Impact of the Coronavirus Disease 2019 Pandemic on Cardiovascular HealthcareUtilization, Quality of Care, and Clinical Outcomes

背景资料：在冠状病毒病2019年(新冠肺炎)大流行期间，退伍军人推迟了住院 在急性心肌梗死的情况下，如冠状动脉血运重建等护理。同时， 心血管护理已经被打乱，临床医生不太可能开出指导方针的药物 适用于常见的心血管疾病，如稳定性冠状动脉疾病或心力衰竭。超额死亡 在新冠肺炎大流行期间也发生了这种情况，特别是在脆弱人群中，这增加了 在那些没有直接感染病毒的人中，医疗保健利用率或护理质量不佳的可能性。 然而，心血管保健利用率和护理质量在以下方面有所下降 大流行与之前时间段的比较以及这些变化是否影响了退伍军人的风险 死亡率的多少是未知的。 意义：心血管疾病是美国最常见的疾病，也是 在大流行早期，非COVID死亡人数过多的原因。拟议的工作可能会找出退伍军人管理局的差距 医疗保健利用和护理质量，有可能直接为国家改善提供信息 为退伍军人提供心血管护理，导致未来更容易获得、更高质量、更公平的护理。 此外，对心血管疾病护理的评估可以作为未来研究的模式 退伍军人事务部医疗专科护理中的其他学科。 具体目标：目标1：比较住院患者和门诊患者的利用情况(门诊就诊/住院/诊断 对有常见心血管疾病(房颤/冠状动脉)的退伍军人进行测试/程序护理 动脉疾病/心力衰竭)与基于 大流行前相应的三年期间。 目标2：比较退伍军人和退伍军人的护理质量(指南指出的药物/护理过渡) COVID期间常见的心血管诊断(房颤/冠状动脉疾病/心力衰竭)- 19大流行，预计是根据大流行之前的相应3年期间计算的。 目标3：评估卫生保健利用和/或护理过程中与大流行有关的潜在变化 质量指标与全因死亡率和/或临床结果的风险增加相关 有常见心血管疾病的退伍军人的心血管死亡率。 方法：我们建议对退伍军人进行一项观察性、回溯性、全国性的队列研究。 心血管疾病。主要数据来源将包括退伍军人事务部数据仓库(CDW) 和非退伍军人护理计划诚信工具(PIT)系统。使用间接标准化，我们将比较 心血管保健利用率和护理质量的潜在下降以及 死亡率与大流行前的死亡率相比，执行亚组分析的重点是年龄、性别和 在样本量允许的情况下，性别、种族和民族。在调解分析中，我们将评估 使用情况和护理质量的变化是否与死亡风险增加相关。 下一步/实施：利益相关者咨询小组，由退伍军人管理局运营负责人、调查人员和 将召集退伍军人制定全面的建议，以优化访问、质量和 新冠肺炎后期和/或新冠肺炎大流行后退伍军人事务部心血管护理的公平性和指导退伍军人事务部政策 句号。

Background: During the coronavirus disease 2019 (COVID-19) pandemic, Veterans have deferred inpatient care such as coronary revascularization in the context of an acute myocardial infarction. Simultaneously, cardiovascular care has been disrupted, with clinicians less likely to prescribe guideline indicated medications for common cardiovascular conditions such as stable coronary artery disease or heart failure. Excess deaths have also occurred during the COVID-19 pandemic, particularly among vulnerable populations, raising the possibility of suboptimal healthcare utilization or quality of care among those not directly infected by the virus. However, the extent to which cardiovascular healthcare utilization and quality of care have decreased during the pandemic compared with preceding time periods and whether these changes have impacted Veterans’ risk of mortality is unknown. Significance: Cardiovascular disease is the most common condition in the United States and the leading cause of excess, non-COVID deaths during the early pandemic. The proposed work may identify gaps in VA healthcare utilization and quality of care with the potential to directly inform national improvements in cardiovascular care for Veterans, leading to more accessible, higher-quality, more equitable care in the future. In addition, the evaluation of care for cardiovascular disease could serve as a model for future research in other disciplines within Veterans Affairs medical specialty care. Specific Aims: Aim 1: Compare inpatient and outpatient utilization (clinic visits / hospitalizations / diagnostic testing / procedural care) among Veterans with common cardiovascular diagnoses (atrial fibrillation / coronary artery disease / heart failure) during the COVID-19 pandemic compared with expected utilization based on the corresponding 3-year period preceding the pandemic. Aim 2: Compare quality of care (guideline indicated medication / transitions of care) among Veterans with common cardiovascular diagnoses (atrial fibrillation / coronary artery disease / heart failure) during the COVID- 19 pandemic with that expected based on the corresponding 3-year period preceding the pandemic. Aim 3: Evaluate whether potential pandemic-related changes in healthcare utilization and/or process of care quality metrics are associated with an increased risk for the clinical outcomes of all-cause mortality and/or cardiovascular mortality among Veterans with common cardiovascular diagnoses. Methodology: We propose an observational, retrospective, national cohort study of Veterans with cardiovascular disease. The primary data sources will consist of the VA Corporate Data Warehouse (CDW) and the Non-VA Care Program Integrity Tools (PIT) system. Using indirect standardization, we will compare potential decreases in cardiovascular healthcare utilization and quality of care and a potential increase in mortality to that which occurred prior to the pandemic, performing subgroup analyses focused on age, sex and gender, and race and ethnicity as allowed by sample sizes. In mediation analyses, we will then assess whether the changes in utilization and quality of care were associated with an increased risk of mortality. Next Steps/Implementation: A stakeholder advisory panel, led by VA operational leaders, investigators, and Veterans, will be convened to develop comprehensive recommendations to optimize the access, quality, and equity of VA cardiovascular care and guide VA policies in the late-COVID-19 and/or post-COVID-19 pandemic period.