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

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.