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. 2023 Jul 1;61(7):456-461.
doi: 10.1097/MLR.0000000000001866. Epub 2023 May 22.

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

Kertu Tenso  1   2 , Kiersten L Strombotne  1   2 , Yevgeniy Feyman  1   2 , Samantha G Auty  1 , Aaron Legler  2 , Kevin N Griffith  2   3
Affiliations

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

Kertu Tenso et al. Med Care. .

Abstract

Importance: The COVID-19 pandemic resulted in excess mortality among the general US population and at Veterans Health Administration (VHA) facilities. It is critical to understand the characteristics of facilities that experienced the highest and lowest pandemic-related mortality to inform future mitigation efforts.

Objective: To identify facility-level excess mortality during the pandemic and to correlate these estimates with facility characteristics and community-wide rates of COVID-19 burden.

Design: We used pre-pandemic data to estimate mortality risk prediction models using 5-fold cross-validation and Poisson quasi-likelihood regression. We then estimated excess mortality and observed versus expected (O/E) mortality ratios by the VHA facility from March to December 2020. We examined facility-level characteristics by excess mortality quartile.

Participants: Overall, there were 11.4 million VHA enrollees during 2016 and 2020.

Main measures: Facility-level O/E mortality ratios and excess all-cause mortality.

Result: VHA-enrolled veterans experienced 52,038 excess deaths from March to December 2020, equating to 16.8% excess mortality. Facility-specific rates ranged from -5.5% to +63.7%. Facilities in the lowest quartile for excess mortality experienced fewer COVID-19 deaths (0.7-1.51, P <0.001) and cases (52.0-63.0, P =0.002) per 1,000 population compared with the highest quartile. The highest quartile facilities had more hospital beds (276.7-187.6, P =0.024) and a higher percent change in the share of visits conducted via telehealth from 2019 to 2020 (183%-133%, P <0.008).

Conclusions: There was a large variation in mortality across VHA facilities during the pandemic, which was only partially explained by the local COVID-19 burden. Our work provides a framework for large health care systems to identify changes in facility-level mortality during a public health emergency.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

FIGURE 1.
FIGURE 1.
Observed versus expected mortality ratios at VHA Facilities, March–December 2020. Notes: VHA = Veterans Health Administration. Observed versus expected (O/E) ratios were calculated by dividing the total number of deaths from any cause by the number of deaths predicted by a Poisson quasi-likelihood regression model; see the main text for more details of this procedure. Each point represents the location of a VHA facility.
FIGURE 2.
FIGURE 2.
Distribution of COVID-19 cases within VHA facility catchments, March–December 2020. Notes: VHA = Veterans Health Administration. County-month-level data on confirmed COVID-19 cases and deaths among the US general population were extracted from the Johns Hopkins Coronavirus Resource Center. Each point represents the location of a VHA facility.
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