Healthcare System Resilience and Adaptation: A 6-Year Analysis of Heart Failure Care in the Veterans Affairs System

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BACKGROUND: The Veterans Health Administration (VA) healthcare system cares for almost 200 000 Veterans with heart failure with reduced ejection fraction. It is not known how this population fared regarding continuity of care quality measures and access over the past 6 years, including during the COVID-19 pandemic and its aftermath. This study describes temporal trends in heart failure care delivery and clinical outcomes for Veterans with heart failure with reduced ejection fraction from January 1, 2019 to December 31, 2024. METHODS: An interrupted time series analysis examined care patterns across prepandemic, early COVID, and late COVID periods using linear regression models with monthly fixed effects. RESULTS: The study included 210 535 individuals (mean age, 73.1 years; 2.2% women; mean ejection fraction, 32.8%). Heart failure with reduced ejection fraction medication prescriptions were maintained or improved over the 6-year study, with upward trends for most medications in the early COVID period and for all medications in the late COVID period (range, 0.1-0.9 percentage point increase per 6-week period, compared with pre-COVID baseline), although treatment gaps for all medication classes persisted. The onset of COVID led to a 2- to 4-fold increase in telehealth utilization (primary care, 12.4 [95% CI, 9.5-15.2] percentage points; cardiology, 5.5 [95% CI, 4.5-6.5] percentage points). There was a 31% relative decrease in all-cause hospitalization and 27% relative decrease in heart failure hospitalization, but a 13% increase in mortality at pandemic onset, compared with pre-COVID baseline. CONCLUSIONS: Heart failure with reduced ejection fraction medication rates for Veterans were generally sustained or improved during the study period, but care gaps remain. Telehealth replaced some in-person primary and specialty care early in the pandemic, and in-person primary care has sustained at lower rates than before the pandemic. The rate of hospitalization sustained at lower levels while mortality has increased.

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