Quality of care for Veterans with heart failure with reduced ejection fraction before, during, and after the COVID-19 pandemic

Abstract:Heart failure is a highly prevalent and morbid disease. The US Department of Veterans Affairs healthcare system spans 1,380 healthcare facilities caring for 200,000 Veterans with a diagnosis of heart failure. The purpose of this dissertation is to provide a comprehensive evaluation of heart failure quality for Veterans with heart failure with reduced ejection fraction from 2019-2024, including the COVID-19 pandemic, examining temporal changes in medication use, healthcare utilization, hospitalizations, and mortality and characterizing racial and ethnic differences in the same outcomes. The first paper, “National Trends of Healthcare Utilization and Outcomes for US Veterans with Heart Failure During the COVID-19 Pandemic,” used an interrupted time series and a survival analysis to comprehensively describe care patterns and prognostic factors for mortality and hospitalization among Veterans with heart failure with reduced ejection fraction. The study found an increased use of guideline directed medical therapy over the past 6 years, as well as increased use of telehealth, sustained decrease in hospitalizations, and sustained increase in mortality, compared to the pre-COVID period. Cumulative survival for the cohort was 56.1% at 6 years, with prognostic factors that include age, sex, and cardiac comorbidities. The second paper, “Applying Statistical Process Control to Assess Healthcare System Quality for US Veterans with Heart Failure,” used advanced Shewhart methodology to evaluate change over the same timeframe. This method for learning from variation revealed that newer-to-market medications had consistent growth while older medications had phases of stability and of growth in this period. Conclusions about telehealth use, hospitalizations, and mortality trends are consistent with the interrupted time series results in the first paper. The third paper, “Racial/Ethnic Differences in Healthcare Utilization and Outcomes for US Veterans with Heart Failure in the COVID-19 Pandemic and Its Aftermath,” compared heart-failure related healthcare utilization and outcomes in racial and ethnic minorities. Compared to the White reference group, racial and ethnic minorities had similar rates of medication use, used more telehealth, had increased risk of hospitalization, and had lower risk of mortality.