COVID-19 Infection in the Veterans Health Administration: Gender-specific Racial and Ethnic Differences

An Evidence Map of the Women Veterans' Health Literature, 2016 to 2023: A Systematic Review

Importance

Women veterans are the fastest-growing veteran subpopulation in the US. Women veterans often experience military service-related health issues in addition to conditions common to all women. Because women veterans are more likely to receive care in the civilian setting than through the Department of Veterans Affairs (VA), all women's health clinicians should be equipped to provide patient-centered care for women veterans. The health care of women veterans requires evidence-based care informed by population-specific scientific literature. An updated evidence map evaluating women veteran-focused health literature is needed.

Objective

To map the scope and breadth of women veterans' health literature published from 2016 to 2023.

Evidence Review

In this systematic review, MEDLINE, Embase, and CINAHL Complete were searched for eligible articles published from 2016 to 2023. Articles reporting about US women veterans' health outcomes or on the experience of providing care to women veterans were included. Included articles were required to report patient-level outcomes that included either data for only women veterans or reported results separately for women veterans. Articles were grouped by primary focus area based on categories previously established by the VA Women's Health research agendas and prior evidence maps.

Findings

The volume of women veterans' health literature published between 2016 and 2023 of 932 articles was double that of the prior 8 years. The largest portion of this literature was focused on chronic medical conditions (137 articles [15%]), general mental health (203 articles [22%]), and interpersonal violence (121 articles 3[13%]). Areas of greatest growth included reproductive health (physical and mental), pain, suicide, and nonsuicidal self-injury. Additionally, emerging areas of inquiry were found, including military-related toxic exposures and harassment within the health care setting.

Conclusions and Relevance

In this systematic review of literature focused on the health of women veterans, the volume of literature was found to have doubled and expanded in important areas that aligned with VA research priorities. However, despite the growth in research related to women veterans, several important research gaps remain within this field of study. Research addressing health issues pertinent to a growing and aging women veterans' population will require rigorous research and program evaluations.

Health and Health Care Use of American Indian/Alaska Native Women Veterans: A Scoping Review

BACKGROUND

American Indian/Alaska Native (AI/AN) women serve in the U.S. military, use Veterans Health Administration (VA) health care, and reside in rural areas at the highest rates compared with other women veterans. However, little is known about their unique health care needs, access, and health care use.

OBJECTIVE

We assessed the existing literature on the health and health care use of U.S. AI/AN women veterans.

METHODS

Online databases were searched to identify studies. Study characteristics extracted included health care topic, study design, overall sample size and number of AI/AN women veterans, and funding source. We screened 1,508 publications for inclusion; 28 publications were ultimately retained.

RESULTS

Health care access and use were the most common health care research topics (39%), followed by mental health (36%) and physical health (25%). Few studies considered the impact of rurality. Most studies found significant differences between AI/AN women veterans and other women veterans or AI/AN men veterans. Publication dates ranged from 1998 to 2023, with 71% published after 2010. The majority of studies (75%) were secondary analyses of extant health care data. More than three-quarters of studies (82%) were funded federally (e.g., VA). Many studies were based on VA administrative data, resulting in a gap in knowledge regarding AI/AN women veterans who are not eligible for, or choose not to use, VA health care.

CONCLUSION

Research to inform the health and health care of AI/AN women veterans is limited, especially in terms of known AI/AN and women veterans' prevalent health concerns (e.g., diabetes, hypertension), women's health and reproduction, and how AI/AN women veterans access, use, and confront barriers to health care. Moreover, there is scarce research specific to cultural, tribal, and regional factors that likely affect access and use of particular health care systems or that can affect perspectives on illness that impact long-term treatment adherence and patient outcomes.

Racial and Regional Disparities Surrounding In-Hospital Mortality among Patients with 2019 Novel Coronavirus Disease (COVID-19): Evidence from NIS Sample in 2020

OBJECTIVE

This study explores differences in COVID-19 in-hospital mortality rates by patient and geographic factors to identify at-risk populations and analyze how strained health disparities were exacerbated during the pandemic.

METHODS

The latest 2020 United States National Inpatient Sample (NIS) data was used to obtain a population-based estimate for patients with COVID-19. We conducted a cross-sectional retrospective data analysis, and sampling weights were used for all statistical analyses to represent nationwide in-hospital mortality of patients with COVID-19. We used multivariate logistic regression models to identify predictors for how patients with COVID-19 are associated with in-hospital death.

RESULTS

Of 200,531 patients, 88.9% did not have an in-hospital death (n=178,369), and 11.1% had in-hospital death (n=22,162). Patients older than 70 were 10 times more likely to have an in-hospital death than patients younger than 40 (p<0.001). Male patients were 37% more likely to have an in-hospital death than female patients (p<0.001). Hispanic patients were 25% more likely to have in-hospital deaths than White patients (p<0.001). In the sub-analysis, Hispanic patients in the 50-60, 60-70, and 70 age groups were 32%, 34%, and 24%, respectively, more likely to have in-hospital death than White patients (p<0.001). Patients with hypertension and diabetes were 69% and 29%, respectively, more likely to have in-hospital death than patients without hypertension and diabetes.

CONCLUSION

Health disparities in the COVID-19 pandemic occurred across races and regions and must be addressed to prevent future deaths. Age and comorbidities like diabetes have a well-established link to increased disease severity, and we have linked both to higher mortality risk. Low-income patients had a significantly increased risk of in-hospital death starting at over 40 years old.

Clinical Signs and Treatment of New-Onset Bone Marrow Failure Associated SARS-CoV-2 Infection in Children: A Single Institution Prospective Cohort Study

Background

Viral infections can cause direct and indirect damage to hematopoietic stem cells. The objectives of this study were to identify the frequency and severity of aplastic anemia in children infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as well as recognize the response to treatment.

Methodology

13 children with newly diagnosed severe aplastic anemia were enrolled in this prospective clinical trial. Blood samples were obtained from all patients to detect SARS-CoV-2 antibodies, and nasopharyngeal swabs were collected for reverse-transcription Polymerase Chain Reaction to detect SARS-CoV-2 viruses. According to the laboratory results, patients were classified as having SARS-CoV-2 positive antibodies and SARS-CoV-2 negative antibodies. Both groups received combined cyclosporine (CsA) + Eltrombopag (E-PAG). The hematological response, either complete response (CR) or partial response (PR), no response (NR), and overall response (OR) rates of combined E-PAG + CsA treatment after 6 months were evaluated.

Results

Four children were recognized to have aplastic anemia and SARS-CoV-2 positive antibodies. Two patients fulfilled the hematological criteria for CR and no longer required transfusion of packed red blood cells (PRBCs) or platelets, and one had PR and was still PRBC transfusion-dependent but no longer required platelet transfusion. The remaining patient showed NR, and he had died before reaching the top of the HSCT waiting list. Moreover, six patients in the SARS-CoV-2 negative antibodies group had CR, while three patients had PR. The difference in ANC, Hg, and platelet counts between both groups was not significant.

Conclusion

The SARS-CoV-2 virus is added to several viral infections known to be implicated in the pathogenesis of aplastic anemia. Studies are needed to establish a definitive association and determine whether the response of bone marrow failure to standard therapy differs from that of idiopathic cases.

VA Research and Operations Uniting to Combat COVID-19 Inequities

As novel coronavirus 2019 disease (COVID-19) began to spread across the United States in early 2020, health care systems faced extreme demands on resources. As the country's largest single-payer health care system, the U.S. Department of Veterans Affairs (VA) was uniquely positioned to study how the virus impacted different communities and work to improve care provided to all. Early on, a literature review of prior epidemics revealed that occupational exposures and an inability to socially distance could impact some groups more than others. The VA's Office of Health Equity leveraged a general sense of community to create a collaborative research space and a dedicated analytic space to inform pandemic operations. VA researchers and operations staff were able to quickly share information and respond to updates to produce accurate and reliable publications for medical professionals and the general public. Partnerships with VA Medical Centers and Veteran Service Organizations helped to increase communication across the nation and determine the most critical needs. Although COVID-19 was dynamic in nature, VA's intentional examination of social and structural factors was crucial in informing a more equitable approach. Moving forward, these inequities must be intentionally addressed in future pandemic responses.

Provider discussion of health goals and psychosocial needs: Comparing older to younger veteran experience

OBJECTIVE

To examine by age, the veterans' report on whether components of age-friendly health systems were discussed during primary care visits.

DATA SOURCES AND STUDY SETTING

Veterans Affairs (VA) Survey of Healthcare Experience of Patients from October 2015 to September 2019.

STUDY DESIGN

Cross-sectional survey of VA users by age group (18-44 years, 45-64 years, 65+ years; N = 1,042,318). We used weighted logistic regression models to evaluate disparities in whether veterans discussed with anyone in their provider's office: health goals, depression symptoms, stress, personal problems, and medications. Models were adjusted for socio-demographic characteristics (sex, socioeconomic status, education, rurality) and comorbidity.

DATA COLLECTION/EXTRACTION METHOD

Surveys were administered by mail and online. Additional veteran characteristics were extracted from VA administrative data.

PRINCIPAL FINDINGS

In unadjusted analyses, VA users age 18-44 had a higher (-8.2%; CI: -9.0, -7.3) and users aged 45 to 64 had lower (4.0%; CI: 3.7, 4.3) predicted, probably discussing health goals compared to age 65+. Fewer VA users age 65+ reported discussing depression symptoms, personal problems, and stress than other age groups, whereas more VA users age 65+ discussed medications. Results were unchanged after adjusting for socio-demographics and comorbidity.

CONCLUSIONS

Delivery of goal-concordant care relies on understanding the needs of individual patients. Lower rates of discussing what matters and mood represent potential missed opportunities to deliver age-friendly care for older veterans.

Coexistence of Pancytopenia and Myositis After Developing COVID-19

COVID-19 causes not only acute but also subacute medical conditions during the clinical course. COVID-19 causes severe inflammatory conditions; therefore, patients may develop long-term complications. Among patients with acute COVID-19, some patients can experience persistent symptoms, such as fatigue, joint pain, and smell and taste abnormalities, known as the long COVID-19 syndrome. The symptoms can be severe and require continuous medical care. Patients with severe clinical courses of COVID-19 may have critical symptoms again after the cure of the acute infections, especially among older patients. We encountered a case of neutropenia and myositis one month after contracting COVID-19. An 89-year-old man presented to our hospital with acute-onset systemic muscle pain and difficulty in movement and speaking. The patient had neutropenia and myositis with an extremely high level of immunoglobulin G caused by COVID-19. A granulocyte colony-stimulating factor could be effective for treating neutropenia. Besides, prednisolone was effective for treating myositis. In community hospitals, after developing COVID-19, appropriate history taking and physical examination should be performed in older patients with ambiguous symptoms, as they might have critical medical conditions such as neutropenia and myositis. The appropriate diagnosis and treatments of older patients with the complications of COVID-19 should be performed.