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

Educational Objective
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.

Abstract

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.

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