COvid Post-Exposure Evaluation and Symptomatology (COPES) Center: Identifying Post-COVID Phenotypes and Related Health Inequities

Background: An estimated 10-50% of patients with a history of COVID-19 infection (C+) experience PASC. PASC presents as a multisystem syndrome, with symptoms ranging in severity and regularity that can last weeks to months after acute infection. These symptoms can lead to mild to severe functional limitations that adversely impact quality of life. Emerging evidence suggests that inequities in PASC are experienced especially by historically underserved populations (as with acute COVID-19). The lack of a standard case definition risks burdening patients by delaying access to treatment and management. Yet currently there are no evidence-based practices (EBP) for managing and treating PASC. Efforts to define PASC are urgently needed to address knowledge gaps, advance discovery of EBPs, and improve care. Significance: Our long-term goal is to ensure that every Veteran with PASC receives appropriate, timely, and effective EBP to reduce PASC-related morbidity and maintain Veterans' quality of life. Since the cumulative cases of COVID-19 exceed 520,000 in VA, and 146 million in the US, and many are still at risk, our findings will have broad public health impact within and beyond VA. Innovation and Impact: VA has a unique opportunity to play a central role in defining PASC by leveraging its multiple high-quality data sources, such as the COVID-19 Shared Data Resource. PASC definitions can be derived from: 1) International Classification of Disease diagnosis codes, 2) electronic health record (EHR) chart review, and 3) Veteran-reported symptom surveys. We propose to integrate these VA data sources and mechanisms to identify a unified phenotypic description of PASC. Interviews with Veterans and other stakeholders will further enrich our understanding of PASC. Collectively, these data will address research gaps in understanding current PASC treatment models and assess variability and inequities in care. Specific Aims: 1. Define and characterize PASC in the VA C+ population using EHR and survey data. 2. Characterize clinical management strategies and care delivery models for PASC, including pharmacological and non-pharmacological treatments (e.g., Whole Health, Pain, Rehabilitation). 3. Assess health inequities in PASC phenotypes, symptom trajectories, and management. Methodology: In Aim 1 we will identify distinct symptom clusters among C+ Veterans in VA using unsupervised clustering and examine the consequences of applying different criteria for PASC on estimation of PASC incidence and on the relationship between PASC and symptom clusters. In Aim 2 we will characterize clinical management leveraging EHR data and Veterans' self-care via survey data. We will also conduct key informant interviews in facilities with high and low C+ prevalence to determine how healthcare teams identify PASC and select management and care delivery approaches. In Aim 3 we will examine relationships between Aims 1-2 metrics and social determinants of health. We will also evaluate Veterans' health and care experiences with PASC using video interview methodologies of the Health Experiences Research Network. Next Steps/Implementation: By completing these aims, we will provide a comprehensive, actionable definition of PASC. Using our definition, we will address gaps in understanding the epidemiology, health services utilized, and inequities related to PASC. This knowledge will advance efforts in developing EBPs for PASC.