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. 2023 May 1;6(5):e2312140.
doi: 10.1001/jamanetworkopen.2023.12140.

Excess Mortality Among Patients in the Veterans Affairs Health System Compared With the Overall US Population During the First Year of the COVID-19 Pandemic

Daniel M Weinberger  1   2 , Liam Rose  3   4 , Christopher Rentsch  2   5   6 , Steven M Asch  3   7   8 , Jesse A Columbo  9   10 , Joseph King Jr  2   11 , Caroline Korves  9 , Brian P Lucas  9   10 , Cynthia Taub  12 , Yinong Young-Xu  9 , Anita Vashi  3   8   13 , Louise Davies  9   14 , Amy C Justice  2   6   15
Affiliations

Excess Mortality Among Patients in the Veterans Affairs Health System Compared With the Overall US Population During the First Year of the COVID-19 Pandemic

Daniel M Weinberger et al. JAMA Netw Open. .

Abstract

Importance: During the first year of the COVID-19 pandemic, there was a substantial increase in the rate of death in the United States. It is unclear whether those who had access to comprehensive medical care through the Department of Veterans Affairs (VA) health care system had different death rates compared with the overall US population.

Objective: To quantify and compare the increase in death rates during the first year of the COVID-19 pandemic between individuals who received comprehensive medical care through the VA health care system and those in the general US population.

Design, setting, and participants: This cohort study compared 10.9 million enrollees in the VA, including 6.8 million active users of VA health care (those with a visit in the last 2 years), with the general population of the US, with deaths occurring from January 1, 2014, to December 31, 2020. Statistical analysis was conducted from May 17, 2021, to March 15, 2023.

Main outcomes and measures: Changes in rates of death from any cause during the COVID-19 pandemic in 2020 compared with previous years. Changes in all-cause death rates by quarter were stratified by age, sex, race and ethnicity, and region, based on individual-level data. Multilevel regression models were fit in a bayesian setting. Standardized rates were used for comparison between populations.

Results: There were 10.9 million enrollees in the VA health care system and 6.8 million active users. The demographic characteristics of the VA populations were predominantly male (>85% in the VA health care system vs 49% in the general US population), older (mean [SD], 61.0 [18.2] years in the VA health care system vs 39.0 [23.1] years in the US population), and had a larger proportion of patients who were White (73% in the VA health care system vs 61% in the US population) or Black (17% in the VA health care system vs 13% in the US population). Increases in death rates were apparent across all of the adult age groups (≥25 years) in both the VA populations and the general US population. Across all of 2020, the relative increase in death rates compared with expected values was similar for VA enrollees (risk ratio [RR], 1.20 [95% CI, 1.14-1.29]), VA active users (RR, 1.19 [95% CI, 1.14-1.26]), and the general US population (RR, 1.20 [95% CI, 1.17-1.22]). Because the prepandemic 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: In this cohort study, a comparison of excess deaths between populations suggests that active users of the VA health system had similar relative increases in mortality compared with the general US population during the first 10 months of the COVID-19 pandemic.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Weinberger reported receiving grants and personal fees from Pfizer and Merck and personal fees from GSK outside the submitted work. Dr Rose reported receiving grants from the US Department of Veterans Affairs and the National Institutes of Health during the conduct of the study. Dr Columbo reported receiving grants from the Hitchcock Foundation outside the submitted work. Dr King reported receiving grants from the US Department of Veterans Affairs Health Services Research and Development during the conduct of the study. Dr Korves reported receiving grants from the US Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development, and the Disrupted Care National Project during the conduct of the study, and Dr Korves’ research group has received funding from Pfizer, Sanofi Pasteur, and Vir Biotechnology for work outside of the conduct of the study. Dr Vashi reported receiving grants from the US Department of Veterans Affairs Health Services Research and Development during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Trajectory of the Risk Ratio (RR) for the General US Population, Veterans Affairs (VA) Enrollees, and VA Active Users
A, RRs calculated using the raw mortality rates. B, RRs calculated using the mortality rates standardized by age, sex, race and ethnicity, and region. The closer alignment for the standardized plot suggests that any differences in the unadjusted plot are associated with demographic differences. Q indicates quarter.
Figure 2.
Figure 2.. Observed Mortality Rates and Expected Mortality Rates in the General US Population, Veterans Affairs (VA) Enrollees, and VA Active Users, Stratified by Age
Circles on the left sides of the lines are expected mortality rates, and circles on the right sides of the lines are observed mortality rates. The slope of the line indicates the relative increase during the pandemic (the risk ratio). Mortality rates are standardized based on the sex, race and ethnicity, region, and distribution of the 65- to 79-year VA enrollee population. Parallel slopes of the lines indicate a similar relative increase (risk ratio).
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