Are social and behavioral risk factors associated with mortality in US veterans with COVID-19?
In this cohort study of 27 640 veterans who received a positive test result for COVID-19, risk factors such as housing problems, financial hardship, alcohol use, tobacco use, and substance use were not associated with higher mortality.
This study found no association between social and behavioral risk factors and death from COVID-19 in an integrated VA health system; such a system is known to transcend social vulnerabilities and has the potential to be a model of support services for households and at-risk populations in the US.
The US Department of Veterans Affairs (VA) offers programs that reduce barriers to care for veterans and those with housing instability, poverty, and substance use disorder. In this setting, however, the role that social and behavioral risk factors play in COVID-19 outcomes is unclear.
To examine whether social and behavioral risk factors were associated with mortality among US veterans with COVID-19 and whether this association might be modified by race/ethnicity.
Design, Setting, and Participants
This cohort study obtained data from the VA Corporate Data Warehouse to form a cohort of veterans who received a positive COVID-19 test result between March 2 and September 30, 2020, in a VA health care facility. All veterans who met the inclusion criteria were eligible to participate in the study, and participants were followed up for 30 days after the first SARS-CoV-2 or COVID-19 diagnosis. The final follow-up date was October 31, 2020.
Social risk factors included housing problems and financial hardship. Behavioral risk factors included current tobacco use, alcohol use, and substance use.
Main Outcomes and Measures
The primary outcome was all-cause mortality in the 30-day period after the SARS-CoV-2 or COVID-19 diagnosis date. Multivariable logistic regression was used to estimate odds ratios, clustering for health care facilities and adjusting for age, sex, race, ethnicity, marital status, clinical factors, and month of COVID-19 diagnosis.
Among 27 640 veterans with COVID-19 who were included in the analysis, 24 496 were men (88.6%) and the mean (SD) age was 57.2 (16.6) years. A total of 3090 veterans (11.2%) had housing problems, 4450 (16.1%) had financial hardship, 5358 (19.4%) used alcohol, and 3569 (12.9%) reported substance use. Hospitalization occurred in 7663 veterans (27.7%), and 1230 veterans (4.5%) died. Housing problems (adjusted odds ratio [AOR], 0.96; 95% CI, 0.77-1.19; P = .70), financial hardship (AOR, 1.13; 95% CI, 0.97-1.31; P = .11), alcohol use (AOR, 0.82; 95% CI, 0.68-1.01; P = .06), current tobacco use (AOR, 0.85; 95% CI, 0.68-1.06; P = .14), and substance use (AOR, 0.90; 95% CI, 0.71-1.15; P = .41) were not associated with higher mortality. Interaction analyses by race/ethnicity did not find associations between mortality and social and behavioral risk factors.
Conclusions and Relevance
Results of this study showed that, in an integrated health system such as the VA, social and behavioral risk factors were not associated with mortality from COVID-19. Further research is needed to substantiate the potential of an integrated health system to be a model of support services for households with COVID-19 and populations who are at risk for the disease.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Accepted for Publication: April 13, 2021.
Published: June 9, 2021. doi:10.1001/jamanetworkopen.2021.13031
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Kelly JD et al. JAMA Network Open.
Corresponding Author: J. Daniel Kelly, MD, MPH, Department of Epidemiology and Biostatistics, University of California, San Francisco, 550 16th St, San Francisco, CA 94143 (firstname.lastname@example.org).
Author Contributions: Mr Leonard and Dr Keyhani had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Kelly, Wray, Myers, Keyhani.
Acquisition, analysis, or interpretation of data: Kelly, Bravata, Bent, Leonard, Boscardin, Keyhani.
Drafting of the manuscript: Kelly, Leonard.
Critical revision of the manuscript for important intellectual content: Kelly, Bravata, Bent, Wray, Boscardin, Myers, Keyhani.
Statistical analysis: Kelly, Leonard, Boscardin.
Obtained funding: Keyhani.
Administrative, technical, or material support: Kelly, Bravata, Bent, Wray, Leonard, Myers.
Supervision: Kelly, Keyhani.
Conflict of Interest Disclosures: None reported.
Funding/Support: This work was supported by grant 1IP1HX001994 from the US Department of Veterans Affairs. Dr Kelly was supported by K23 grant AI135037 from the National Institute of Allergy and Infectious Diseases.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: We thank the US veterans for their contributions to this research and ultimately ending the COVID-19 pandemic.
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