Healthcare System Resilience and Adaptation: A Six-Year Analysis of Heart Failure Care in the Veterans Affairs System

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Abstract Background The Veterans Health Administration (VA) healthcare system cares for almost 200,000 Veterans with heart failure with reduced ejection fraction (HFrEF). It is not known how this population fared regarding continuity of care quality measures and access over the past 6 years, including the COVID-19 pandemic and its aftermath. This study aimed to evaluate temporal trends in heart failure care delivery and identify prognostic factors for clinical outcomes for Veterans with HFrEF from 1/1/2019-12/31/2024. Methods An interrupted time series analysis examined care patterns across pre-pandemic, early COVID, and late COVID periods using linear regression models with monthly fixed effects. Survival analysis of Veterans with HFrEF identified prognostic factors for mortality and hospitalization. Results The study included 210,535 individuals (mean age 73.1; 2.2% women; mean ejection fraction 32.5%). HFrEF medication prescriptions were maintained or improved, with upward trends for most medications in the early COVID period and all medications in the late COVID period (range: 0.1-0.9 percentage point increase per 6-week period, compared to pre-COVID baseline), yet with significant treatment gaps for all medication classes by study end. The onset of COVID led to a 2-4-fold increase in telehealth utilization (primary care: 18.2 percentage points, 95% CI: 14.7 to 21.6; cardiology: 8.6 percentage points, 95% CI: 7.4 to 9.8). There was a sustained 45% relative decrease in all-cause hospitalization and 40% relative decrease in heart failure hospitalization, but a sustained 20% increase in mortality. Cumulative survival was 56.1% at 6 years. Conclusions HFrEF medication rates were generally sustained or improved but well below optimal levels for Veterans with HFrEF. Telehealth replaced some in-person care early in the pandemic. Despite these changes, this high-risk population experienced a sustained decrease in hospitalizations and increase in mortality. Clinical Perspective What is new? Veterans with heart failure with reduced ejection fraction increasingly used guideline directed medical therapy over the past 6 years with significant gaps remaining. There was an increased use of telehealth, sustained decrease in hospitalizations, and sustained increase in all-cause mortality for this patient population, compared to pre-COVID trends. What are the clinical implications? The sustained increase in mortality despite maintained medication access and successful telehealth implementation suggests that traditional care quality measures may not fully capture patient care associated with outcomes during major healthcare disruptions, warranting further investigation and validation in other health systems.

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