key: cord-0994068-xxug1v0k
authors: Aboumrad, Maya; Shiner, Brian; Riblet, Natalie; Huizenga, Hugh; Neupane, Nabin; Young-Xu, Yinong
title: A national analysis of trends in COVID-19 infection and clinical management in Veterans Health Administration medical facilities
date: 2021-01-18
journal: bioRxiv
DOI: 10.1101/2021.01.18.427092
sha: bec3a76b5094bcb9dfcf95aec8e2fd64e6651c67
doc_id: 994068
cord_uid: xxug1v0k

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 43,267 patients diagnosed with COVID-19 in the 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 a nonparametric rank-sum test for trend to examine any differences in the distribution of our study variables across the six months. RESULTS During our study period, 8,240 patients were hospitalized, and 1,081 (13.1%) died within 30 days of admission. Hospitalizations increased over time, but the proportion of patients that died consistently declined from March (N=221/890, 24.8%) to August (N=111/1,396, 8.0%). Patients hospitalized in March compared to August were younger on average, mostly black, and symptomatic. 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, receipt of mechanical ventilation and Hydroxychloroquine declined from March to August, while treatment with Dexamethasone and Remdesivir increased. CONCLUSION We found evidence of declining COVID-19 severity and fatality over time within a national health care system.

To address this knowledge gap, we explored potential trends and patterns in 143 infection rates among all U.S. Veterans Health Administration (VHA) users diagnosed 144 with COVID-19, and clinical management for those that were subsequently hospitalized 145 at VHA medical facilities during the initial six months of the pandemic. Specifically, our 146 objectives were to describe any changes from March 1, 2020 to August 30, 2020 in 1) 147 sociodemographic characteristics, 2) reported symptoms, 3) laboratory findings, 4) 148 pharmacological and non-pharmacological treatment, 5) 30-day in-hospital mortality, and 149 6) comorbidities among both hospitalized and in-hospital deceased patients. As the 150 nation's largest integrated health care system, the VHA was required to respond to 151 COVID-19 in all geographic regions. 21 10.1 (10.9) 10.8 (11.9) 11.8 (12.4) 10.6 (11.7) 9.6 (9.9) 9.3 (9. 

Patient Characteristics: We examined sociodemographic characteristics at the time of 196 hospitalization for COVID-19 including age, sex, race/ethnicity, urbanicity of residence, 197 and VHA priority rating (1-8). VHA priority group served as a proxy for socioeconomic 198 status (SES) as it is partially based on income and the capacity for gainful employment. It 199 is also connected to service-related disability, reflecting both health and VHA coverage

Symptoms: We examined COVID-related symptoms within 30 days preceding 204 hospitalization for COVID-19 including abdominal pain, chills, common cold, cough, 205 diarrhea, dyspnea, fatigue, fever, headache, myalgia, nausea, and sore throat

Laboratory Values: We examined laboratory values within seven days following 208 hospitalization for COVID-19 including white blood cell count (WBC), absolute 209 lymphocyte count (LC), platelet count (PC), creatinine, blood urea nitrogen (BUN), total 8 210 bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), ferritin, 211 lactate, troponin I

Treatments: We examined receipt of any relevant/concomitant pharmacological and non-215 pharmacological treatment(s) during the course of patients' hospitalization

Pharmacological treatment included angiotensin-converting enzyme (ACE) inhibitors

Azithromycin combined with Hydroxychloroquine, beta-blockers, 219 bronchodilators, corticosteroids

non-steroidal anti-inflammatory drugs (NSAIDs), statins, and/or 221 vasopressors. 29,30 Non-pharmacological treatment included mechanical ventilation, 222 dialysis

Comorbidities: We examined the presence of clinical comorbidities within 12 months 225 preceding hospitalization for COVID-19 according to the Charlson Comorbidity Index 226 (CCI). The CCI score is a validated

For all VHA users with laboratory-confirmed COVID-19, we reported the of 43,267 VHA users with laboratory-confirmed COVID-19 during 246 our study period. Of these cases, 5.4% (N=2,344) were diagnosed in March

Patient characteristics among VHA users hospitalized with COVID-19

1% (N=1,081) experienced in-hospital 253 mortality within 30-days of admission. The proportion of hospitalized patients increased 254 overall (P trend <0.001) and fluctuated over time

The majority resided in an urban area 260 (N=6,815, 82.7%), and close to 40% (N=3,189) had a priority rating of 5-6. The average 261 age of hospitalized patients increased overall from March (M=67.4, SD=13.0) to August 262 (M=68.4, SD=13.5), and patients aged 60 years and older consistently represented at least 263 70% of hospitalizations (P trend =0.001)

Close to one-half (N=3,774, 45.8%) of hospitalized patients were treated with 319 corticosteroids, the use of which significantly increased

Dexamethasone represented 65% (N=2,433/3,774) of corticosteroids overall and 321 increased from 14% (N=33/245) in March to

Among antivirals, Hydroxychloroquine was 324 the most commonly used treatment in March (N=492/529, 93.0%) and April (N=514/577, 325 89.1%), while treatment with Remdesivir dramatically increased from May

This was 328 common in March (N=370/890, 41.6%), but dropped to less than 1% by August 329 (P trend <0.001)

Close to one-fifth (N=1,461, 17.7%) of hospitalized patients received mechanical 332 ventilation

WBC=White Blood Cell Count; LC=Lymphocyte Count; PC=Platelet Count; BUN=Blood Urea Nitrogen; AST=Aspartate Aminotransferase; ALT=Alanine Aminotransferase; BNP=Brain-type Natriuretic Peptide; CRP=C-reactive Protein. * Laboratory values were examined within seven days following hospitalization for

Patients hospitalized in March 348 compared to later months were younger, mostly black, urban-dwelling, symptomatic, and 349 more likely to present with abnormal laboratory findings. They also had worse overall 350 health as indicated by higher CCI scores and frequency of baseline comorbidities. Lastly, 351 we observed a decline in use of intensive

Many prior studies have worked to identify risk factors for COVID-19 infection, 355 severity, and fatality. 1,3-18 Literature published early on in the pandemic, as well as more 356 recent studies, have consistently reported an elevated risk of both testing positive and 357 severe or fatal disease among older populations (age 65 years) after adjusting for 358 sociodemographic characteristics and comorbidities

Therefore, containing disease spread may require more ubiquitous 364 government restrictions and policies including testing, contact tracing, social distancing 365 and work-from-home guidelines

hospital mortality and treatment-related indicators of severe illness

while use of more evidence-backed treatments such as Dexamethasone and 374 Remdesivir significantly increased. 11,19,33,34 375 In addition to older age, prior work has documented evidence of increased risk for

Although the risk factors. In our study, patients hospitalized in March 381 compared to later months had more exacerbating symptoms (e.g., fever, dyspnea, cough) 382 and evidence of biomarkers on inflammation, infection, cardiac and muscle injury, 383 decreased liver and kidney function. 4,7,13,14,28 Additionally, we found that both 384 hospitalized and deceased patients had more underlying comorbidities in March 385 compared to later months including severe cardiovascular diseases, diabetes

Lastly, various studies have reported elevated hospitalization and mortality rates 394 among black compared to white patients with COVID-19, citing differences in access and 395 quality of care, more underlying comorbidities, and lower SES as potential reasons for 396 these disparities

317 VHA patients with COVID-19 found 408 evidence of greater adjusted risk for contracting COVID-19 among racial and ethnic 409 minorities, but no difference in 30-day mortality. 5 Unlike the general U.S. population, all 410 patients treated within the VHA have insurance coverage, and could readily seek high 411 quality health care and treatment services if needed. 5,13,40 Therefore, in addition to 20 that is older, medically complex, and have greater risk behaviors compared to 419 the general U.S. population. 41 However, prior work has found no evidence of differences 420 in comorbidity burden between VHA and non-VHA users after controlling for age, sex, 421 race, geographic region, and urbanicity of residence. 24 Additionally, the frequency and 422 type of comorbidities identified in this study are similar to those reported among non-423 VHA patients hospitalized with COVID-19. 15-17 Therefore, our findings may still be 424 generalizable to the larger U.S. population. Our analysis was limited to patients 425 diagnosed and hospitalized for COVID-19 within the VHA health care system and may 426 not capture cases, hospitalizations, treatments received, or deaths occurring at non-VHA 427 facilities. We reported the month-to-month and cumulative disease burden on the VHA, 428 which may not account for regional differences in sociodemographic characteristics, 429 government restrictions and policies, or the magnitude and timing of case peaks. Future COVID-19 severity and 30-day in-hospital mortality

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