; odds ratio 0.74; 95% CI 0.65 to 0.84; p [≤] 0.001). In a subset of patients on doxazosin specifically, an inhibitor of all three alpha-1 adrenergic receptors, we observed a relative risk reduction for death of 74% (odds ratio 0.23; 95% CI 0.03 to 0.94; p = 0.028) compared to matched controls not on any 1-AR antagonist at the time of admission. These findings suggest that use of 1-AR antagonists may reduce mortality in COVID-19, supporting the need for randomized, placebo-controlled clinical trials in patients with early symptomatic infection.