Analyze the following R data that is attached and formulate a 15 page written report on the following topic: Factors associated with hospitalization and mortality from COVID-19. Cite a minimum of 8 re
Original Investigation| Infectious DiseasesRisk Factors for Hospitalization, Mechanical Ventilation,
or Death Among 10 131 US Veterans With SARS-CoV-2 Infection
George N. Ioannou, BMBCh, MS; Emily Locke, MPH; Pamela Green, PhD; Kristin Berry, PhD; Ann M. O’Hare, MD; Javeed A. Shah, MD; Kristina Crothers, MD;
McKenna C. Eastment, MD; Jason A. Dominitz, MD, MHS; Vincent S. Fan, MD, MS
Abstract
IMPORTANCEIdentifying independent risk factors for adverse outcomes in patients infected with
severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can support prognostication,
resource utilization, and treatment.
OBJECTIVETo identify excess risk and risk factors associated with hospitalization, mechanical
ventilation, and mortality in patients with SARS-CoV-2 infection.
DESIGN, SETTING, AND PARTICIPANTSThis longitudinal cohort study included 88 747 patients
tested for SARS-CoV-2 nucleic acid by polymerase chain reaction between Feburary 28 and May 14,
2020, and followed up through June 22, 2020, in the Department of Veterans Affairs (VA) national
health care system, including 10 131 patients (11.4%) who tested positive.
EXPOSURESSociodemographic characteristics, comorbid conditions, symptoms, and laboratory
test results.
MAIN OUTCOMES AND MEASURESRisk of hospitalization, mechanical ventilation, and death were
estimated in time-to-event analyses using Cox proportional hazards models.
RESULTSThe 10 131 veterans with SARS-CoV-2 were predominantly male (9221 [91.0%]), with
diverse race/ethnicity (5022 [49.6%] White, 4215 [41.6%] Black, and 944 [9.3%] Hispanic) and a
mean (SD) age of 63.6 (16.2) years. Compared with patients who tested negative for SARS-CoV-2,
those who tested positive had higher rates of 30-day hospitalization (30.4% vs 29.3%; adjusted
hazard ratio [aHR], 1.13; 95% CI, 1.08-1.13), mechanical ventilation (6.7% vs 1.7%; aHR, 4.15; 95% CI,
3.74-4.61), and death (10.8% vs 2.4%; aHR, 4.44; 95% CI, 4.07-4.83). Among patients who tested
positive for SARS-CoV-2, characteristics significantly associated with mortality included older age
(eg, 80 years vs <50 years: aHR, 60.80; 95% CI, 29.67-124.61), high regional COVID-19 disease
burden (eg, 700 vs <130 deaths per 1 million residents: aHR, 1.21; 95% CI, 1.02-1.45), higher
Charlson comorbidity index score (eg, 5 vs 0: aHR, 1.93; 95% CI, 1.54-2.42), fever (aHR, 1.51; 95%
CI, 1.32-1.72), dyspnea (aHR, 1.78; 95% CI, 1.53-2.07), and abnormalities in the certain blood tests,
which exhibited dose-response associations with mortality, including aspartate aminotransferase
(>89 U/L vs 25 U/L: aHR, 1.86; 95% CI, 1.35-2.57), creatinine (>3.80 mg/dL vs 0.98 mg/dL: aHR,
3.79; 95% CI, 2.62-5.48), and neutrophil to lymphocyte ratio (>12.70 vs 2.71: aHR, 2.88; 95% CI,
2.12-3.91). With the exception of geographic region, the same covariates were independently
associated with mechanical ventilation along with Black race (aHR, 1.52; 95% CI, 1.25-1.85), male sex
(aHR, 2.07; 95% CI, 1.30-3.32), diabetes (aHR, 1.40; 95% CI, 1.18-1.67), and hypertension (aHR, 1.30;
95% CI, 1.03-1.64). Notable characteristics that were not significantly associated with mortality in
adjusted analyses included obesity (body mass index 35 vs 18.5-24.9: aHR, 0.97; 95% CI, 0.77-1.21),
Black race (aHR, 1.04; 95% CI, 0.88-1.21), Hispanic ethnicity (aHR, 1.03; 95% CI, 0.79-1.35), chronic
(continued)
Key Points
QuestionWhat are the risk factors
associated with hospitalization,
mechanical ventilation, and death
among patients with severe acute
respiratory syndrome coronavirus 2
(SARS-CoV-2) infection?
FindingsIn this national cohort study
of 88 747 veterans tested for SARS-
CoV-2, hospitalization, mechanical
ventilation, and mortality were
significantly higher in patients with
positive SARS-CoV-2 test results than
among those with negative test results.
Significant risk factors for mortality
included older age, high regional
coronavirus disease 2019 burden, higher
Charlson Comorbidity Index score, fever,
dyspnea, and abnormal results in many
routine laboratory tests; however,
obesity, Black race, Hispanic ethnicity,
chronic obstructive pulmonary disease,
hypertension, and smoking were not
associated with mortality.
MeaningIn this study, most deaths
from SARS-CoV-2 occurred in patients
with age of 50 years or older, male sex,
and greater comorbidity burden.
+ Supplemental content
Author affiliations and article information are
listed at the end of this article.
Open Access.This is an open access article distributed under the terms of the CC-BY License.
JAMA Network Open.2020;3(9):e2022310. doi:10.1001/jamanetworkopen.2020.22310(Reprinted)September 23, 2020 1/18Downloaded From: https://jamanetwork.com/ on 10/29/2020 Abstract (continued)
obstructive pulmonary disease (aHR, 1.02; 95% CI, 0.88-1.19), hypertension (aHR, 0.95; 95% CI,
0.81-1.12), and smoking (eg, current vs never: aHR, 0.87; 95% CI, 0.67-1.13). Most deaths in this cohort
occurred in patients with age of 50 years or older (63.4%), male sex (12.3%), and Charlson
Comorbidity Index score of at least 1 (11.1%).
CONCLUSIONS AND RELEVANCEIn this national cohort of VA patients, most SARS-CoV-2 deaths
were associated with older age, male sex, and comorbidity burden. Many factors previously reported
to be associated with mortality in smaller studies were not confirmed, such as obesity, Black race,
Hispanic ethnicity, chronic obstructive pulmonary disease, hypertension, and smoking.
JAMA Network Open.2020;3(9):e2022310. doi:10.1001/jamanetworkopen.2020.22310
Introduction
Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has a very broad
spectrum of clinical severity, ranging from asymptomatic infection to life-threatening illness. 1,2It
remains unclear why some patients infected with SARS-CoV-2 develop the severe complications of
coronavirus disease 2019 (COVID-19), which include acute respiratory distress syndrome (ARDS)
and death.
Multiple risk factors for developing severe COVID-19 disease have been reported, including
sociodemographic factors and comorbid conditions.
1,3-24 However, mostprior studies, particularly
those published earlier in the course of the pandemic, did not include multivariable adjustment to
identify independent risk factors, and few studies examined a range of different disease outcomes,
including hospitalization, mechanical ventilation, and death. Most prior studies have been local or
regional, rather than national, in scope. Finally, most studies have not compared patients who tested
positive for SARS-CoV-2 with those who tested negative to determine the excess risk associated with
SARS-CoV-2 infection itself as opposed to other underlying comorbid conditions in patients who
happen to have SARS-CoV-2 infection. To address this knowledge gap, we used national data from
the Department of Veterans Affairs (VA) health care system to determine the risk of hospitalization,
mechanical ventilation, and death associated with infection and to identify characteristics
independently associated with these outcomes in patients who tested positive for SARS-CoV-2.
Methods
Data Source and Study Population
The VA supports the largest integrated national health care system in the United States and provides
care for more than 6 million veterans annually. The VA uses a single, national comprehensive
electronic health care information network. We derived data from the VA’s Corporate Data
Warehouse, a data repository of electronic medical records, developed by the VA Informatics and
Computing Infrastructure (VINCI) to facilitate research. To support COVID-19 research, VINCI analysts
created and are continually updating the COVID-19 Shared Data Resource,
25which includes analytic
variables extracted from the Corporate Data Warehouse for all VA enrollees tested for SARS-CoV-2.
Using this resource, we identified all VA enrollees (N = 88 747) who had nasopharyngeal swabs
tested for SARS-CoV-2 nucleic acid by polymerase chain reaction in inpatient or outpatient VA
facilities (including VA nursing homes) between February 28 and May 14, 2020, for any indication,
excluding those who were VA employees. Most tests were performed in VA laboratories using the US
Food and Drug Administration–approved RealTime (Abbott Laboratories) or Xpert-Xpress (Cepheid)
SARS-CoV-2 assays; some were sent to commercial or state public health laboratories, especially
during the early days of the pandemic. Cohort members were followed up through June 22, 2020, JAMA Network Open |Infectious Diseases
Risk Factors for Hospitalization, Mechanical Ventilation, or Death Among Veterans With SARS-CoV-2
JAMA Network Open.2020;3(9):e2022310. doi:10.1001/jamanetworkopen.2020.22310(Reprinted)September 23, 2020 2/18Downloaded From: https://jamanetwork.com/ on 10/29/2020 for study outcomes allowing for a minimum follow-up of 39 days. This study was approved by the
institutional review board of the Veterans Affairs Puget Sound Healthcare System, which granted a
waiver of informed consent because this was a retrospective cohort study based on an existing
database. This study followed the Strengthening the Reporting of Observational Studies in
Epidemiology (STROBE) reporting guideline.
Definition of Positive or Negative SARS-CoV-2 Status and Index Date
Patients were defined as positive for SARS-CoV-2 if they had at least 1 positive polymerase chain
reaction test (n = 10 131 [11.4%]) during the ascertainment period. Patients were defined as negative
for SARS-CoV-2 if all polymerase chain reaction tests were negative (n = 78 616 [88.6%]). Final
adjudication of SARS-CoV-2 status was performed by the VA National Surveillance Tool, which is
intended to be the single, authoritative data source for the determination of positive and negative
cases within the Veterans Health Administration. Theindex datefor all analyses was defined as the
date of the earliest positive test (for patients with SARS-CoV-2) or the date of the earliest negative
test (for patients with no SARS-CoV-2), unless the patient had been admitted to a VA hospital during
the preceding 15 days, in which case the date of admission served as the index date.
Adverse Outcomes
We determined the following 3 outcomes: (1) hospitalization at the index date or within 15 days of the
index date, (2) mechanical ventilation at the index date or within 60 days, and (3) all-cause mortality
at any time after the index date. Deaths that occurred both in and out of the VA are comprehensively
captured in the Corporate Data Warehouse through a variety of sources, including VA inpatient files,
VA Beneficiary Identification and Records Locator System, Social Security Administration death files,
and the Department of Defense.
26Episodes of mechanical ventilation and hospitalization that
occurred outside the VA were captured only if the VA paid for these hospitalizations at non-VA
facilities under the VA Community Care program.
Baseline Characteristics Evaluated for Associations With Adverse Outcomes
We included characteristics that were evaluated in prior studies or that we hypothesized might be
associated with adverse outcomes. Baseline sociodemographic characteristics included age, sex,
race, ethnicity, body mass index (calculated as weight in kilograms divided by height in meters
squared), urban vs rural residence (based on zip codes), and regional per capita COVID-19–related
mortality, operationalized as the number of COVID-19–related deaths per million residents in each
participant’s state of residence as of June 11, 2020 (Table 1).
27
Comorbid conditions were extracted by VINCI analysts based onInternational Classification of
Diseases and Related Health Problems, Tenth Revision(ICD-10) recorded in VA electronic health
records during the 2-year period on or before the index date.
25We used the Charlson Comorbidity
Index (CCI) to estimate the overall burden of comorbidity (Table 2).
We also included documented symptoms thought to be related to SARS-CoV-2, identified by
VINCI analysts based on a combination of natural language processing of text notes in patients’
electronic medical records and searching for relevantICD-10codes,
25occurring on or within 30 days
prior to the index date (Table 3). We do not report associations with loss of smell or taste, given that
these symptoms were not widely recognized during the ascertainment period and thus rarely
reported.
We analyzed 13 routinely available laboratory blood tests (Table 4). For each test, we extracted
the value closest to the index date, on or within 10 days before the index date, or, if absent, within 5
days after the index date (2539 of 2905 [87.4%] were performed within 2 days of the index date). JAMA Network Open |Infectious Diseases
Risk Factors for Hospitalization, Mechanical Ventilation, or Death Among Veterans With SARS-CoV-2
JAMA Network Open.2020;3(9):e2022310. doi:10.1001/jamanetworkopen.2020.22310(Reprinted)September 23, 2020 3/18Downloaded From: https://jamanetwork.com/ on 10/29/2020 Table 1. Associations Between Sociodemographic Characteristics and Hospitalization, Mechanical Ventilation, or Mortality Among 10 131 PatientsWho Tested Positive for SARS-CoV-2
Between February 28 and May 14, 2020 Demographic factor Patients, No. (%)Hospitalization Mechanical ventilation Mortality
30-d
Rate, %Hazard ratio (95% CI)
30-d
Rate, %Hazard ratio (95% CI)
30-d
Rate, %Hazard ratio (95% CI)
Age-adjusted Adjusted
a
Age-adjusted Adjusted
a
Age-adjusted Adjusted
a
All patients 10 131 (100) 34.2 NA NA 6.7 NA NA 10.8 NA NA
Sex Women 910 (9.0) 19.6 1 [Reference] 1 [Reference] 2.1 1 [Reference] 1 [Reference] 2.8 1 [Reference] 1 [Reference] Men 9221 (91.0) 35.7 1.37 (1.18-1.60) 1.22 (1.04-1.42) 7.2 2.28 (1.43-3.63) 2.07 (1.30-3.32) 11.6 1.52 (1.02-2.25) 1.38 (0.93-2.06)
Age, y 1.03 (1.02-1.03) 1.02 (1.02-1.03) 1.03 (1.02-1.03) 1.03 (1.02-1.03) 1.07 (1.07-1.08) 1.07 (1.06-1.08) 18-49 1973 (19.5) 14.9 1 [Reference] 1 [Reference] 1.6 1 [Reference] 1 [Reference] 0.4 1 [Reference] 1 [Reference] 50-64 2917 (28.8) 30.7 2.21 (1.94-2.52) 1.76 (1.53-2.02) 6.0 3.89 (2.65-5.70) 2.72 (1.82-4.05) 4.1 10.35 (5.06-21.19) 9.27 (4.51-19.08) 65-79 3724 (36.8) 43.4 3.27 (2.88-3.70) 2.40 (2.08-2.77) 10.1 6.69 (4.63-9.67) 4.32 (2.88-6.47) 13.8 36.37 (18.08-73.16) 27.47 (13.48-55.99) ≥80 1517 (15.0) 44.1 3.62 (3.15-4.16) 2.94 (2.50-3.46) 6.7 4.87 (3.24-7.31) 3.98 (2.54-6.24) 29.7 82.22 (40.82-165.63) 60.80 (29.67-124.61)
Race White 5022 (49.6) 30.7 1 [Reference] 1 [Reference] 5.2 1 [Reference] 1 [Reference] 12.2 1 [Reference] 1 [Reference] Black 4215 (41.6) 39.9 1.30 (1.20-1.40) 1.13 (1.04-1.23) 8.9 1.64 (1.37-1.97) 1.52 (1.25-1.85) 9.6 1.09 (0.93-1.26) 1.04 (0.88-1.21) Asian 80 (0.8) 28.8 1.17 (0.78-1.77) 1.20 (0.79-1.81) 6.3 1.68 (0.68-4.17) 2.17 (0.87-5.45) 7.5 1.67 (0.72-3.87) 1.99 (0.85-4.65) American Indian or
American Native,
Native Hawaiian or
Pacific Islander140 (1.4) 21.5 0.74 (0.51-1.06) 0.74 (0.52-1.06) 8.0 1.81 (0.97-3.36) 1.69 (0.90-3.19) 11.5 1.59 (0.95-2.66) 1.67 (0.99-2.82) Missing or unknown 674 (6.7) 28.4 0.97 (0.83-1.13) 1.03 (0.87-1.22) 4.5 0.96 (0.65-1.41) 1.08 (0.71-1.66) 8.2 0.90 (0.69-1.19) 1.06 (0.78-1.44)
Ethnicity Non-Hispanic 8876 (87.6) 34.9 1 [Reference] 1 [Reference] 6.9 1 [Reference] 1 [Reference] 11.3 1 [Reference] 1 [Reference] Hispanic 944 (9.3) 30.8 1.04 (0.91-1.19) 1.08 (0.94-1.24) 5.7 0.97 (0.72-1.33) 1.09 (0.78-1.52) 7.5 1.05 (0.81-1.36) 1.03 (0.79-1.35) Missing or unknown 311 (3.1) 26.1 0.80 (0.64-1.00) 0.96 (0.75-1.23) 4.5 0.81 (0.48-1.39) 1.06 (0.58-1.92) 6.5 0.63 (0.41-0.98) 0.63 (0.39-1.03)
COVID-19 related deaths
per million residents
b
<130 1925 (19.0) 35.6 1 [Reference] 1 [Reference] 6.8 1 [Reference] 1 [Reference] 9.8 1 [Reference] 1 [Reference] 130-350 2359 (23.3) 32.6 0.94 (0.75-1.17) 0.90 (0.81-1.00) 5.5 0.68 (0.41-1.14) 0.81 (0.63-1.04) 9.9 0.67 (0.46-0.98) 1.13 (0.93-1.37) 350-700 2629 (26.0) 37.4 0.83 (0.65-1.06) 0.89 (0.80-0.98) 8.2 0.99 (0.56-1.72) 0.96 (0.76-1.20) 9.5 0.67 (0.44-1.01) 1.02 (0.84-1.24) ≥700 3218 (31.8) 32.1 0.92 (0.69-1.22) 0.79 (0.72-0.87) 6.4 1.22 (0.63-2.35) 0.90 (0.72-1.13) 13.1 0.68 (0.44-1.05) 1.21 (1.02-1.45)
Urban vs rural Rural or highly rural 2412 (23.8) 26.7 1 [Reference] 1 [Reference] 5.4 1 [Reference] 1 [Reference] 10.2 1 [Reference] 1 [Reference] Urban 7714 (76.1) 36.6 1.28 (1.16-1.41) 1.17 (1.07-1.28) 7.1 1.25 (1.00-1.56) 1.10 (0.91-1.35) 11.0 1.01 (0.85-1.20) 0.92 (0.80-1.07)
BMI at index date 18.5-24.9, indicating
normal weight1889 (18.6) 43.3 1 [Reference] 1 [Reference] 6.5 1 [Reference] 1 [Reference] 16.2 1 [Reference] 1 [Reference] <18.5, indicating
underweight281 (2.8) 57.5 1.25 (1.05-1.48) 1.19 (1.00-1.42) 6.8 1.01 (0.63-1.62) 0.90 (0.56-1.46) 22.9 1.32 (1.01-1.74) 1.29 (0.98-1.70)
(continued)
JAMA Network Open |Infectious Diseases Risk Factors for Hospitalization, Mechanical Ventilation, or Death Among Veterans With SARS-CoV-2
JAMA Network Open.2020;3(9):e2022310. doi:10.1001/jamanetworkopen.2020.22310(Reprinted)September 23, 2020 4/18Downloaded From: https://jamanetwork.com/ on 10/29/2020 Table 1. Associations Between Sociodemographic Characteristics and Hospitalization, Mechanical Ventilation, or Mortality Among 10 131 PatientsWho Tested Positive for SARS-CoV-2
Between February 28 and May 14, 2020 (continued) Demographic factor Patients, No. (%)Hospitalization Mechanical ventilation Mortality
30-d
Rate, %Hazard ratio (95% CI)
30-d
Rate, %Hazard ratio (95% CI)
30-d
Rate, %Hazard ratio (95% CI)
Age-adjusted Adjusted
a
Age-adjusted Adjusted
a
Age-adjusted Adjusted
a
25.0-29.9, indicating
overweight3167 (31.3) 33.2 0.83 (0.76-0.91) 0.84 (0.77-0.93) 6.5 1.14 (0.91-1.43) 1.04 (0.82-1.31) 10.6 0.91 (0.77-1.06) 0.90 (0.77-1.06) 30.0-34.9, indicating
obesity I2574 (25.4) 30.2 0.81 (0.74-0.90) 0.80 (0.72-0.89) 6.4 1.23 (0.97-1.57) 1.03 (0.80-1.33) 7.8 0.86 (0.71-1.03) 0.84 (0.69-1.01) ≥35, indicating
obesity II or III1968 (19.4) 32.2 0.94 (0.84-1.05) 0.87 (0.77-0.98) 8.0 1.71 (1.33-2.20) 1.22 (0.93-1.61) 7.9 1.12 (0.91-1.37) 0.97 (0.77-1.21) Missing 252 (2.5) 11.9 0.37 (0.26-0.53) 0.49 (0.34-0.71) 3.3 0.74 (0.36-1.52) 1.08 (0.52-2.27) 12.1 0.81 (0.55-1.20) 0.86 (0.57-1.30)
Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared);
COVID-19, coronavirus disease 2019; NA, not applicable; SARS-CoV-2, severe acute respiratory syndrome
coronavirus 2. aAdjusted for all sociodemographic characteristics, comorbid conditions, and symptoms listed in Table 1, Table 2,
and Table 3 and stratified by station. bCategorized according to the number of COVID-19 related deaths per million reported by each state as of June
11, 2020,
27categorized as less than 130 per 1 million for Alaska, Arkansas, California, Hawaii, Idaho, Kansas,Kentucky, Maine, Montana, North Carolina, North Dakota, Nebraska, Oklahoma, Oregon, Puerto Rico, South
Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Wisconsin, West Virginia, and Wyoming; 130 to 350
per 1 million for Alabama, Arizona, Colorado, Florida, Georgia, Iowa, Minnesota, Missouri, Mississippi, New
Hampshire, New Mexico, Nevada, Ohio, Virginia, and Washington; 350 to 700 per 1 million for Delaware, Illinois,
Indiana, Louisiana, Maryland, Michigan, and Pennsylvania; and more than 700 per 1 million for Connecticut,
Massachusetts, New Jersey, New York, and Rhode Island. These analyses were not stratified by station to avoid
geographical overadjustment.
JAMA Network Open |Infectious Diseases Risk Factors for Hospitalization, Mechanical Ventilation, or Death Among Veterans With SARS-CoV-2
JAMA Network Open.2020;3(9):e2022310. doi:10.1001/jamanetworkopen.2020.22310(Reprinted)September 23, 2020 5/18Downloaded From: https://jamanetwork.com/ on 10/29/2020 Table 2. Associations Between Comorbid Conditions and Hospitalization, Mechanical Ventilation, or Mortality Among 10 131 VA Patients Who Tested Positive for SARS-CoV-2
Between February 28 and May 14, 2020 Condition Patients, No. (%)Hospitalization Mechanical ventilation Mortality
30-d
Rate, %Hazard ratio (95% CI)
30-d
Rate, %Hazard ratio (95% CI)
30-d
Rate, %Hazard ratio (95% CI)
Age-adjusted Adjusted
a
Age-adjusted Adjusted
a
Age-adjusted Adjusted
a
Diabetes No 6270 (61.9) 28.4 1 [Reference] 1 [Reference] 4.5 1 [Reference] 1 [Reference] 8.9 1 [Reference] 1 [Reference] Yes 3861 (38.1) 43.8 1.31 (1.23-1.41) 1.17 (1.08-1.26) 10.3 1.73 (1.48-2.02) 1.40 (1.18-1.67) 13.8 1.22 (1.08-1.38) 1.13 (0.99-1.29)
Cancer No 7835 (77.3) 31.7 1 [Reference] 1 [Reference] 6.0 1 [Reference] 1 [Reference] 10.0 1 [Reference] 1 [Reference] Yes 2296 (22.7) 43.0 1.13 (1.05-1.22) 0.98 (0.91-1.06) 9.0 1.15 (0.97-1.36) 0.99 (0.84-1.18) 13.4 0.98 (0.86-1.12) 0.92 (0.80-1.05)
Hypertension No 3837 (37.9) 22.7 1 [Reference] 1 [Reference] 3.1 1 [Reference] 1 [Reference] 7.5 1 [Reference] 1 [Reference] Yes 6294 (62.1) 41.3 1.40 (1.29-1.52) 1.15 (1.05-1.26) 8.9 1.84 (1.50-2.26) 1.30 (1.03-1.64) 12.8 1.05 (0.91-1.21) 0.95 (0.81-1.12)
Coronary artery disease No 7928 (78.3) 30.9 1 [Reference] 1 [Reference] 5.8 1 [Reference] 1 [Reference] 8.9 1 [Reference] 1 [Reference] Yes 2203 (21.7) 46.4 1.23 (1.14-1.33) 1.04 (0.95-1.13) 10.0 1.27 (1.07-1.50) 0.95 (0.78-1.15) 17.5 1.18 (1.04-1.34) 1.02 (0.88-1.18)
Congestive heart failure No 9006 (88.9) 31.7 1 [Reference] 1 [Reference] 5.9 1 [Reference] 1 [Reference] 9.3 1 [Reference] 1 [Reference] Yes 1125 (11.1) 55.1 1.45 (1.32-1.59) 1.05 (0.95-1.17) 13.2 1.68 (1.39-2.04) 1.08 (0.86-1.36) 22.8 1.54 (1.33-1.78) 1.30 (1.10-1.54)
Cerebrovascular disease No 9770 (96.4) 33.8 1 [Reference] 1 [Reference] 6.6 1 [Reference] 1 [Reference] 10.4 1 [Reference] 1 [Reference] Yes 361 (3.6) 47.7 1.16 (1.00-1.36) 1.00 (0.86-1.18) 9.2 1.07 (0.75-1.54) 0.92 (0.63-1.32) 21.2 1.31 (1.04-1.67) 1.22 (0.96-1.55)
Dialysis No 9786 (96.6) 33.4 1 [Reference] 1 [Reference] 6.6 1 [Reference] 1 [Reference] 10.6 1 [Reference] 1 [Reference] Yes 345 (3.4) 59.3 1.53 (1.32-1.76) 1.06 (0.91-1.24) 10.4 1.18 (0.84-1.65) 0.76 (0.52-1.09) 16.5 1.23 (0.94-1.62) 0.83 (0.62-1.11)
Chronic kidney disease No 8264 (81.6) 30.0 1 [Reference] 1 [Reference] 5.6 1 [Reference] 1 [Reference] 8.8 1 [Reference] 1 [Reference] Yes 1867 (18.4) 53.3 1.49 (1.38-1.61) 1.21 (1.11-1.32) 11.7 1.57 (1.32-1.85) 1.16 (0.96-1.41) 19.5 1.41 (1.24-1.61) 1.25 (1.08-1.45)
Cirrhosis No 9836 (97.1) 33.7 1 [Reference] 1 [Reference] 6.6 1 [Reference] 1 [Reference] 10.6 1 [Reference] 1 [Reference] Yes 295 (2.9) 53.5 1.47 (1.25-1.72) 1.27 (1.08-1.49) 12.0 1.54 (1.09-2.19) 1.39 (0.97-2.00) 16.9 1.76 (1.33-2.34) 1.55 (1.16-2.07)
Asthma No 9386 (92.6) 34.3 1 [Reference] 1 [Reference] 6.6 1 [Reference] 1 [Reference] 11.0 1 [Reference] 1 [Reference] Yes 745 (7.4) 33.9 1.08 (0.95-1.22) 0.99 (0.87-1.13) 7.7 1.29 (0.99-1.69) 1.06 (0.80-1.41) 7.8 0.85 (0.65-1.11) 0.80 (0.60-1.05)
COPD No 8228 (81.2) 31.3 1 [Reference] 1 [Reference] 5.8 1 [Reference] 1 [Reference] 9.5 1 [Reference] 1 [Reference] Yes 1903 (18.8) 47.0 1.27 (1.17-1.37) 1.05 (0.96-1.14) 10.7 1.44 (1.21-1.71) 1.20 (0.99-1.45) 16.3 1.15 (1.00-1.32) 1.02 (0.88-1.19)
Obstructive sleep apnea No 7411 (73.2) 32.9 1 [Reference] 1 [Reference] 5.8 1 [Reference] 1 [Reference] 11.2 1 [Reference] 1 [Reference] Yes 2720 (26.8) 38.0 1.21 (1.13-1.31) 1.07 (0.99-1.17) 9.2 1.64 (1.39-1.93) 1.22 (1.01-1.46) 9.6 1.19 (1.03-1.37) 1.11 (0.94-1.30)
(continued)
JAMA Network Open |Infectious Diseases Risk Factors for Hospitalization, Mechanical Ventilation, or Death Among Veterans With SARS-CoV-2
JAMA Network Open.2020;3(9):e2022310. doi:10.1001/jamanetworkopen.2020.22310(Reprinted)September 23, 2020 6/18Downloaded From: https://jamanetwork.com/ on 10/29/2020 Table 2. Associations Between Comorbid Conditions and Hospitalization, Mechanical Ventilation, or Mortality Among 10 131 VA Patients Who Tested Positive for SARS-CoV-2
Between February 28 and May 14, 2020 (continued) Condition Patients, No. (%)Hospitalization Mechanical ventilation Mortality
30-d
Rate, %Hazard ratio (95% CI)
30-d
Rate, %Hazard ratio (95% CI)
30-d
Rate, %Hazard ratio (95% CI)
Age-adjusted Adjusted
a
Age-adjusted Adjusted
a
Age-adjusted Adjusted
a
Obesity hypoventilation No 10 053 (99.2) 34.1 1 [Reference] 1 [Reference] 6.6 1 [Reference] 1 [Reference] 10.7 1 [Reference] 1 [Reference] Yes 78 (0.8) 52.8 1.46 (1.07-1.99) 1.20 (0.87-1.65) 26.2 3.15 (1.98-5.00) 1.99 (1.19-3.31) 23.4 2.23 (1.38-3.62) 1.66 (0.99-2.77)
Alcohol dependence No 9041 (89.2) 33.5 1 [Reference] 1 [Reference] 6.8 1 [Reference] 1 [Reference] 11.2 1 [Reference] 1 [Reference] Yes 1090 (10.8) 40.3 1.36 (1.23-1.51) 1.24 (1.11-1.39) 5.8 0.95 (0.73-1.23) 1.05 (0.79-1.39) 7.6 1.01 (0.80-1.26) 1.04 (0.82-1.32)
Hyperlipidemia No 4501 (44.4) 28.3 1 [Reference] 1 [Reference] 4.8 1 [Reference] 1 [Reference] 9.2 1 [Reference] 1 [Reference] Yes 5630 (55.6) 39.0 1.14 (1.06-1.23) 0.98 (0.90-1.06) 8.2 1.26 (1.06-1.49) 0.94 (0.78-1.13) 12.1 1.02 (0.90-1.16) 0.96 (0.83-1.11)
Smoking Never 3644 (36.0) 29.9 1 [Reference] 1 [Reference] 6.0 1 [Reference] 1 [Reference] 8.3 1 [Reference] 1 [Reference] Former 4077 (40.2) 38.7 1.08 (1.00-1.17) 1.01 (0.94-1.10) 8.5 1.11 (0.93-1.32) 1.02 (0.85-1.22) 12.8 1.08 (0.93-1.25) 1.02 (0.88-1.19) Current 1135 (11.2) 36.1 1.17 (1.04-1.31) 1.10 (0.98-1.25) 5.3 0.81 (0.60-1.07) 0.94 (0.69-1.28) 7.2 0.87 (0.68-1.11) 0.87 (0.67-1.13) Unknown 1275 (12.6) 30.7 0.95 (0.84-1.07) 1.21 (1.06-1.38) 4.5 0.73 (0.54-0.99) 1.04 (0.75-1.43) 14.5 1.22 (1.01-1.48) 1.32 (1.07-1.63)
Charlson Comorbidity
Index score
b
0 3139 (31.0) 18.8 1 [Reference] 1 [Reference] 2.7 1 [Reference] 1 [Reference] 4.5 1 [Reference] 1 [Reference] 1-2 3023 (29.8) 31.7 1.39 (1.25-1.55) 1.32 (1.18-1.47) 6.2 1.75 (1.34-2.28) 1.54 (1.17-2.04) 9.4 1.30 (1.06-1.60) 1.40 (1.12-1.74) 3-4 1784 (17.6) 42.3 1.76 (1.57-1.97) 1.61 (1.42-1.82) 8.4 2.15 (1.62-2.85) 1.86 (1.38-2.51) 14.3 1.52 (1.23-1.89) 1.64 (1.30-2.07) ≥5 2185 (21.6) 53.6 2.17 (1.94-2.42) 1.82 (1.61-2.05) 12.1 2.83 (2.17-3.70) 2.15 (1.61-2.87) 18.9 1.89 (1.55-2.31) 1.93 (1.54-2.42)
Abbreviations: COPD, chronic obstructive pulmonary disease; SARS-CoV-2, severe acute respiratory syndrome
coronavirus 2; VA, Veterans Health Administration. aAdjusted for all sociodemographic characteristics, comorbid conditions, and symptoms listed in Table 1, Table 2,
and Table 3 and stratified by station.
bIndividual comorbid conditions were not adjusted for.
JAMA Network Open |Infectious Diseases Risk Factors for Hospitalization, Mechanical Ventilation, or Death Among Veterans With SARS-CoV-2
JAMA Network Open.2020;3(9):e2022310. doi:10.1001/jamanetworkopen.2020.22310(Reprinted)September 23, 2020 7/18Downloaded From: https://jamanetwork.com/ on 10/29/2020 Table 3. Associations Between Symptoms and Hospitalization, Mechanical Ventilation, or Mortality Among 10 131 Patients Who Tested Positive for SARS-CoV-2 Between February 28 and May 14, 2020 Symptom Patients, No. (%)Hospitalization Mechanical ventilation Mortality
30-d
Rate, %Hazard ratio (95% CI)
30-d
Rate, %Hazard ratio (95% CI)
30-d
Rate, %Hazard ratio (95% CI)
Age-adjusted Adjusted
a
Age-adjusted Adjusted
a
Age-adjusted Adjusted
a
Constitutional
Fever No 5944 (58.7) 24.1 1 [Reference] 1 [Reference] 3.8 1 [Reference] 1 [Reference] 9.8 1 [Reference] 1 [Reference] Yes 4187 (41.3) 48.6 2.22 (2.07-2.38) 1.91 (1.78-2.06) 10.8 2.83 (2.40-3.33) 2.31 (1.95-2.75) 12.2 1.54 (1.36-1.74) 1.51 (1.32-1.72)
Cold No 8735 (86.2) 34.2 1 [Reference] 1 [Reference] 6.6 1 [Reference] 1 [Reference] 11.5 1 [Reference] 1 [Reference] Yes 1396 (13.8) 34.2 1.02 (0.93-1.13) 0.86 (0.77-0.95) 7.2 1.10 (0.88-1.36) 0.86 (0.69-1.08) 6.0 0.72 (0.57-0.91) 0.69 (0.54-0.87)
Chills No 9838 (97.1) 34.0 1 [Reference] 1 [Reference] 6.7 1 [Reference] 1 [Reference] 10.8 1 [Reference] 1 [Reference] Yes 293 (2.9) 44.0 1.32 (1.11-1.58) 1.01 (0.85-1.21) 8.2 1.20 (0.80-1.81) 0.84 (0.55-1.28) 8.9 1.08 (0.73-1.60) 1.07 (0.72-1.60)
Myalgia No 9934 (98.1) 34.4 1 [Reference] 1 [Reference] 6.8 1 [Reference] 1 [Reference] 11.0 1 [Reference] 1 [Reference] Yes 197 (1.9) 26.4 0.89 (0.68-1.17) 0.70 (0.53-0.93) 2.6 0.40 (0.17-0.97) 0.32 (0.13-0.79) 2.0 0.35 (0.13-0.93) 0.37 (0.14-1.00)
Fatigue No 9229 (91.1) 31.7 1 [Reference] 1 [Reference] 6.3 1 [Reference] 1 [Reference] 10.3 1 [Reference] 1 [Reference] Yes 902 (8.9) 60.8 1.69 (1.54-1.86) 1.32 (1.20-1.46) 11.2 1.41 (1.14-1.75) 1.07 (0.85-1.33) 16.1 1.15 (0.96-1.38) 1.03 (0.86-1.24)
Respiratory
Cough No 7511 (74.1) 32.6 1 [Reference] 1 [Reference] 6.2 1 [Reference] 1 [Reference] 12.0 1 [Reference] 1 [Reference] Yes 2620 (25.9) 38.8 1.29 (1.19-1.39) 0.90 (0.83-0.97) 8.1 1.30 (1.10-1.54) 0.78 (0.65-0.93) 7.4 0.84 (0.72-0.99) 0.69 (0.58-0.82)
Dyspnea No 8224 (81.2) 27.3 1 [Reference] 1 [Reference] 4.4 1 [Reference] 1 [Reference] 9.8 1 [Reference] 1 [Reference] Yes 1907 (18.8) 64.0 2.49 (2.31-2.67) 2.18 (2.02-2.36) 16.9 3.56 (3.04-4.16) 2.95 (2.49-3.49) 15.2 1.76 (1.53-2.03) 1.78 (1.53-2.07)
Sore throat No 10 017 (98.9) 34.3 1 [Reference] 1 [Reference] 6.7 1 [Reference] 1 [Reference] 10.9 1 [Reference] 1 [Reference] Yes 114 (1.1) 30.8 1.09 (0.78-1.52) 1.05 (0.75-1.46) 7.0 1.27 (0.62-2.56) 1.31 (0.63-2.72) 1.8 0.30 (0.08-1.23) 0.38 (0.09-1.56)
Gastrointestinal
Nausea No 9801 (96.7) 33.4 1 [Reference] 1 [Reference] 6.5 1 [Reference] 1 [Reference] 10.8 1 [Reference] 1 [Reference] Yes 330 (3.3) 60.1 1.94 (1.68-2.25) 1.43 (1.23-1.67) 12.8 1.91 (1.39-2.62) 1.56 (1.11-2.19) 11.1 1.22 (0.87-1.70) 1.21 (0.85-1.72)
Diarrhea No 9585 (94.6) 33.0 1 [Reference] 1 [Reference] 6.3 1 [Reference] 1 [Reference] 10.8 1 [Reference] 1 [Reference] Yes 546 (5.4) 56.6 1.79 (1.59-2.02) 1.29 (1.14-1.46) 13.9 2.05 (1.61-2.62) 1.57 (1.21-2.02) 10.3 1.09 (0.83-1.42) 1.02 (0.77-1.35)
Abdominal pain No 9851 (97.2) 33.5 1 [Reference] 1 [Reference] 6.6 1 [Reference] 1 [Reference] 10.8 1 [Reference] 1 [Reference] Yes 280 (2.8) 61.8 1.82 (1.56-2.12) 1.39 (1.19-1.63) 9.8 1.21 (0.82-1.78) 0.90 (0.60-1.35) 9.8 0.86 (0.58-1.26) 0.76 (0.51-1.13)
Neurological
Headache No 9784 (96.6) 34.4 1 [Reference] 1 [Reference] 6.8 1 [Reference] 1 [Reference] 11.0 1 [Reference] 1 [Reference] Yes 347 (3.4) 30.9 1.08 (0.89-1.31) 0.90 (0.74-1.10) 4.9 0.85 (0.52-1.38) 0.67 (0.41-1.09) 4.0 0.70 (0.41-1.19) 0.73 (0.42-1.24)
Abbreviation: SARS-CoV-2, severe acute respiratory syndrome coronavirus 2. aAdjusted for all sociodemographic characteristics, comorbid conditions, and symptoms listed in Table 1, Table 2, and Table 3 and stratified by station.
JAMA Network Open |Infectious Diseases Risk Factors for Hospitalization, Mechanical Ventilation, or Death Among Veterans With SARS-CoV-2
JAMA Network Open.2020;3(9):e2022310. doi:10.1001/jamanetworkopen.2020.22310(Reprinted)September 23, 2020 8/18Downloaded From: https://jamanetwork.com/ on 10/29/2020 Table 4. Associations Between Selected Laboratory Test Results and Mechanical Ventilation or Mortality Among 2905 VA Patients Who Tested Positive
for SARS-CoV-2 and Were Hospitalized Between February 28 and May 14, 2020
Test result Patients, No. (%)Mechanical ventilation Mortality
30-d
Rate, %Hazard ratio (95% CI)
30-d
Rate, (%)Hazard ratio (95% CI)
Age-adjusted Adjusted a Age-adjusted Adjusted a
All patients 2905 (100) 21.2 NA NA 21.3 NA NA
Albumin, g/dL
>3.9 607 (20.9) 18.7 1 [Reference] 1 [Reference] 16.3 1 [Reference] 1 [Reference]
>3.5 to 3.9 671 (23.1) 20.5 1.00 (0.77-1.30) 0.94 (0.72-1.23) 19.0 1.07 (0.82-1.41) 1.00 (0.75-1.32)
>3.1 to 3.5 673 (23.2) 23.8 1.27 (0.98-1.66) 1.23 (0.93-1.61) 22.3 1.17 (0.89-1.54) 1.09 (0.82-1.44)
>2.7 to 3.1 455 (15.7) 21.4 1.19 (0.88-1.62) 1.17 (0.86-1.61) 26.1 1.45 (1.07-1.96) 1.33 (0.97-1.81)
≤2.7 315 (10.8) 29.3 1.78 (1.29-2.45) 1.90 (1.36-2.67) 30.6 2.19 (1.58-3.03) 2.05 (1.46-2.88)
Missing 184 (6.3) 7.3 0.30 (0.15-0.60) 0.34 (0.17-0.69) 12.6 0.67 (0.38-1.19) 0.66 (0.37-1.18)
ALT, U/L
≤18 696 (24.0) 15.6 1 [Reference] 1 [Reference] 20.6 1 [Reference] 1 [Reference]
>18 to 28 700 (24.1) 20.6 1.28 (0.99-1.65) 1.23 (0.95-1.60) 23.1 1.35 (1.07-1.70) 1.38 (1.09-1.76)
>28 to 44 652 (22.4) 25.4 1.75 (1.36-2.25) 1.65 (1.27-2.15) 21.0 1.30 (1.02-1.66) 1.39 (1.08-1.80)
>44 to 68 387 (13.3) 28.3 2.07 (1.57-2.74) 1.86 (1.39-2.49) 22.3 1.67 (1.27-2.20) 1.74 (1.30-2.32)
>68 270 (9.3) 26.3 1.90 (1.39-2.60) 1.74 (1.26-2.41) 22.6 1.76 (1.29-2.41) 1.86 (1.35-2.57)
Missing 200 (6.9) 7.7 0.24 (0.11-0.56) 0.26 (0.11-0.62) 13.3 0.53 (0.28-1.00) 0.53 (0.28-1.01)
AST, U/L
≤25 688 (23.7) 13.2 1 [Reference] 1 [Reference] 15.2 1 [Reference] 1 [Reference]
>25 to 37 687 (23.6) 15.5 1.23 (0.92-1.63) 1.21 (0.91-1.62) 18.7 1.24 (0.95-1.61) 1.29 (0.98-1.68)
>37 to 57 672 (23.1) 27.3 2.25 (1.74-2.92) 2.20 (1.69-2.88) 22.5 1.67 (1.30-2.16) 1.74 (1.34-2.26)
>57 to 89 395 (13.6) 33.5 2.92 (2.22-3.85) 2.76 (2.07-3.68) 30.0 2.28 (1.74-2.99) 2.34 (1.77-3.10)
>89 261 (9.0) 33.1 3.09 (2.28-4.20) 2.92 (2.13-4.02) 33.7 2.82 (2.10-3.78) 3.00 (2.21-4.07)
Missing 202 (7.0) 7.2 0.42 (0.22-0.81) 0.46 (0.24-0.90) 12.0 0.78 (0.46-1.33) 0.80 (0.47-1.38)
Creatinine, mg/dL
≤0.98 697 (24.0) 13.2 1 [Reference] 1 [Reference] 13.6 1 [Reference] 1 [Reference]
>0.98 to 1.24 686 (23.6) 18.4 1.43 (1.08-1.88) 1.35 (1.01-1.79) 14.9 1.19 (0.89-1.58) 1.22 (0.91-1.64)
>1.24 to 1.82 689 (23.7) 23.0 1.79 (1.37-2.34) 1.75 (1.32-2.32) 23.9 1.72 (1.32-2.24) 1.87 (1.42-2.47)
>1.82 to 3.80 414 (14.3) 36.8 2.90 (2.21-3.81) 3.24 (2.38-4.41) 36.3 2.62 (2.00-3.43) 3.05 (2.26-4.11)
>3.80 275 (9.5) 27.3 2.07 (1.51-2.84) 3.30 (2.25-4.84) 30.2 2.31 (1.70-3.14) 3.79 (2.62-5.48)
Missing 144 (5.0) 8.5 0.27 (0.09-0.85) 0.39 (0.13-1.23) 14.3 1.33 (0.59-3.01) 1.57 (0.70-3.52)
White blood cell count, /μL
≤4770 712 (24.5) 16.3 1 [Reference] 1 [Reference] 17.2 1 [Reference] 1 [Reference]
>4770 to 6200 716 (24.6) 21.1 1.35 (1.05-1.73) 1.36 (1.06-1.76) 19.9 1.15 (0.90-1.48) 1.17 (0.91-1.50)
>6200 to 8300 707 (24.3) 21.2 1.37 (1.07-1.75) 1.41 (1.09-1.81) 22.0 1.20 (0.94-1.53) 1.23 (0.96-1.57)
>8300 to 11 220 424 (14.6) 24.6 1.61 (1.22-2.11) 1.74 (1.32-2.30) 22.6 1.25 (0.95-1.64) 1.28 (0.97-1.69)
>11 220 284 (9.8) 30.2 2.02 (1.52-2.70) 2.34 (1.74-3.14) 32.2 2.04 (1.54-2.70) 2.16 (1.62-2.87)
Missing 62 (2.1) 11.7 NA NA 16.4 2.17 (0.84-5.56) 2.62 (0.99-6.91)
Neutrophil count, /μL
≤3180 695 (23.9) 16.6 1 [Reference] 1 [Reference] 17.6 1 [Reference] 1 [Reference]
>3180 to 4500 702 (24.2) 18.2 1.06 (0.82-1.37) 1.04 (0.80-1.35) 17.9 0.99 (0.76-1.28) 1.00 (0.77-1.30)
>4500 to 6610 687 (23.6) 24.3 1.53 (1.20-1.96) 1.51 (1.18-1.93) 23.6 1.25 (0.99-1.60) 1.27 (0.99-1.62)
>6610 to 10 140 417 (14.4) 24.1 1.42 (1.08-1.87) 1.50 (1.13-1.98) 23.9 1.27 (0.97-1.66) 1.29 (0.98-1.70)
>10 140 277 (9.5) 29.1 2.25 (1.64-3.11) 2.65 (1.90-3.69) 29.7 2.01 (1.47-2.74) 2.03 (1.47-2.80)
Missing 127 (4.4) 18.5 1.05 (0.61-1.80) 1.18 (0.68-2.04) 20.6 1.69 (1.05-2.74) 1.75 (1.07-2.86)
Lymphocyte count, /μL
>1400 663 (22.8) 13.3 1 [Reference] 1 [Reference] 12.2 1 [Reference] 1 [Reference]
>990 to 1400 693 (23.9) 21.8 1.77 (1.33-2.36) 1.67 (1.25-2.24) 19.2 1.48 (1.10-1.99) 1.44 (1.07-1.95)
>700 to 990 596 (20.5) 22.9 1.87 (1.39-2.51) 1.74 (1.29-2.35) 22.6 1.67 (1.24-2.25) 1.72 (1.27-2.33)
>500 to 700 404 (13.9) 25.4 2.01 (1.47-2.74) 1.95 (1.42-2.67) 27.8 2.14 (1.57-2.91) 2.14 (1.56-2.93)
(continued)
JAMA Network Open |Infectious Diseases Risk Factors for Hospitalization, Mechanical Ventilation, or Death Among Veterans With SARS-CoV-2
JAMA Network Open.2020;3(9):e2022310. doi:10.1001/jamanetworkopen.2020.22310(Reprinted)September 23, 2020 9/18Downloaded From: https://jamanetwork.com/ on 10/29/2020 Statistical Analysis
Using the Kaplan-Meier method, we calculated 30-day hospitalization, mechanical ventilation, and
mortality rates from the index date through June 22, 2020. Participants who did not experience the
outcome of interest were censored at the end of follow-up.
All analyses were stratified by the VA medical center where patients were tested for SARS-
CoV-2. We used Cox proportional hazards models to compare patients with and without SARS-CoV-2
with respect to risk of adverse outcomes. We also used Cox proportional hazards models to identify
independent risk factors for each outcome among patients with SARS-CoV-2, adjusting for
sociodemographic characteristics, comorbid conditions, and presenting symptoms, as listed in
Table 1, Table 2, and Table 3. Laboratory tests were not included in multivariable adjustment due to
concerns about overadjustment, given that these were felt to be part of the causal pathway of the
disease rather than predisposing risk factors. Laboratory tests were categorized based on quintiles
(ie, 25th, >25th to 50th, >50th to 75th, >75th to 90th, and >90th percentiles), with an additional
category for missing tests, which were relatively rare. In secondary analyses, we used competing
risks analysis for the outcomes of hospitalization or ventilation to account for the competing risk
of death.
Multivariable population attributable fractions (PAFs) for each major risk factor were estimated
by finding the mean over randomly selected permutations of the PAF when other risk factors were
sequentially removed from the model. The number of permutations was sufficient to approximate
the true mean to within 0.1%. Confidence intervals were calculated using Monte Carlo simulation
(500 iterations over 5000 samples).
Analysis was conducted in Stata MP version 15 (StataCorp), R 64-bit version 3.6.1 (R Project for
Statistical Computing), with the averisk package version 1.0.3. Statistical significance was set at
P< .05, and all tests were 2-tailed.
Results
Of 88 747 VA enrollees tested for SARS-CoV-2, 10 131 (11.4%) tested positive (Figure, A). Compared
with individuals who tested negative, those testing positive were older (mean [SD] age, 61.6 [15.9]
years vs 63.6 [16.2] years), more likely to be Black individuals (19 340 [24.6%] vs 4215 [41.6%]), more
likely to have obesity (31 604 [40.2%] vs 4542 [44.8%]), and more likely to live in states with high
Table 4. Associations Between Selected Laboratory Test Results and Mechanical Ventilation or Mortality Among 2905 VA Patients Who Tested Positive
for SARS-CoV-2 and Were Hospitalized Between February 28 and May 14, 2020 (continued)
Test result Patients, No. (%)Mechanical ventilation Mortality
30-d
Rate, %Hazard ratio (95% CI)
30-d
Rate, (%)Hazard ratio (95% CI)
Age-adjusted Adjusted a Age-adjusted Adjusted a
≤500 374 (12.9) 27.7 2.18 (1.59-2.98) 1.98 (1.44-2.73) 30.9 2.17 (1.59-2.94) 2.00 (1.46-2.74)
Missing 175 (6.0) 19.4 1.33 (0.78-2.26) 1.41 (0.82-2.43) 23.6 2.69 (1.67-4.32) 2.69 (1.66-4.35)
Neutrophil to
lymphocyte ratio
≤2.71 700 (24.1) 12.6 1 [Reference] 1 [Reference] 12.5 1 [Reference] 1 [Reference]
>2.71 to 4.56 699 (24.1) 19.0 1.59 (1.20-2.11) 1.50 (1.13-2.00) 18.9 1.53 (1.16-2.03) 1.48 (1.11-1.96)
>4.56 to 7.71 695 (23.9) 23.2 1.83 (1.39-2.40) 1.71 (1.30-2.27) 23.4 1.71 (1.30-2.24) 1.71 (1.29-2.25)
>7.71 to 12.70 422 (14.5) 31.4 2.72 (2.04-3.62) 2.69 (2.01-3.61) 26.7 1.88 (1.40-2.52) 1.83 (1.36-2.46)
>12.70 280 (9.6) 31.6 2.88 (2.10-3.94) 2.84 (2.06-3.92) 38.6 3.00 (2.23-4.05) 2.88 (2.12-3.91)
Missing 109 (3.8) 12.2 0.45 (0.18-1.14) 0.45 (0.18-1.14) 13.9 1.22 (0.61-2.43) 1.20 (0.59-2.45)
Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; NA, not
applicable; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; VA, Veterans
Health Administration.
SI conversion factors: To convert albumin to grams per liter, multiply by 10.0; ALT and
AST to microkatals per liter, multiply by 0.0167; creatinine to millimoles per liter, multiplyby 88.4; and lymphocyte count, neutrophil count, and white blood cell count to ×10
9per
liter, multiply by 0.001.
aAdjusted for all sociodemographic characteristics, comorbid conditions, and symptoms
listed in Table 1, Table 2, and Table 3 and stratified by station.
JAMA Network Open |Infectious Diseases Risk Factors for Hospitalization, Mechanical Ventilation, or Death Among Veterans With SARS-CoV-2
JAMA Network Open.2020;3(9):e2022310. doi:10.1001/jamanetworkopen.2020.22310(Reprinted)September 23, 2020 10/18Downloaded From: https://jamanetwork.com/ on 10/29/2020 COVID-19 burden ( 700 deaths/1 million residents: 8019 [10.2%] vs 3218 [31.8%]) but had a similar
distribution of comorbid conditions and CCI scores (eTable 1 in theSupplement).
Compared with individuals who tested negative for SARS-CoV-2, those who tested positive had
higher 30-day rates of hospitalization (30.4% vs 29.3%; adjusted hazard ratio [aHR], 1.13; 95% CI,
1.08-1.13), mechanical ventilation (6.7% vs 1.7%; aHR, 4.15; 95% CI, 3.74-4.61), and mortality (10.8%
vs 2.4%; aHR, 4.44; 95% CI, 4.07-4.83) after adjusting for sociodemographic characteristics and
comorbid conditions (Figure, B; eTable 2 in theSupplement). Competing risks analysis (death treated
as a competing risk) did not appreciably change the associations for hospitalization or ventilation
(eTable 2 in theSupplement).
Sociodemographic Characteristics and Adverse Outcomes in Patients
Who Tested Positive for SARS-CoV-2
Veterans who tested positive for SARS-CoV-2 had a mean (SD) age of 63.6 (16.2) years; 9221 (91.0%)
were men, 944 (9.3%) were Hispanic individuals, 5022 (49.6%) were White individuals, and 4215
(41.6%) were Black individuals (Table 1). They were more commonly from urban rather than rural
Figure. Distribution of Veterans Affairs (VA) Patients Tested for Severe Acute Respiratory Coronavirus 2 (SARS-CoV-2), Associations With Mortality,
and Population Attributable Fractions (PAFs) for Major Risk Factors of Mortality
Number of VA patients tested in each state and number testing positiveA
1.00
0.95
0.90
0.85
0.80
No. at risk
0
77 908
9589 78 616
10 131 20
76 811
884330
76 705
8761
40
Survival probability
Time from index date, d 10
77 296
9077
Negative
PositiveMortality of patients with vs without SARS-CoV-2
B
40
30
20
10
0
Population attributable fractions, %
Risk factor Population attributable fractions of major risk factors for 30-day mortality
D
1.0
0.8
0.6
0.4
0.2
0
No. at risk
0
1951
2868 1973
2917 20
1927
274830
1922
2728
40
Survival probability
Time from index date, d 10
1939
2787
1288 1517 1036 10101116
18-49 y
50-64 y
3482 3724 3132 31013235 65-79 y
≥80 yMortality for patients with SARS-CoV-2, by age group
C
18-49 y50-64 y65-79 y≥80 y
3000 80007000 6000 10005000 5004000 250
2000
1500
1250
1000
750
500
250
Age
50-64 y
Age
65-79 y Age≥80 y Male
sex CCI,
1-2 CCI,
3-4 CCI,≥5 Fever Dyspnea Other
Patients tested, No.
Positive
cases, No.
Negative
Positive
D, Whiskers indicate 95% CIs. CCI indicates Charlson Comorbidity Index.
JAMA Network Open |Infectious Diseases Risk Factors for Hospitalization, Mechanical Ventilation, or Death Among Veterans With SARS-CoV-2
JAMA Network Open.2020;3(9):e2022310. doi:10.1001/jamanetworkopen.2020.22310(Reprinted)September 23, 2020 11/18Downloaded From: https://jamanetwork.com/ on 10/29/2020 areas(7714 [76.1%] vs 2412 [23.8%]) and had a high prevalence of obesity (4542 [44.8%]). They
originated from all 50 US states and Puerto Rico, with the greatest number from New York (1555
[15.3%]), New Jersey (757 [7.5%]), Louisiana (598 [5.9%]), and Pennsylvania (563 [5.6%]) (Figure,
A; eTable 3 in theSupplement).
Increasing age was the characteristic most strongly associated with risk of hospitalization,
mechanical ventilation, and death. Compared with patients younger than 50 years of age (30-day
mortality, 0.4%), those aged 50 to 64 years (30-day mortality, 4.1%; aHR, 9.27; 95% CI, 4.51-19.08),
65 to 79 years (30-day mortality, 13.8%; aHR, 27.47; 95% CI, 13.48-55.99), and 80 years and older
(30-day mortality, 29.7%; aHR, 60.80; 95% CI, 29.67-124.61) had progressively higher mortality
(Figure, C). Compared with White patients, Black patients were more likely to be hospitalized (aHR,
1.13; 95% CI, 1.04-1.23) and to receive mechanical ventilation (aHR, 1.52; 95% CI, 1.25-1.85) but no
more likely to die (aHR, 1.04; 95% CI, 0.88-1.21). Compared with women, men were likely to be
hospitalized (aHR, 1.22; 95% CI, 1.04-1.42) or to receive mechanical ventilation (aHR, 2.07; 95% CI,
1.30-3.32), but the association of male sex with mortality did not reach statistical significance (aHR,
1.38; 95% CI, 0.93-2.06), likely reflecting the small number of women in the sample. Areas with high
regional COVID-19 disease burden were associated with increased risk of death (eg, 700 vs <130
deaths per 1 million residents: aHR, 1.21; 95% CI, 1.02-1.45). Hispanic ethnicity (mortality: aHR, 1.03;
95% CI, 0.79-1.35), having overweight (mortality, body mass index 30.0-34.9 vs 18.5-24.9: aHR,
0.90; 95% CI, 0.77-1.06) or obesity (mortality, body mass index 35 vs 18.5-24.9: aHR, 0.97; 95% CI,
0.77-1.21), and urban residence (mortality: aHR, 0.92; 95% CI, 0.80-1.07) were also not associated
with increased risk of adverse outcomes.
Comorbid Conditions and Adverse Outcomes in Patients
Who Tested Positive for SARS-CoV-2
Veterans who tested positive for SARS-CoV-2 had a high overall burden of comorbidity (Table 2), with
less than one-third having no coexisting comorbid conditions (3139 [31.0%]). A higher CCI score was
strongly associated with increasing risk of hospitalization (eg, 5 vs 0: aHR, 1.82; 95% CI, 1.61-2.05),
mechanical ventilation (eg, 5 vs 0: aHR, 2.15; 95% CI, 1.61-2.87), and death (eg, 5vs0:aHR,1.93;
95% CI, 1.54-2.42). Comorbid conditions that were significantly associated with hospitalization
included diabetes (aHR, 1.17; 95% CI, 1.08-1.26), hypertension (aHR, 1.15; 95% CI, 1.05-1.26), chronic
kidney disease (aHR, 1.21; 95% CI, 1.11-1.32), cirrhosis (aHR, 1.27; 95% CI, 1.08-1.49), and alcohol
dependence (aHR, 1.24; 95% CI, 1.11-1.39). Comorbid conditions that were significantly associated
with mechanical ventilation included diabetes (aHR, 1.40; 95% CI, 1.18-1.67), hypertension (aHR,
1.30; 95% CI, 1.03-1.64), obstructive sleep apnea (aHR, 1.22; 95% CI, 1.01-1.46), and obesity
hypoventilation (aHR, 1.99; 95% CI, 1.19-3.31). Congestive heart failure (aHR, 1.30; 95% CI, 1.10-1.54),
chronic kidney disease (aHR, 1.25; 95% CI, 1.08-1.45), and cirrhosis (aHR, 1.55; 95% CI, 1.16-2.07)
were the only comorbid conditions significantly associated with mortality. Chronic obstructive
pulmonary disease (aHR, 1.02; 95% CI, 0.88-1.19), hypertension (aHR, 0.95; 95% CI, 0.81-1.12), and
smoking (eg, current vs never: aHR, 0.87; 95% CI, 0.67-1.13) were not associated with mortality.
Documented Symptoms and Adverse Outcomes in Patients
Who Tested Positive for SARS-CoV-2
The most common documented symptoms included fever (4187 [41.3%]), cough (2620 [25.9%]),
and dyspnea (1907 [18.8%]) (Table 3). Symptoms that were significantly associated with
hospitalization included fever (aHR, 1.91; 95% CI, 1.78-2.06), dyspnea (aHR, 2.18; 95% CI, 2.02-2.36),
nausea (aHR, 1.43; 95% CI, 1.23-1.67), diarrhea (aHR, 1.29; 95% CI, 1.14-1.46), abdominal pain (aHR,
1.39; 95% CI, 1.19-1.63), and fatigue (aHR, 1.32; 95% CI, 1.20-1.46). Symptoms that were significantly
associated with mechanical ventilation included fever (aHR, 2.31; 95% CI, 1.95-2.75), dyspnea (aHR,
2.95; 95% CI, 2.49-3.49), nausea (aHR 1.56; 95% CI, 1.11-2.19), and diarrhea (aHR, 1.57; 95% CI,
1.21-2.02). Only fever (aHR, 1.51; 95% CI, 1.32-1.72) and dyspnea (aHR, 1.78; 95% CI, 1.53-2.07) were
significantly associated with mortality. JAMA Network Open |Infectious Diseases
Risk Factors for Hospitalization, Mechanical Ventilation, or Death Among Veterans With SARS-CoV-2
JAMA Network Open.2020;3(9):e2022310. doi:10.1001/jamanetworkopen.2020.22310(Reprinted)September 23, 2020 12/18Downloaded From: https://jamanetwork.com/ on 10/29/2020 Laboratory Test Results and Adverse Outcomes Among Patients
Who Tested Positive for SARS-CoV-2
Associations of laboratory tests with outcomes were only determined among 2905 hospitalized
patients because they are not routinely ascertained in nonhospitalized patients. Many laboratory test
results were associated with mechanical ventilation and mortality in a dose-response manner,
including elevated creatinine (>3.80 mg/dL vs 0.98 mg/dL [to convert to millimoles per liter,
multiply by 88.4], mechanical ventilation: aHR, 3.30; 95% CI, 2.25-4.84; mortality: aHR, 3.79; 95%
CI, 2.62-5.48), elevated serum aspartate aminotransferase (>89 U/L vs 25 U/L [to convert to
microkatals per liter, multiply by 0.0167], mechanical ventilation: aHR, 2.92; 95% CI, 2.13-4.02;
mortality: aHR, 3.00; 95% CI, 2.21-4.07), elevated neutrophil to lymphocyte ratio (>12.70 vs 2.71,
mechanical ventilation: aHR, 2.84; 95% CI, 2.06-3.92; mortality: aHR, 2.88; 95% CI, 2.12-3.91),
elevated total white blood cell count (>11 200/μL vs 4770/μL [to convert to ×10
9, multiply by
0.001], mechanical ventilation: aHR, 2.34; 95% CI, 1.74-3.14; mortality: aHR, 2.16; 95% CI, 1.62-2.87),
elevated neutrophil count (>10 140/μL vs 3180/μL [to convert to ×10
9, multiply by 0.001],
mechanical ventilation: aHR, 2.65; 95% CI, 1.90-3.69; mortality, aHR, 2.03; 95% CI, 1.47-2.80),
reduced lymphocyte count ( 500/μL vs >1400/μL [to convert to ×10
9, multiply by 0.001],
mechanical ventilation: aHR, 1.98; 95% CI, 1.44-2.73; mortality: aHR, 2.00; 95% CI, 1.46-2.74),
reduced albumin (>3.9 g/dL vs 2.7 g/dL [to convert to grams per liter, multiply by 10.0], mechanical
ventilation: aHR, 1.90; 95% CI, 1.36-2.67; mortality: aHR, 2.05; 95% CI, 1.46-2.88), and elevated
alanine aminotransferase ( 18 U/L vs >68 U/L [to convert to microkatals per liter, multiply by
0.0167], mechanical ventilation: aHR, 1.74; 95% CI, 1.26-2.41; mortality, aHR, 1.86; 95% CI, 1.35-2.57)
(Table 4), but not serum bilirubin, platelet count, hemoglobin, and international normalized ratio
(eTable 4 in theSupplement).
PAFs of Major Risk Factors for 30-Day Mortality
Most deaths (63.4%) were associated with older age groups relative to the reference group (ie, aged
18-49 years): 6.2% (95% CI, 6.1%-6.3%) were associated with age 50 to 64 years, 28.9% (95% CI,
20.9%-36.6%) with age 65 to 79 years, and 28.3% (95% CI, 20.1%-30.8%) with age of 80 years or
older (Figure, D). Male sex (relative to female sex) contributed 12.3% (95% CI,5.8%-19.1%).
Comorbidity burden contributed 2.0% (95% CI, 0.1%-4.0%) for CCI score of 1 or 2, 2.6% (95% CI,
1.9%-5.8%) for CCIscore of 3 or 4, and 6.5% (95% CI, 6.3%-6.6%) for CCI score of 5 or greater.
Finally, fever contributed 5.0% (95% CI, 3.5%-6.8%) and dyspnea, 4.0% (95% CI, 2.6%-5.2%), with
negligible contributions from other risk factors.
Discussion
In a national study of 88 747 US veterans tested for SARS-CoV-2 infection between February 28 and
May 14, 2020, those testing positive had a 4.2-fold risk of mechanical ventilation and a 4.4-fold risk
of death compared with those testing negative. Among those who tested positive for SARS-CoV-2,
older age was the strongest risk factor associated with hospitalization, mechanical ventilation, and
mortality. Most deaths in this cohort were attributed to age of 50 years or older (63.4%), male sex
(12.3%), and comorbidity burden, with CCI score of at least 1 (11.1%). Other risk factors for mortality
included select preexisting comorbid conditions (ie, heart failure, chronic kidney disease, and
cirrhosis) and presenting symptoms (ie, fever and dyspnea). Abnormal results in a range of routine
laboratory tests were associated with mechanical ventilation or mortality in a dose-
response manner.
Early estimates from the US Centers for Disease Control and Prevention suggested that 20.7%
to 31.4% of US adults infected with SARS-CoV-2 were hospitalized.
2Within health systems, the
percentage of patients who have been hospitalized ranged from 8% to 80.7%, depending on the
clinical context of testing.
21,28-32 The percentages of patients who require mechanical ventilation has JAMA Network Open |Infectious Diseases
Risk Factors for Hospitalization, Mechanical Ventilation, or Death Among Veterans With SARS-CoV-2
JAMA Network Open.2020;3(9):e2022310. doi:10.1001/jamanetworkopen.2020.22310(Reprinted)September 23, 2020 13/18Downloaded From: https://jamanetwork.com/ on 10/29/2020 ranged from 2.3% of the Chinese population to 93.2% of critically ill patients infected with SARS-
CoV-2 admitted to New York area hospitals. 1,4,7,9,10,14,24,32-46 Short-term mortality rates in the US
population are estimated to be between 1.8% and 3.4%, 2which is higher than the 1.4% estimate from
China earlier in the pandemic. 33However,short-term mortality rates in case series of hospitalized
patients and high-risk populations have been much higher, ranging from 10.2% to
67%.
8-10,18,24,28,36,38,43,45-51 Our findings demonstrating 30-day rates of hospitalization, mechanical
ventilation, and death of 30.4%, 6.7%, and 10.8%, respectively, spotlight the substantial
consequences of SARS-CoV-2 on the Veteran population, associated with the high prevalence of
advanced age, male sex, and comorbid conditions.
Recognizing risk factors for adverse outcomes is a preliminary step toward developing
prognostic models that will allow for real-time identification of patients most and least likely to
benefit from available interventions (eg, close monitoring at home vs hospitalization, intensive care
unit admission and mechanical ventilation, or selected therapeutics). Some risk factors may be
reversible or modifiable, such that eliminating them might be a strategy for reducing the mortality
rate of SARS-CoV-2 or may provide clues as to the pathogenesis of severe, life-threatening SARS-
CoV-2. Risk factors that have been identified in prior studies include older age, male sex,
hypertension, diabetes, chronic obstructive pulmonary disease, cardiac disease, liver disease,
chronic kidney disease, neurologic disorders, cancer, obesity, higher overall burden of comorbidity,
and smoking.
1,3-24
In our cohort, older age was by far the strongest risk factor associated with ventilation and
death, even after adjusting for comorbid conditions; 63.5% of deaths were attributed to being aged
50 years or older based in PAF calculations. While we observed linear associations between age and
mortality, the association of age with mechanical ventilation appeared to be nonlinear, with the
highest risk noted for those aged 65 to 79 years, perhaps reflecting treatment preferences and/or
clinical practice. We observed strong linear associations with CCI score and all measured outcomes,
suggesting that a measure of overall disease burden may be more helpful than the presence of
individual comorbid conditions. PAF calculations suggested that 11.1% of deaths were attributed to
having a CCI score of at least 1. Although male sex was not statistically significantly associated with
mortality, 12.3% of deaths were attributed to male sex based on PAF calculations, which were
statistically significant. Among hospitalized patients, abnormalities in a range of routine laboratory
tests were strongly and linearly associated with ventilation and death, suggesting that these could be
useful in risk stratification at the time of hospitalization.
Some risk factors for mortality reported by earlier studies did not reach statistical significance
in our analyses including Black race, Hispanic ethnicity, body mass index, underlying lung disease,
smoking, diabetes, and hypertension. This may reflect differences in the study population (eg, male
sex, older age), differences in the confounders that were adjusted for, or attenuation of racial/ethnic
disparities in access to care in the VA system relative to the private sector.
52Additionally, we
investigated risk factors for adverse outcomes among patients who tested positive for SARS-CoV-2
rather than in the general population
53because the latter approach provides a composite of the risk
of infection and subsequent risk of death. For example, Black and Hispanic patients may be much
more likely to acquire SARS-CoV-2 but not more likely to die if infected. The finding that Black
patients did not have higher mortality rates but had higher mechanical ventilation rates may be
related to lower rates of advance directives in Black patients.
54
Surprisingly, neither chronic obstructive pulmonary disease nor smoking—which are prevalent
in the veteran population—were associated with adverse outcomes. Geographic burden of SARS-
CoV-2 was not as strongly associated with mortality as we had anticipated. VA patients in the most
highly affected states (ie, Connecticut, Massachusetts, New Jersey, New York, and Rhode Island) only
had a 1.21-fold higher mortality rate than patients from the least affected states. JAMA Network Open |Infectious Diseases
Risk Factors for Hospitalization, Mechanical Ventilation, or Death Among Veterans With SARS-CoV-2
JAMA Network Open.2020;3(9):e2022310. doi:10.1001/jamanetworkopen.2020.22310(Reprinted)September 23, 2020 14/18Downloaded From: https://jamanetwork.com/ on 10/29/2020 Limitations
This study has limitations. Our results in the predominantly male veteran population may not be
generalizable to other populations and groups, especially women. We usedICD-10codes for the
determination of comorbid conditions. However, mostICD-10–based definitions have been widely
used and validated in VA studies. Novel natural language processing plusICD-10codes were used for
the definition of SARS-CoV-2 symptoms, although the performance characteristics of these
definitions are not yet known. We captured deaths that occurred both within and outside the VA;
however,hospitalizations or mechanical ventilations that occurred outside the VA and were not paid
for by the VA were not captured. Our results are limited to those patients who were tested within
the VA system. Therefore, our results likely reflect institutional policies and practices related to
testing. Strengths of our study include its national scope, large number of patients, relatively long
follow-up for a range of outcomes, and analysis of many potential risk factors.
Conclusions
In this study, we found high rates of mechanical ventilation and death among 10 131 VA patients with
SARS-CoV-2 infection. Most deaths were associated with older age, male sex, and a high overall
burden of comorbidity.
ARTICLE INFORMATION
Accepted for Publication:August 18, 2020.
Published:September 23, 2020. doi:10.1001/jamanetworkopen.2020.22310
Open Access:This is an open access article distributed under the terms of theCC-BY License. © 2020 Ioannou GN
et al.JAMA Network Open.
Corresponding Author:George N. Ioannou, BMBCh, MS, Division of Gastroenterology, Veterans Affairs Puget
Sound Healthcare System, 1660 S Columbian Way, Seattle, WA 98108 ([email protected]).
Author Affiliations:Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University
of Washington, Seattle (Ioannou, Dominitz); Research and Development, Veterans Affairs Puget Sound Health
Care System, Seattle, Washington (Locke, Green, Berry); Division of Nephrology, Veterans Affairs Puget Sound
Healthcare System and University of Washington, Seattle (O’Hare); Division of Allergy and Infectious Disease,
Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle (Shah, Eastment); Division
of Pulmonary and Critical Care, Veterans Affairs Puget Sound Healthcare System and University of Washington,
Seattle (Crothers, Fan).
Author Contributions:Dr Ioannou had full access to all of the data in the study and takes responsibility for the
integrity of the data and the accuracy of the data analysis.
Concept and design:Ioannou, Locke, Green, Berry, O'Hare, Shah, Crothers, Fan.
Acquisition, analysis, or interpretation of data:Ioannou, Locke, Green, Berry, Eastment, Dominitz, Fan.
Drafting of the manuscript:Ioannou, O'Hare.
Critical revision of the manuscript for important intellectual content:All authors.
Statistical analysis:Ioannou, Berry, Eastment.
Obtained funding:Ioannou, Shah.
Administrative, technical, or material support:Locke, Green, Shah.
Supervision:Ioannou, Shah.
Conflict of Interest Disclosures:Dr O’Hare reported receiving grants from the Veterans Affairs Health Services
Research and Development, the National Institute of Diabetes and Digestive and Kidney Diseases, the US Centers
for Disease Control and Prevention; receiving operations project support from the VA National Center for Ethics
in Health Care; and receiving personal fees from UpToDate; Kaiser Permanente Southern California; University of
California, San Francisco; University of Pennsylvania; University of Alabama; the Denevir Foundation;
Hammersmith Hospital; Dialysis Clinics, Inc; Fresenius Medical Care; Chugai Pharmaceutical Co; the Japanese
Society of Dialysis Therapy; and the New York Society of Nephrology outside the submitted work. Dr Fan reported
JAMA Network Open |Infectious Diseases Risk Factors for Hospitalization, Mechanical Ventilation, or Death Among Veterans With SARS-CoV-2
JAMA Network Open.2020;3(9):e2022310. doi:10.1001/jamanetworkopen.2020.22310(Reprinted)September 23, 2020 15/18Downloaded From: https://jamanetwork.com/ on 10/29/2020 receiving grants from the Department of Veterans Affairs, the Firland Foundation, and the Patient-Centered
Outcomes Research Institute outside the submitted work. No other disclosures were reported.
Funding/Support:This study was supported using data from the Veterans Affairs COVID-19 Shared Data
Resource. The study was supported in part by the US Department of Veterans Affairs, Office of Research and
Development (CSR&D grant, COVID19-8900-11) to Dr Ioannou.
Role of the Funder/Sponsor:The funder had no role in the design and conduct of the study; collection,
management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and
decision to submit the manuscript for publication.
Disclaimer:The contents do not represent the views of the US Department of Veterans Affairs or the US
government.
Additional Contributions:We acknowledge the VA Informatics and Computing Infrastructure (VINCI) group, who
worked tirelessly to create the COVID-19 Shared Data Resource.
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SUPPLEMENT.
eTable 1.Comparison of Baseline Characteristics of Veterans Who Tested Positive (n = 10 131) vs Negative
(n = 78 616) for SARS-CoV-2
eTable 2.Comparing Hospitalization, Mechanical Ventilation, and Mortality Rates Between Veterans Who Did and
Did Not Test Positive for SARS-CoV-2
eTable 3.Number of Patients Who Tested Positive for SARS-CoV-2 in the VA Health Care System as of May 14,
2020, by State
eTable 4.Associations Between Laboratory Test Results and Mechanical Ventilation or Mortality Among 2905 VA
Patients Who Tested Positive for SARS-CoV-2 and Were Hospitalized Between February 28 and May 14, 2020
JAMA Network Open |Infectious Diseases Risk Factors for Hospitalization, Mechanical Ventilation, or Death Among Veterans With SARS-CoV-2
JAMA Network Open.2020;3(9):e2022310. doi:10.1001/jamanetworkopen.2020.22310(Reprinted)September 23, 2020 18/18Downloaded From: https://jamanetwork.com/ on 10/29/2020
