Racial and ethnic disparities in excess mortality among U.S. veterans during the COVID‐19 pandemic

Abstract

Objective The COVID‐19 pandemic disproportionately affected racial and ethnic minorities among the general population in the United States; however, little is known regarding its impact on U.S. military Veterans. In this study, our objectives were to identify the extent to which Veterans experienced increased all‐cause mortality during the COVID‐19 pandemic, stratified by race and ethnicity. Data Sources Administrative data from the Veterans Health Administration's Corporate Data Warehouse. Study Design We use pre‐pandemic data to estimate mortality risk models using five‐fold cross‐validation and quasi‐Poisson regression. Models were stratified by a combined race‐ethnicity variable and included controls for major comorbidities, demographic characteristics, and county fixed effects. Data Collection We queried data for all Veterans residing in the 50 states plus Washington D.C. during 2016–2020. Veterans were excluded from analyses if they were missing county of residence or race‐ethnicity data. Data were then aggregated to the county‐year level and stratified by race‐ethnicity. Principal Findings Overall, Veterans' mortality rates were 16% above normal during March–December 2020 which equates to 42,348 excess deaths. However, there was substantial variation by racial and ethnic group. Non‐Hispanic White Veterans experienced the smallest relative increase in mortality (17%, 95% CI 11%–24%), while Native American Veterans had the highest increase (40%, 95% CI 17%–73%). Black Veterans (32%, 95% CI 27%–39%) and Hispanic Veterans (26%, 95% CI 17%–36%) had somewhat lower excess mortality, although these changes were significantly higher compared to White Veterans. Disparities were smaller than in the general population. Conclusions Minoritized Veterans experienced higher rates excess of mortality during the COVID‐19 pandemic compared to White Veterans, though with smaller differences than the general population. This is likely due in part to the long‐standing history of structural racism in the United States that has negatively affected the health of minoritized communities via several pathways including health care access, economic, and occupational inequities.

Changes in Outpatient Health Care Use After COVID-19 Infection Among Veterans

“…Sustained higher outpatient use may be due to patients with PCC, which merits exploration in future work and has potential implications for VA workforce planning. Third, subgroup analyses found that the short-term visit increase following COVID-19 infection was greater for older veterans, veterans with a high comorbidity burden, Hispanic veterans, rural veterans, and veterans who were not vaccinated . Improved access to telehealth for these more vulnerable veterans may benefit them and their caregivers, if telehealth obviates the need for caregivers to provide veterans with travel for care.…”

“…Veteran characteristics were chosen for subgroup analyses according to differences reported in the clinical severity of COVID-19 infection, 26 , 27 , 28 including age groups (20-44, 45-54, 55-64, 65-74, 75-84, and ≥85 years), sex, self-reported race, self-reported Hispanic ethnicity, smoking status, immunosuppression at index date, vaccination status at index date, rural or urban residence, comorbidity burden (defined as Gagne score 29 quartiles), and the pandemic wave in which the infection occurred. 30 Race and ethnicity in the VA Corporate Data Warehouse are collected through self-identification either at enrollment or at a health care encounter and are included in this study for descriptive purposes and because outpatient visits are known to vary by race and ethnicity.…”

Excess Mortality at Veterans Health Administration Facilities During the COVID-19 Pandemic

“…Moreover, while this analysis focused on institutional characteristics of facilities, future work should identify the extent to which facility-level variation in excess mortality is driven by differences in the characteristics of the veterans in their catchment areas (eg, by urban/rural, race/ethnicity). For instance, Feyman et al found that White veterans experienced a lower rate of excess mortality during the pandemic compared with veterans of color 25…”

“…For instance, Feyman et al found that White veterans experienced a lower rate of excess mortality during the pandemic compared with veterans of color. 25 Our study results could be used to identify the highest and lowest-performing facilities and investigate what influenced their performance. Specifically, the VHA could send mixed-methods researchers to these facilities and conduct surveys and qualitative interviews with management and clinical staff to learn more about what happened.…”

Trends and all-cause mortality associated with multimorbidity of non-communicable diseases among adults in the United States, 1999-2018: a retrospective cohort study

“…Regarding education, one study indicated that all-cause mortality rates were approximately 2 times higher among adults with the least education than among those with the most [ 31 ]. Another study indicated that veterans’ mortality rates varied substantially by racial and ethnic group [ 32 ]. However, the “other Hispanic” and “higher than high school” populations had the highest risks of all-cause mortality associated with multimorbidity.…”