Racial and ethnic disparities in excess mortality among U.S. veterans during the COVID-19 pandemic

Objective: The COVID-19 pandemic disproportionately affected racial and ethnic minorities among the general population in the United States; however, little is known regarding its impact on U.S. military Veterans. In this study, our objectives were to identify the extent to which Veterans experienced increased all-cause mortality during the COVID-19 pandemic, stratified by race and ethnicity. Data Sources: Administrative data from the Veterans Health Administration's Corporate Data Warehouse. Study Design: We use pre-pandemic data to estimate mortality risk models using five-fold cross-validation and quasi-Poisson regression. Models were stratified by a combined race-ethnicity variable and included controls for major comorbidities, demographic characteristics, and county fixed effects. Data Collection: We queried data for all Veterans residing in the 50 states plus Washington D.C. during 2016-2020. Veterans were excluded from analyses if they were missing county of residence or race-ethnicity data. Data were then aggregated to the county-year level and stratified by race-ethnicity. Principal Findings: Overall, Veterans' mortality rates were 16% above normal during March-December 2020 which equates to 42,348 excess deaths. However, there was substantial variation by racial and ethnic group. Non-Hispanic White Veterans experienced the smallest relative increase in mortality (17%, 95% CI 11%-24%), while Native American Veterans had the highest increase (40%, 95% CI 17%-73%). Black Veterans (32%, 95% CI 27%-39%) and Hispanic Veterans (26%, 95% CI 17%-36%) had somewhat lower excess mortality, although these changes were significantly higher compared to White Veterans. Disparities were smaller than in the general population. Conclusions: Minoritized Veterans experienced higher rates excess of mortality during the COVID-19 pandemic compared to White Veterans, though with smaller differences than the general population. This is likely due in part to the long-standing history of structural racism in the United States that has negatively affected the health of minoritized communities via several pathways including health care access, economic, and occupational inequities. KEYWORDS quality of care/patient safety (measurement), racial/ethnic differences in health and health care, VA health care system What is known on this topic * Minoritized individuals in the United States were overrepresented in occupations at risk of COVID-19 exposure and have higher rates of comorbidities associated with risk of COVID-19 mortality. * Place-based factors, such as the zip code of residence have put racially minoritized individuals at increased risk for COVID-19 exposure and mortality, driven by structural racism. * Prior work with limited data and control variables identified disparities in all-cause mortality between White, Black, and Hispanic Veterans. What this study adds * This study uses a validated prediction model to estimate expected mortality among Veterans, relying on five years of data and controls for disease burden. * Excess mortality among minoritized Veterans was higher for Native American/Alaska Native, Black, Hispanic, and Asian/Pacific Islander Veterans as compared to White Veterans during the COVID-19 pandemic. These disparities were smaller in magnitude than those found in the U.S. general population. * Efforts to address structural racism within the VHA may account for lower disparities in excess mortality between racial and ethnic groups during the COVID-19 pandemic as compared to the general population.
1 | INTRODUCTION The long-standing history of structural racism in the United States negatively affects the health of minoritized communities via several pathways including reduced health care access and economic [...]