How have antiviral agents and monoclonal antibodies for mild to moderate COVID-19 been used in the Veterans Affairs health care system?
In this cohort study of 111 717 outpatient US veterans with clinical risk factors for severe COVID-19 who tested positive for SARS-CoV-2 during January and February 2022, 4233 (3.8%) received outpatient pharmacotherapy. Black veterans and Hispanic veterans were less likely to receive treatment, whereas older veterans with a higher number of underlying conditions were more likely to receive treatment.
These findings suggest that during a 2-month period when 4 anti–SARS-CoV-2 pharmacotherapies were authorized for use, few eligible veterans received treatment.
Older adults and individuals with medical comorbidities are at increased risk for severe COVID-19. Several pharmacotherapies demonstrated to reduce the risk of COVID-19–related hospitalization and death have been authorized for use.
To describe factors associated with receipt of outpatient COVID-19 pharmacotherapies in the Veterans Affairs (VA) health care system.
Design, Settings, and Participants
This cohort study assessed outpatient veterans with risk factors for severe COVID-19 who tested positive for SARS-CoV-2 during January and February 2022. The setting was the VA health care system, the largest integrated health care system in the US.
Demographic characteristics, place of residence, underlying medical conditions, and COVID-19 vaccination.
Main Outcomes and Measures
The odds of receipt of any COVID-19 pharmacotherapy, including sotrovimab, nirmatrelvir boosted with ritonavir, molnupiravir, or remdesivir were estimated using multivariable logistic regression.
Among 111 717 veterans included in this study (median [IQR] age, 60 [46-72] years; 96 482 [86.4%] male, 23 362 [20.9%] Black, 10 740 [9.6%] Hispanic, 75 973 [68.0%] White) who tested positive for SARS-CoV-2 during January to February 2022, 4233 (3.8%) received any COVID-19 pharmacotherapy, including 2870 of 92 396 (3.1%) in January and 1363 of 19 321 (7.1%) in February. Among a subset of 56 285 veterans with documented COVID-19–related symptoms in the 30 days preceding a positive SARS-CoV-2 test, 3079 (5.5%) received any COVID-19 pharmacotherapy. Untreated veterans had a median (IQR) age of 60 (46-71) years and a median (IQR) of 3 (2-5) underlying medical conditions. Veterans receiving any treatment were more likely to be older (aged 65 to 74 years vs 50 to 64 years: adjusted odds ratio [aOR], 1.66 [95% CI, 1.52-1.80]; aged at least 75 years vs 50 to 64 years: aOR, 1.67 [95% CI, 1.53-1.84]) and have a higher number of underlying conditions (at least 5 conditions vs 1 to 2 conditions: aOR, 2.17 [95% CI, 1.98-2.39]). Compared with White veterans, Black veterans (aOR, 0.65 [95% CI, 0.60-0.72]) were less likely to receive treatment; and compared with non-Hispanic veterans, Hispanic veterans (aOR, 0.88 [95% CI, 0.77-0.99]) were less likely to receive treatment. There were 16 546 courses of sotrovimab, nirmatrelvir, and molnupiravir allocated across the VA during this period.
Conclusions and Relevance
In this cohort study of veterans who tested positive for SARS-CoV-2 during January and February when supply of outpatient COVID-19 pharmacotherapies was limited, prescription of these pharmacotherapies was underused, and many veterans with risk factors for severe COVID-19 did not receive treatment. Veterans from minority racial and ethnic groups were less likely to receive any pharmacotherapy.
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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: September 14, 2022.
Published: November 11, 2022. doi:10.1001/jamanetworkopen.2022.41434
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Bajema KL et al. JAMA Network Open.
Corresponding Author: Kristina L. Bajema, MD, MSc, Veterans Affairs Portland Health Care System, 3710 SW US Veterans Hospital Rd, Portland, OR 97239 (firstname.lastname@example.org).
Author Contributions: Drs. Bajema and Ioannou had full access to all data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Bajema, Hynes, Streja, Yan, Aslan, Ioannou.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Bajema.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Bajema, Hickok.
Obtained funding: Bajema, Hynes, Maciejewski, Ioannou.
Administrative, technical, or material support: All authors.
Study supervision: Bajema, Hynes, Ioannou.
Conflict of Interest Disclosures: Dr Hickok reported receiving grants from the Department of Veterans Affairs to support his work outside the submitted work. Dr Maciejewski reported receiving Amgen stock ownership due to his spouse's employment. No other disclosures were reported.
Funding/Support: The study was supported by the Veterans Health Administration Health Services Research & Development (HSR&D) grant No. C19 21-278 (Dr Bohnert, Dr Boyko, Dr Hynes, Dr Ioannou, and Dr Maciejewski); HSR&D grant No. C19 21-279 (Dr Hynes, Dr Ioannou, Dr Iwashyna); HSR&D grant No. RCS 10-391 (Dr Maciejewski); HSR&D RCS 21-136 grant No. (Dr Hynes); HSR&D Center to Improve Veteran Involvement in Care (CIVIC) grant (Dr Bajema); Department of Veterans Affairs (VA) Informatics and Computing Infrastructure (VINCI), VA HSR RES 13-457; VA CMS Data for Research US VA HSR&D (SDR 02-237); and the VA Information Resource Center (VIReC) (US VA HSR&D SDR 98-004).
Role of the Funder/Sponsor: The VA 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. Authors who are employees of VA participated in each of these activities.
Disclaimer: The contents do not represent the views of the US Department of Veterans Affairs or the US Government.
Additional Contributions: We thank the Biomedical Advanced Research and Development Authority (BARDA) for their support.
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