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Rates and Factors Associated With Documentation of Diagnostic Codes for Long COVID in the National Veterans Affairs Health Care System

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To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  What are the rates, clinical settings, and factors associated with documentation of care related to COVID-19 at 3 or more months after acute infection?

Findings  In this cohort study of 198 601 persons with a positive SARS-CoV-2 test, COVID-19 care was documented in 13.5% of individuals 3 or more months after infection during a mean follow-up of 13.5 months and was documented more commonly in older persons, those with higher comorbidity burden, those with more severe acute COVID-19 presentation, and those who were unvaccinated at the time of infection.

Meaning  These findings provide guidance for health care systems to develop systematic approaches to the evaluation and management of patients who may be experiencing long COVID.


Importance  Some persons infected with SARS-CoV-2 experience symptoms or impairments many months after acute infection.

Objectives  To determine the rates, clinical setting, and factors associated with documented receipt of COVID-19–related care 3 or more months after acute infection.

Design, Setting, and Participants  This retrospective cohort study used data from the US Department of Veterans Affairs health care system. Participants included persons with a positive SARS-CoV-2 test between February 1, 2020, and April 30, 2021, who were still alive 3 months after infection and did not have evidence of reinfection. Data analysis was performed from February 2020 to December 2021.

Exposures  Positive SARS-CoV-2 test.

Main Outcomes and Measures  Rates and factors associated with documentation of COVID-19–related International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes (U07.1, Z86.16, U09.9, and J12.82) 3 or more months after acute infection (hereafter, long-COVID care), with follow-up extending to December 31, 2021.

Results  Among 198 601 SARS-CoV-2–positive persons included in the study, the mean (SD) age was 60.4 (17.7) years, 176 942 individuals (89.1%) were male, 133 924 (67.4%) were White, 44 733 (22.5%) were Black, and 19 735 (9.9%) were Hispanic. During a mean (SD) follow-up of 13.5 (3.6) months, long-COVID care was documented in a wide variety of clinics, most commonly primary care and general internal medicine (18 634 of 56 310 encounters [33.1%]), pulmonary (7360 of 56 310 encounters [13.1%]), and geriatrics (5454 of 56 310 encounters [9.7%]). Long-COVID care was documented in 26 745 cohort members (13.5%), with great variability across geographical regions (range, 10.8%-18.1%) and medical centers (range, 3.0%-41.0%). Factors significantly associated with documented long-COVID care included older age, Black or American Indian/Alaska Native race, Hispanic ethnicity, geographical region, high Charlson Comorbidity Index score, having documented symptoms at the time of acute infection (adjusted odds ratio [AOR], 1.71; 95% CI, 1.65-1.78) and requiring hospitalization (AOR, 2.60; 95% CI, 2.51-2.69) or mechanical ventilation (AOR, 2.46; 95% CI, 2.26-2.69). Patients who were fully vaccinated at the time of infection were less likely to receive long-COVID care (AOR, 0.78; 95% CI, 0.68-0.90).

Conclusions and Relevance  Long-COVID care was documented in a variety of clinical settings, with great variability across regions and medical centers and was documented more commonly in older persons, those with higher comorbidity burden, those with more severe acute COVID-19 presentation and those who were unvaccinated at the time of infection. These findings provide support and guidance for health care systems to develop systematic approaches to the evaluation and management of patients who may be experiencing long COVID.

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Article Information

Accepted for Publication: June 13, 2022.

Published: July 29, 2022. doi:10.1001/jamanetworkopen.2022.24359

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Ioannou GN et al. JAMA Network Open.

Corresponding Author: George N. Ioannou, BMBCh, MS, Health Services Research and Development, Center of Innovation, Veterans Affairs Puget Sound Healthcare System, 1660 S Columbian Way, Seattle, WA 98108 (georgei@medicine.washington.edu).

Author Contributions: Dr Ioannou and Mr Baraff 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: Ioannou, Maciejewski, Bowling, Iwashyna, Hynes.

Acquisition, analysis, or interpretation of data: Ioannou, Baraff, Fox, Shahoumian, Hickok, O’Hare, Bohnert, Boyko, Bowling, Viglianti, Iwashyna, Hynes.

Drafting of the manuscript: Ioannou.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Ioannou, Baraff, Shahoumian, Hickok.

Obtained funding: Ioannou, O’Hare, Bohnert, Boyko, Iwashyna, Hynes.

Administrative, technical, or material support: Bohnert, Maciejewski, Bowling, Hynes.

Conflict of Interest Disclosures: Dr Ioannou reported receiving grants from the Department of Veterans Affairs (VA) during the conduct of the study. Dr Hickok reported receiving grants from the VA during the conduct of the study. Dr O’Hare reported receiving grants from VA Puget Sound Health and the National Institute of Diabetes and Digestive and Kidney Disease, and personal fees from American Society of Nephrology, Devenir Foundation, Hammersmith Hospital, and Kaiser Permanente Northern California outside the submitted work. Dr Boyko reported receiving grants from the VA during the conduct of the study. Dr Maciejewski reported owning Amgen stock because of his spouse’s employment. Dr Bowling reported receiving grants from VA Health Services Research and Development Service (HSR&D) during the conduct of the study. Dr Hynes reported grants from US VA during the conduct of the study. No other disclosures were reported.

Funding/Support: The study was supported by the Department of Veterans Affairs, Office of Research and Development (HSR&D grants C19 21-278 to Drs Ioannou, Bohnert, Boyko, and Maciejewski and C19 21-279 to Drs O’Hare, Bowling, Iwashyna, Hynes, and Viglianti and RCS 10-391 to Dr Maciejewski).

Role of the Funder/Sponsor: The funder 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.

Disclaimer: The contents do not represent the views of the US Department of Veterans Affairs or the US Government.

World Health Organization. A clinical case definition of post COVID-19 condition by a Delphi consensus. October 6, 2021. Accessed November 19, 2021. https://www.who.int/publications/i/item/WHO-2019-nCoV-Post_COVID-19_condition-Clinical_case_definition-2021.1
Whittaker  HR , Gulea  C , Koteci  A ,  et al.  GP consultation rates for sequelae after acute covid-19 in patients managed in the community or hospital in the UK: population based study.   BMJ. 2021;375:e065834. doi:10.1136/bmj-2021-065834PubMedGoogle ScholarCrossref
Crook  H , Raza  S , Nowell  J , Young  M , Edison  P .  Long covid-mechanisms, risk factors, and management.   BMJ. 2021;374(1648):n1648. doi:10.1136/bmj.n1648PubMedGoogle ScholarCrossref
Xie  Y , Bowe  B , Al-Aly  Z .  Burdens of post-acute sequelae of COVID-19 by severity of acute infection, demographics and health status.   Nat Commun. 2021;12(1):6571. doi:10.1038/s41467-021-26513-3PubMedGoogle ScholarCrossref
Al-Aly  Z , Xie  Y , Bowe  B .  High-dimensional characterization of post-acute sequelae of COVID-19.   Nature. 2021;594(7862):259-264. doi:10.1038/s41586-021-03553-9PubMedGoogle ScholarCrossref
Xie  Y , Xu  E , Bowe  B , Al-Aly  Z .  Long-term cardiovascular outcomes of COVID-19.   Nat Med. 2022;28(3):583-590. doi:10.1038/s41591-022-01689-3PubMedGoogle ScholarCrossref
Ayoubkhani  D , Khunti  K , Nafilyan  V ,  et al.  Post-covid syndrome in individuals admitted to hospital with covid-19: retrospective cohort study.   BMJ. 2021;372(693):n693. doi:10.1136/bmj.n693PubMedGoogle ScholarCrossref
Huang  C , Huang  L , Wang  Y ,  et al.  6-Month consequences of COVID-19 in patients discharged from hospital: a cohort study.   Lancet. 2021;397(10270):220-232. doi:10.1016/S0140-6736(20)32656-8PubMedGoogle ScholarCrossref
Carfì  A , Bernabei  R , Landi  F ; Gemelli Against COVID-19 Post-Acute Care Study Group.  Persistent symptoms in patients after acute COVID-19.   JAMA. 2020;324(6):603-605. doi:10.1001/jama.2020.12603PubMedGoogle ScholarCrossref
Daugherty  SE , Guo  Y , Heath  K ,  et al.  Risk of clinical sequelae after the acute phase of SARS-CoV-2 infection: retrospective cohort study.   BMJ. 2021;373(1098):n1098. doi:10.1136/bmj.n1098PubMedGoogle ScholarCrossref
Katsoularis  I , Fonseca-Rodríguez  O , Farrington  P , Lindmark  K , Fors Connolly  AM .  Risk of acute myocardial infarction and ischaemic stroke following COVID-19 in Sweden: a self-controlled case series and matched cohort study.   Lancet. 2021;398(10300):599-607. doi:10.1016/S0140-6736(21)00896-5PubMedGoogle ScholarCrossref
Gupta  A , Madhavan  MV , Sehgal  K ,  et al.  Extrapulmonary manifestations of COVID-19.   Nat Med. 2020;26(7):1017-1032. doi:10.1038/s41591-020-0968-3PubMedGoogle ScholarCrossref
Nalbandian  A , Sehgal  K , Gupta  A ,  et al.  Post-acute COVID-19 syndrome.   Nat Med. 2021;27(4):601-615. doi:10.1038/s41591-021-01283-zPubMedGoogle ScholarCrossref
US Department of Veterans Affairs. Corporate Data Warehouse. Accessed March 22, 2021. https://www.hsrd.research.va.gov/for_researchers/vinci/cdw.cfm
Veterans Affairs Informatics and Computing Infrastructure. COVID-19: shared data resource. Accessed December 12, 2021. https://vhacdwdwhweb100.vha.med.va.gov/phenotype/index.php/COVID-19:Shared_Data_Resource
US Department of Veterans Affairs. Centralized Interactive Phenomics Resource (CIPHER) program. Accessed March 30, 2022. https://vhacdwdwhweb100.vha.med.va.gov/phenotype/index.php/CIPHER_Program
Veterans Health Administration, Office of Rural Health. Accessed March 28, 2021. https://vaww.vashare.vha.va.gov/sites/ruralhealth/GSOD/default.aspx
Veterans Health Administration. Veterans Integrated Service Networks (VISNs). Accessed June 3, 2022. https://www.va.gov/HEALTH/visns.asp
Santhosh  L , Block  B , Kim  SY ,  et al.  Rapid design and implementation of post-COVID-19 clinics.   Chest. 2021;160(2):671-677. doi:10.1016/j.chest.2021.03.044PubMedGoogle ScholarCrossref
McPeake  J , Henderson  P , MacTavish  P , Quasim  T .  Provision of holistic care after severe COVID-19 pneumonia.   Lancet Respir Med. 2021;9(3):e24. doi:10.1016/S2213-2600(21)00019-9PubMedGoogle ScholarCrossref
Parker  AM , Brigham  E , Connolly  B ,  et al.  Addressing the post-acute sequelae of SARS-CoV-2 infection: a multidisciplinary model of care.   Lancet Respir Med. 2021;9(11):1328-1341. doi:10.1016/S2213-2600(21)00385-4PubMedGoogle ScholarCrossref
US Department of Veterans Affairs. VA launching outreach and care networks for Long COVID. VAntage Point. October 6, 2021. Accessed June 27, 2022. https://blogs.va.gov/VAntage/95516/va-launching-outreach-and-care-networks-for-long-covid/
Groff  D , Sun  A , Ssentongo  AE ,  et al.  Short-term and long-term rates of postacute sequelae of SARS-CoV-2 infection: a systematic review.   JAMA Netw Open. 2021;4(10):e2128568. doi:10.1001/jamanetworkopen.2021.28568PubMedGoogle ScholarCrossref
Carvalho-Schneider  C , Laurent  E , Lemaignen  A ,  et al.  Follow-up of adults with noncritical COVID-19 two months after symptom onset.   Clin Microbiol Infect. 2021;27(2):258-263. doi:10.1016/j.cmi.2020.09.052PubMedGoogle ScholarCrossref
Chopra  V , Flanders  SA , O’Malley  M , Malani  AN , Prescott  HC .  Sixty-day outcomes among patients hospitalized with COVID-19.   Ann Intern Med. 2021;174(4):576-578. doi:10.7326/M20-5661PubMedGoogle ScholarCrossref
Moreno-Pérez  O , Merino  E , Leon-Ramirez  JM ,  et al; COVID19-ALC research group.  Post-acute COVID-19 syndrome: incidence and risk factors—a Mediterranean cohort study.   J Infect. 2021;82(3):378-383. doi:10.1016/j.jinf.2021.01.004PubMedGoogle ScholarCrossref
Whitaker  M , Elliott  J , Chadeau-Hyam  M ,  et al. Persistent symptoms following SARS-CoV-2 infection in a random community sample of 508 707 people. Imperial College London. June 24, 2021. Accessed January 21, 2022. https://spiral.imperial.ac.uk/handle/10044/1/89844
Alwan  NA .  The road to addressing long Covid.   Science. 2021;373(6554):491-493. doi:10.1126/science.abg7113PubMedGoogle ScholarCrossref
Sudre  CH , Murray  B , Varsavsky  T ,  et al.  Attributes and predictors of long COVID.   Nat Med. 2021;27(4):626-631. doi:10.1038/s41591-021-01292-yPubMedGoogle ScholarCrossref
Arnold  DT , Hamilton  FW , Milne  A ,  et al.  Patient outcomes after hospitalisation with COVID-19 and implications for follow-up: results from a prospective UK cohort.   Thorax. 2021;76(4):399-401. doi:10.1136/thoraxjnl-2020-216086PubMedGoogle ScholarCrossref
Halpin  SJ , McIvor  C , Whyatt  G ,  et al.  Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: a cross-sectional evaluation.   J Med Virol. 2021;93(2):1013-1022. doi:10.1002/jmv.26368PubMedGoogle ScholarCrossref
Ioannou  GN , Ferguson  JM , O’Hare  AM ,  et al.  Changes in the associations of race and rurality with SARS-CoV-2 infection, mortality, and case fatality in the United States from February 2020 to March 2021: a population-based cohort study.   PLoS Med. 2021;18(10):e1003807. doi:10.1371/journal.pmed.1003807PubMedGoogle ScholarCrossref
Ioannou  GN , Locke  E , Green  P ,  et al.  Risk factors for hospitalization, mechanical ventilation, or death among 10 131 US veterans with SARS-CoV-2 infection.   JAMA Netw Open. 2020;3(9):e2022310. doi:10.1001/jamanetworkopen.2020.22310PubMedGoogle ScholarCrossref
Fan  VS , Dominitz  JA , Eastment  MC ,  et al.  Risk factors for testing positive for severe acute respiratory syndrome coronavirus 2 in a national US healthcare system.   Clin Infect Dis. 2021;73(9):e3085-e3094. doi:10.1093/cid/ciaa1624PubMedGoogle ScholarCrossref
Antonelli  M , Penfold  RS , Merino  J ,  et al.  Risk factors and disease profile of post-vaccination SARS-CoV-2 infection in UK users of the COVID Symptom Study app: a prospective, community-based, nested, case-control study.   Lancet Infect Dis. 2022;22(1):43-55. doi:10.1016/S1473-3099(21)00460-6PubMedGoogle ScholarCrossref
Kuodi  P , Gorelik  Y , Zayyad  H ,  et al.  Association between vaccination status and reported incidence of post-acute COVID-19 symptoms in Israel: a cross-sectional study of patients tested between March 2020 and November 2021.   medRxiv. Posted online January 17, 2022. doi:10.1101/2022.01.05.22268800Google Scholar
Taquet  M , Dercon  Q , Harrison  PJ .  Six-month sequelae of post-vaccination SARS-CoV-2 infection: a retrospective cohort study of 10,024 breakthrough infections.   Brain Behav Immun. 2022;103:154-162. doi:10.1016/j.bbi.2022.04.013PubMedGoogle ScholarCrossref
UK Health Security Agency. The effectiveness of vaccination against long COVID: a rapid evidence briefing. Accessed on February 22, 2022. https://ukhsa.koha-ptfs.co.uk/cgi-bin/koha/opac-retrieve-file.pl?id=fe4f10cd3cd509fe045ad4f72ae0dfff
Al-Aly  Z , Bowe  B , Xie  Y .  Long COVID after breakthrough SARS-CoV-2 infection.   Nat Med. Published online May 25, 2022. doi:10.1038/s41591-022-01840-0PubMedGoogle ScholarCrossref
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