A Learning Health System Approach to Long COVID Care.

Background: Global initiatives to mitigate COVID-19 transmission have shifted health system priorities to management of patients with prolonged long COVID symptoms. To better meet the needs of patients, clinicians, and systems, a learning health system approach can use rapid-cycle methods to integrate data and real-world experience to iteratively evaluate and adapt models of long COVID care. Observations: Employees in the Veterans Health Administration formed a multidisciplinary workgroup. We sought to develop processes to learn more about this novel long COVID syndrome and innovative long COVID care models that can be applied within and outside of our health care system. We describe our workgroup processes and goals to create a mechanism for cross-facility communication, identify gaps in care and research, and cocreate knowledge on best practices for long COVID care delivery. Conclusions: The learning health system approach will be critical in reimagining health care service delivery after the COVID-19 pandemic.

Geographic and temporal variation in racial and ethnic disparities in SARS-CoV-2 positivity between February 2020 and August 2021 in the United States.

The coronavirus pandemic has disproportionally impacted racial and ethnic minority communities in the United States. Patterns of these disparities may be changing over time as outbreaks occur in different communities. Utilizing electronic health record data from the US Department of Veterans Affairs (VA), we estimated odds ratios, stratified by time period and region, for testing positive among 1,313,402 individuals tested for SARS-CoV-2 between February 12, 2020 and August 16, 2021 at VA medical facilities. We adjusted for personal characteristics (sex, age, rural/urban residence, VA facility) and a wide range of clinical characteristics that have been evaluated in prior SARS-CoV-2 reports and could potentially explain racial/ethnic disparities in SARS-CoV-2. Our study found racial and ethnic disparities for testing positive were most pronounced at the beginning of the pandemic and decreased over time. A key finding was that the disparity among Hispanic individuals attenuated but remained elevated, while disparities among Asian individuals reversed by March 1, 2021. The variation in racial and ethnic disparities in SARS-CoV-2 positivity by time and region, independent of underlying health status and other demographic characteristics in a nationwide cohort, provides important insight for strategies to prevent further outbreaks.

Differences in COVID-19 Risk by Race and County-Level Social Determinants of Health among Veterans.

COVID-19 disparities by area-level social determinants of health (SDH) have been a significant public health concern and may also be impacting U.S. Veterans. This retrospective analysis was designed to inform optimal care and prevention strategies at the U.S. Department of Veterans Affairs (VA) and utilized COVID-19 data from the VAs EHR and geographically linked county-level data from 18 area-based socioeconomic measures. The risk of testing positive with Veterans' county-level SDHs, adjusting for demographics, comorbidities, and facility characteristics, was calculated using generalized linear models. We found an exposure-response relationship whereby individual COVID-19 infection risk increased with each increasing quartile of adverse county-level SDH, such as the percentage of residents in a county without a college degree, eligible for Medicaid, and living in crowded housing.

Differences in COVID-19 Testing and Test Positivity Among Veterans, United States, 2020.

OBJECTIVE: COVID-19 disproportionately affects racial/ethnic minority groups in the United States. We evaluated characteristics associated with obtaining a COVID-19 test from the Veterans Health Administration (VHA) and receiving a positive test result for COVID-19. METHODS: We conducted a retrospective cohort analysis of 6 292 800 veterans in VHA care at 130 VHA medical facilities. We assessed the number of tests for SARS-CoV-2 administered by the VHA (n = 822 934) and the number of positive test results (n = 82 094) from February 8 through December 28, 2020. We evaluated associations of COVID-19 testing and test positivity with demographic characteristics of veterans, adjusting for facility characteristics, comorbidities, and county-level area-based socioeconomic measures using nested generalized linear models. RESULTS: In fully adjusted models, veterans who were female, Black/African American, Hispanic/Latino, urban, and low income and had a disability had an increased likelihood of obtaining a COVID-19 test, and veterans who were Asian had a decreased likelihood of obtaining a COVID-19 test. Compared with veterans who were White, veterans who were Black/African American (risk ratio [RR] = 1.23; 95% CI, 1.19-1.27) and Native Hawaiian/Other Pacific Islander (RR = 1.13; 95% CI, 1.05-1.21) had an increased likelihood of receiving a positive test result. Hispanic/Latino veterans had a 43% higher likelihood of receiving a positive test result than non-Hispanic/Latino veterans did. CONCLUSIONS: Although veterans have access to subsidized health care at the VHA, the increased risk of receiving a positive test result for COVID-19 among Black and Hispanic/Latino veterans, despite receiving more tests than White and non-Hispanic/Latino veterans, suggests that other factors (eg, social inequities) are driving disparities in COVID-19 prevalence.

Witnessed versus unwitnessed random urine tests in the treatment of opioid dependence.

BACKGROUND AND OBJECTIVES: Clinics licensed to provide pharmacotherapy for opiate dependence disorder are required to perform random urine drug screen (RUDS) tests. The results provide the empirical basis of individual treatment and programmatic effectiveness, and public health policy. Patients consent to witnessed testing but most tests are unwitnessed. The purpose of the present study was to compare treatment effectiveness estimates derived from witnessed versus unwitnessed urine samples. METHODS: We adopted a policy requiring visually witnessed urine drug screens (WUDS) and studied its impact (a single group, pretest-posttest design) on the RUDS test results in 115 male veterans enrolled in the St. Louis VA Opioid Treatment Program. RESULTS: The percentage of opioid-positive urine samples increased significantly following implementation of WUDS (25% vs. 41%, χ(2) = 66.5, p < .001). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Results of this preliminary study suggest that random testing alone does not ensure the integrity of UDS testing. Outcome calculations based on random unwitnessed tests may overestimate the effectiveness of opioid dependence disorder treatment.