Research and Quality Improvement Publications
Research and Quality Improvement Publications
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This site is operated in my personal capacity. Citations and links are provided for convenience. Institutional references identify where the work was performed at the time and do not indicate current affiliation, sponsorship, or endorsement by those institutions or by my current employer or research group. External sites are subject to their own terms. Copyright remains with the respective rights holders.
Persistent Inpateint Delirium Associated with Increased Length of Stay and Mortality
University of Miami, Miami VA GRECC and University of Louisville
Introduction: Delirium is associated with an increased risk of post-hospitalization mortality. However, the impact of persistent delirium on mortality is not well defined.
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Methods: We conducted a retrospective cohort study on the association of non-persistent or persistent delirium and mortality. We included patients aged > 65 years admitted to the Owensboro Health Regional Hospital between August 2021 and August 2022. Delirium was determined based on a score of ≥ 2 on the Nurse Delirium Screening Scale (NuDESC) recorded on all admitted patients three times a day during nursing shift change. Multivariate logistic regression models were used to evaluate the association between non-persistent or persistent delirium and 30-day, 60-day, 90-day, 180-day, and 360-day mortality after adjusting for covariates. Sensitivity analysis was performed to compare different definitions of delirium as ≥ 2, ≥ 3, or ≥ 4 days of delirium occurring consecutively or non-consecutively.
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Results: 4560 hospitalized patients were included in this study. Of these, 634 (13.9%) were identified as having delirium (persistent or non-persistent) and 3926 (86.1%) as without delirium. Patients with delirium were slightly older than those without (77 ± 7.9 vs. 79.5 ± 8.5 years old). The patients in each group were relatively comparable in terms of sex, race, smoking status, Medicare user status, and comorbidities. After adjusting for comorbidities, delirium was associated with an increase of mortality at 30 days for patients with persistent delirium of 2 days (aOR 4.88, 95% CI 3.63–6.54), 3 days (aOR 5.64, 95% CI 3.95–7.98), 4 days (aOR 7.21, 95% CI 4.74–10.8). Persistent delirium was associated with higher 60-day, 90-day, 180-day, and 360-day mortality rates, with an incremental increase in the risk of mortality for each additional day of delirium.
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Conclusion: Persistent delirium is consistently associated with increased mortality, with an increased risk of mortality for each additional day of delirium, underscoring the need for early identification and treatment.
Lower Cancer Incidence Three Years after COVID-19 Infection in a Large Veteran Population
University of Miami and Miami VA GRECC
Introduction: The role of COVID-19 infection in cancer incidence risk is not known. COVID-19 infection may lead to increased cancer risk, as seen with other viruses, or to decreased risk due to the activation of the immune response during acute infection. This study aimed to determine the association between cancer incidence in US Veterans and COVID-19 infection.
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Methods: We conducted a retrospective cohort study of US Veterans comparing those who tested positive for COVID-19 during the first wave of COVID-19 between March 15, 2020, and Nov 30, 2020, to those who tested negative. We used data from the COVID-19 Shared Data Resource and Cox proportional hazard regression models to determine the hazard ratio of a new cancer diagnosis within a three-year follow-up period for the COVID-19 positive patients compared to those who were negative. Covariates included age, race, ethnicity, sex, BMI, smoking, being an active patient in the VHA system within a year of the COVID-19 test, and other factors.
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Results: 499,396 patients were included in this study, with 88590 (17.2%) COVID-19 positive, 427566 (82.8%) COVID-19 negative. The ages of the COVID-19 positive and negative patients were 57.9 ± 16.4 and 59.5 ± 15.8, respectively. For those who survived for at least 30 days after COVID-19 testing, COVID-19 infection was associated with a 25% reduction in the hazard of cancer (HR = 0.75, 95% CI: 0.73–0.77). The reduction of the hazard was similar across sexes and races, except in Asians. Above 45 years of age, the hazard of cancer incidence further decreased with advancing age.
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Conclusion: Patients who were diagnosed with COVID-19 in the first wave of the pandemic had a decreased risk of cancer incidence in a 3-year follow-up across gender and race. Further multicenter prospective cohort studies are needed to evaluate the mechanism of this interaction.
Long COVID Frailty: A Comparative Analysis in a Veteran Population
University of Miami and Miami VA GRECC
Abstract: Long COVID is characterized by persistent symptoms affecting one or more organ systems for at least 3 months following a SARS-CoV-2 infection. Our study aimed to examine the characteristics of frailty seen in patients with Long COVID compared to the frailty seen in aging patients with multimorbidity. This is a retrospective cohort study conducted in the Miami Veterans Affairs Medical Center (VAMC). The data used to calculate the Fried phenotype through the Johns Hopkins frailty calculator was collected from two separate clinics, a Long COVID clinic and a geriatric frailty clinic. We obtained the VA Frailty Index from VA CDW (Corporate Data Warehouse). We included 106 patients from the Long COVID clinic and 97 from the frailty clinic. Patients from the Long COVID clinic were significantly younger than those from the frailty clinic (60 ± 12.6 vs. 79.8 ± 5.8, p < 0.01). Patients with frailty in the Long COVID group experienced exhaustion (96.4% vs. 53.3%) and low activity (78.6% vs. 63.3%) at a higher rate than those in the geriatric frailty clinic. Long COVID may predispose patients to develop frailty that presents with a higher frequency of exhaustion and low activity.
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The Effects of SSRIs and Antipsychotics on Long COVID Development in a Large Veteran Population
University of Miami and Miami VA GRECC
Abstract: The development of Long COVID is a complex disease process that may be partially driven by neuroinflammation. Antipsychotics have been shown to exert neuroprotective effects under certain conditions. Our study aimed to determine if veterans treated with antipsychotics and/or selective serotonin reuptake inhibitors (SSRIs) for a psychiatric condition had a reduced risk of developing long-term COVID. We conducted a retrospective cohort study with two cohorts of patients based on the COVID-19 wave in which the patient’s initial infection occurred (Cohort 1: alpha/beta waves, and Cohort 2: delta/omicron waves) with stratification by age. A multivariate logistic regression model was used to evaluate the association between the use of antipsychotics and Long COVID diagnosis. In Cohort 1, antipsychotic use was associated with 43% and 34% reductions in the odds of developing Long COVID in patients aged <65 and >65 years, respectively. This association was reduced in the second cohort to 11% in patients aged <65 years and without an association over 65 years of age. SSRIs showed no benefit in either age group or cohort. Our results show that antipsychotic use for the treatment of a mental health condition was associated with a reduction in the risk of developing Long COVID, and the magnitude of this reduction varied between COVID-19 cohorts.
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The Association of Non-severe COVID-19 Infection and Progression to Frailty Among Robust Older Veterans
University of Miami and Miami VA GRECC
Background: Studies have shown that frailty was increased in hospitalized COVID-19 patients. However, it is not clear whether non-severe COVID-19 increases the risk for pre-frailty and frailty development. Our study aimed to determine the risk of developing frailty and pre-frailty in robust veterans who contracted non-severe COVID-19.
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Methods: We conducted a retrospective cohort study to assess the association of SARS-CoV-2 infection with the development of pre-frailty and frailty status among robust U.S. veterans using VA COVID-19 Shared Data Resource. We included patients 55 years and older who had at least one SARS-CoV-2 testing between March 15, 2020, and November 30, 2020, had been active patients in the past 12 months, and had a VA frailty index of zero (robust status) at the time of testing. Cox proportional hazard model was used to assess the association between COVID-19 infection and developing frailty or pre-frailty and frailty. We also assessed the association by patients’ age groups, sex, and race.
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Findings: We identified 82070 veterans mean age 68.3 ± 7.8, 74738 (91.1%) male, 53899 (65.7%) white, 7557 (9.2%) with mild COVID-19 infection. Over the follow up period of 36 months, testing positive for COVID-19 was associated with a 66% increase in the hazard of becoming frail (adjusted HR = 1.66, 95%CI: 1.32–2.08), and a 68% increase in the hazard of becoming pre-frail (adjusted HR = 1.68, 95%CI: 1.45–1.94). Among male patients, mild COVID-19 infection was associated with a 54% increase in the hazard of becoming frail (adjusted HR = 1.54, 95% CI: 1.21−1.96), while among female patients there was a 330% increase (adjusted HR = 4.30, 95% CI: 2.13−8.64).
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Conclusions and Relevance: Non-severe COVID-19 infection that occurred in robust older adults increased the risk of developing frailty. Further multi-center prospective cohort studies evaluating the mechanism of action and clinical trials of treatment options for post-COVID frailty are indicated in Veterans to support clinical care.