Birt-Hogg-Dubé syndrome (BHD) is an autosomal dominant disease that arises from loss-of-function mutations in the FLCN gene. FLCN encodes folliculin, which is presumed to function as a tumor suppressor, though its precise role is incompletely understood.^1,2 BHD is characterized by multiple pulmonary cysts leading to recurrent spontaneous pneumothoraces, cutaneous lesions—specifically fibrofolliculomas—and an increased risk of renal malignancies. Diagnosing BHD is challenging due to the variable presentation of the disease. Some patients may only have cystic lung diseases, while others may not have characteristic skin lesions.^3-5 It is important to maintain awareness of BHD, especially when the diagnosis dictates the need for genetic counseling.

Case Presentation

A male veteran in his 60s, who was a lifelong nonsmoker with a history of extensive bullous emphysema and recurrent pneumothoraces, presented to the Veterans Affairs Greater Los Angeles Healthcare System pulmonary clinic while transferring care from a separate institution.

According to the patient, the first pneumothorax episode occurred about 20 years before presentation, followed by a recurrence a few years later after he was diagnosed with emphysema. He underwent pleurodesis of the right lung during his service abroad. Another episode nearly a decade after the first pneumothorax necessitated pleurodesis of the left lung (Figure 1). The patient's family history revealed pulmonary cysts in 1 immediate family member but no history of renal tumors. Notably, his mother passed away at a young age due to tuberculosis.

On physical examination, numerous skin tags and acrochordons on the face were observed, which had been stable for > 30 years. Despite a slow decline in exercise capacity following pleurodesis, the patient could still walk multiple miles daily and climb 3 flights of stairs before needing to rest. Pulmonary function testing (PFT) showed a forced expiratory volume in 1 second (FEV₁)/forced vital capacity ratio of 0.84 with reduced FEV₁, total lung capacity (TLC), and diffusion capacity for carbon monoxide (DL_CO), indicating a mild restrictive ventilatory defect and reduced diffusing capacity.

Laboratory results revealed a normal α-1 antitrypsin level: 133 mg/dL (reference, 83-199 mg/dL), with a Pi*MS phenotype and undetectable antinuclear antibodies. The most recent chest computed tomography (CT) in 2019, displayed paraseptal and centrilobular emphysema, scattered blebs, and scarring consistent with prior pleurodesis procedures (Figure 2).

Genetic testing for the FLCN gene revealed heterozygous pathogenic mutation: c.1285del and p.His429Thrfs*39, which confirmed the diagnosis of BHD. A shave biopsy of a postauricular papular lesion confirmed a histologic pattern of fibrofolliculoma/trichodiscoma.

Follow-up and Outcomes

After confirmation of the BHD diagnosis, the patient was referred to genetic counseling and scheduled for annual magnetic resonance imaging (MRI) of the abdomen and pelvis to screen for renal malignancies. As the patient was able to establish care with a new long-term primary care practitioner in the outpatient setting, he continues regular follow-up visits in the pulmonary clinic with stable respiratory symptoms and no recurrent pneumothoraces thus far.

Discussion

Differential Diagnoses of Cystic Pulmonary Lesions

BHD is an important differential diagnosis to consider in the presentation of diffuse cystic lung diseases. Still, 2 other crucial considerations are pulmonary Langerhans cell histiocytosis (PLCH) and lymphangioleiomyomatosis (LAM), which occur at slightly higher frequencies than BHD.⁶

One of the first steps in radiographically evaluating cystic lung diseases is to characterize the cysts. The Fleischner Society defines true cysts as a “round parenchymal lucency or low-attenuating area with a well-defined interface with normal lung.”⁷ Mimics of cystic lesions may include cavitary lung lesions, thick-walled spaces within another area of mass, nodule, or consolidation. Another mimic is a pneumatocele, a pseudocyst that lacks epithelial lining and may be secondary to bacterial pneumonia, pneumocystis infections, trauma, or prior mechanical ventilation.⁸After characterizing true cysts, different patterns of cystic lesions can also be associated with specific diseases. Cysts in PLCH are commonly more uniform and round, whereas the cysts in LAM may be more irregularly shaped. ⁹ Cysts in BHD may be larger and predominantly located in basal and paramediastinal areas.⁴LAM is associated with tuberous sclerosis, which can also present with skin lesions (angiofibromas) and renal tumors (angiomyolipomas), thus creating a very similar picture to BHD. Therefore, tissue biopsies of skin lesions are essential as histopathology can identify characteristic fibrofolliculomas specific to BHD. While genetic testing would also strongly support the diagnosis of BHD, it is essential to note that negative genetic testing does not rule out BHD.⁴Lastly, lymphoid interstitial pneumonia (LIP) is another important consideration in the differential diagnosis of cystic lung diseases. LIP presents with not only perivascular cysts and centrilobular nodules but also diffuse ground-glass attenuation.¹⁰ In contrast to BHD, LIP is associated with autoimmune diseases such as Sjögren syndrome and infectious diseases such as HIV; thus, it may be differentiated from BHD by the presence of underlying disease processes and may warrant serologic testing for potential rheumatologic disorders.

Characteristics and Diagnostic Criteria


Cystic lung disease is the most common presentation of BHD. It presents in > 80% of cases and confers a 50-fold increase in the risk of spontaneous pneumothorax compared with the general population.^4,11 Recurrent pneumothoraces are observed in about 25% to 30% of patients with BHD, typically occurring between the third and fifth decades of life and at significantly decreased rates after 50 years of age.¹² A spontaneous pneumothorax might serve as the initial and perhaps the sole clinical presentation for some patients with BHD, but others may present with other respiratory symptoms such as cough and exertional dyspnea. PFT results may be normal or reveal a mild restrictive ventilatory defect and reduced DL_CO, as reported in a few cases.⁶ The management of pulmonary complications primarily revolves around reducing the risk of pneumothoraces, which includes precautions such as avoiding positive pressure ventilation and air travel. Early pleurodesis with the first occurrence of a spontaneous pneumothorax is considered in some cases.¹³

The distinctive dermatologic features associated with BHD include multiple white papules primarily found on the nose and face. Pathologically, these manifestations have a range of histologic distinctions, from fibrofolliculomas to benign hamartomas of the hair follicles and trichodiscomas.⁵ The diagnostic criteria outlined by Menko et al note that confirmation of BHD requires the presence of either ≥ 5 pathologically confirmed fibrofolliculomas or trichodiscomas, a documented pathogenic FLCN gene mutation, or the fulfillment of 2 minor criteria. These minor criteria include the presence of multiple lung cysts, early-onset renal cancer, or a first-degree relative with BHD.⁵

Recurrent Pneumothoraces Management

After the first episode of spontaneous pneumothorax, early pleurodesis is indicated as the risk of recurrence can be as high as 75%.^4,14 Specific pleurodesis modalities have shown promising results, such as total pleural covering with cellulose mesh. In a small retrospective review, cellulose mesh demonstrated a significant reduction in the recurrence rate of pneumothorax at 7.5 years for patients with BHD compared with partial covering.¹⁵ Apart from preventing further pneumothorax episodes in the affected lung, it is also important to highlight patient education and monitoring after initial pleurodesis, as the contralateral lung is also at risk. As demonstrated in this case, the patient had received pleurodesis of his right lung but experienced another pneumothorax of his contralateral lung a few years later.

Lastly, the patient was advised to avoid air travel altogether; however, current data may suggest that air travel may not be an absolute contraindication for patients with BHD. Although the literature on this topic is limited, a retrospective study by Johannesma et al involving 158 patients with BHD surveyed on pneumothorax occurrence after air travel indicated a calculated risk of 0.63% per flight. Notably, only 3 of 13 patients with BHD and recurrent pneumothoraces after travel had undergone pleurodesis in the past.¹⁶ Therefore, counseling patients on the potential risks of air travel and allowing essential flights while diligently monitoring for symptoms during and after travel may be a reasonable, patient-centered approach in contrast to a complete restriction on air travel.

Timing to Diagnosis

Diagnosing BHD is challenging and often delayed. In a 2022 study by Steinlein et al, the average delay in BHD diagnoses in their cohort was 9.3 years, with 4 patients also diagnosed with renal malignancy during the study period.¹⁷ The difficulty in diagnosis can be attributed to the heterogeneous presentation among affected family members, some of whom may exclusively exhibit pulmonary cystic lesions without dermatologic findings.

A lack of longitudinal care for this patient may have contributed to the diagnostic delay. The patient had pneumothorax events across separate care settings and locations, and due to employment-related relocations, he often re-established care at various health care systems. This case highlights the importance of continuity of care, especially in BHD, where monitoring for renal tumors is also essential to long-term management.^17,18

Renal Tumor Monitoring

Finally, once BHD is diagnosed, one of the most important considerations is to begin routine monitoring for renal malignancies. Current recommendations advise starting lifelong renal cancer screening, even as early as age 20 years, with annual MRIs, as renal ultrasound may not be sufficiently sensitive to detect smaller lesions.¹⁹ The screening interval can be extended to every 2 years for patients without a family history of renal tumors or suspicious renal lesions. If tumors are found, then nephron-sparing surgery is recommended, given the potential for the development of chronic renal insufficiency in patients with BHD.²⁰

Conclusions

BHD is a rare and complex syndrome in which early recognition and diagnosis play a pivotal role in preventing potentially severe complications such as renal malignancies. Suspicion of a genetic disorder, such as BHD, LAM, or PLCH, should arise in patients who experience spontaneous pneumothorax, especially in the presence of multiple cystic lesions or a family history of pneumothoraces. Early consideration of pleurodesis after the first spontaneous pneumothorax is advisable. The complex presentation of BHD contributes to the difficulty of diagnosis and may delay recognition, which can be exacerbated by variable continuity of care.

Birt-Hogg-Dubé syndrome (BHD) is an autosomal dominant disease that arises from loss-of-function mutations in the FLCN gene. FLCN encodes folliculin, which is presumed to function as a tumor suppressor, though its precise role is incompletely understood.^1,2 BHD is characterized by multiple pulmonary cysts leading to recurrent spontaneous pneumothoraces, cutaneous lesions—specifically fibrofolliculomas—and an increased risk of renal malignancies. Diagnosing BHD is challenging due to the variable presentation of the disease. Some patients may only have cystic lung diseases, while others may not have characteristic skin lesions.^3-5 It is important to maintain awareness of BHD, especially when the diagnosis dictates the need for genetic counseling.

Case Presentation

A male veteran in his 60s, who was a lifelong nonsmoker with a history of extensive bullous emphysema and recurrent pneumothoraces, presented to the Veterans Affairs Greater Los Angeles Healthcare System pulmonary clinic while transferring care from a separate institution.

According to the patient, the first pneumothorax episode occurred about 20 years before presentation, followed by a recurrence a few years later after he was diagnosed with emphysema. He underwent pleurodesis of the right lung during his service abroad. Another episode nearly a decade after the first pneumothorax necessitated pleurodesis of the left lung (Figure 1). The patient's family history revealed pulmonary cysts in 1 immediate family member but no history of renal tumors. Notably, his mother passed away at a young age due to tuberculosis.

On physical examination, numerous skin tags and acrochordons on the face were observed, which had been stable for > 30 years. Despite a slow decline in exercise capacity following pleurodesis, the patient could still walk multiple miles daily and climb 3 flights of stairs before needing to rest. Pulmonary function testing (PFT) showed a forced expiratory volume in 1 second (FEV₁)/forced vital capacity ratio of 0.84 with reduced FEV₁, total lung capacity (TLC), and diffusion capacity for carbon monoxide (DL_CO), indicating a mild restrictive ventilatory defect and reduced diffusing capacity.

Laboratory results revealed a normal α-1 antitrypsin level: 133 mg/dL (reference, 83-199 mg/dL), with a Pi*MS phenotype and undetectable antinuclear antibodies. The most recent chest computed tomography (CT) in 2019, displayed paraseptal and centrilobular emphysema, scattered blebs, and scarring consistent with prior pleurodesis procedures (Figure 2).

Genetic testing for the FLCN gene revealed heterozygous pathogenic mutation: c.1285del and p.His429Thrfs*39, which confirmed the diagnosis of BHD. A shave biopsy of a postauricular papular lesion confirmed a histologic pattern of fibrofolliculoma/trichodiscoma.

Follow-up and Outcomes

After confirmation of the BHD diagnosis, the patient was referred to genetic counseling and scheduled for annual magnetic resonance imaging (MRI) of the abdomen and pelvis to screen for renal malignancies. As the patient was able to establish care with a new long-term primary care practitioner in the outpatient setting, he continues regular follow-up visits in the pulmonary clinic with stable respiratory symptoms and no recurrent pneumothoraces thus far.

Discussion

Differential Diagnoses of Cystic Pulmonary Lesions

BHD is an important differential diagnosis to consider in the presentation of diffuse cystic lung diseases. Still, 2 other crucial considerations are pulmonary Langerhans cell histiocytosis (PLCH) and lymphangioleiomyomatosis (LAM), which occur at slightly higher frequencies than BHD.⁶

One of the first steps in radiographically evaluating cystic lung diseases is to characterize the cysts. The Fleischner Society defines true cysts as a “round parenchymal lucency or low-attenuating area with a well-defined interface with normal lung.”⁷ Mimics of cystic lesions may include cavitary lung lesions, thick-walled spaces within another area of mass, nodule, or consolidation. Another mimic is a pneumatocele, a pseudocyst that lacks epithelial lining and may be secondary to bacterial pneumonia, pneumocystis infections, trauma, or prior mechanical ventilation.⁸After characterizing true cysts, different patterns of cystic lesions can also be associated with specific diseases. Cysts in PLCH are commonly more uniform and round, whereas the cysts in LAM may be more irregularly shaped. ⁹ Cysts in BHD may be larger and predominantly located in basal and paramediastinal areas.⁴LAM is associated with tuberous sclerosis, which can also present with skin lesions (angiofibromas) and renal tumors (angiomyolipomas), thus creating a very similar picture to BHD. Therefore, tissue biopsies of skin lesions are essential as histopathology can identify characteristic fibrofolliculomas specific to BHD. While genetic testing would also strongly support the diagnosis of BHD, it is essential to note that negative genetic testing does not rule out BHD.⁴Lastly, lymphoid interstitial pneumonia (LIP) is another important consideration in the differential diagnosis of cystic lung diseases. LIP presents with not only perivascular cysts and centrilobular nodules but also diffuse ground-glass attenuation.¹⁰ In contrast to BHD, LIP is associated with autoimmune diseases such as Sjögren syndrome and infectious diseases such as HIV; thus, it may be differentiated from BHD by the presence of underlying disease processes and may warrant serologic testing for potential rheumatologic disorders.

Characteristics and Diagnostic Criteria


Cystic lung disease is the most common presentation of BHD. It presents in > 80% of cases and confers a 50-fold increase in the risk of spontaneous pneumothorax compared with the general population.^4,11 Recurrent pneumothoraces are observed in about 25% to 30% of patients with BHD, typically occurring between the third and fifth decades of life and at significantly decreased rates after 50 years of age.¹² A spontaneous pneumothorax might serve as the initial and perhaps the sole clinical presentation for some patients with BHD, but others may present with other respiratory symptoms such as cough and exertional dyspnea. PFT results may be normal or reveal a mild restrictive ventilatory defect and reduced DL_CO, as reported in a few cases.⁶ The management of pulmonary complications primarily revolves around reducing the risk of pneumothoraces, which includes precautions such as avoiding positive pressure ventilation and air travel. Early pleurodesis with the first occurrence of a spontaneous pneumothorax is considered in some cases.¹³

The distinctive dermatologic features associated with BHD include multiple white papules primarily found on the nose and face. Pathologically, these manifestations have a range of histologic distinctions, from fibrofolliculomas to benign hamartomas of the hair follicles and trichodiscomas.⁵ The diagnostic criteria outlined by Menko et al note that confirmation of BHD requires the presence of either ≥ 5 pathologically confirmed fibrofolliculomas or trichodiscomas, a documented pathogenic FLCN gene mutation, or the fulfillment of 2 minor criteria. These minor criteria include the presence of multiple lung cysts, early-onset renal cancer, or a first-degree relative with BHD.⁵

Recurrent Pneumothoraces Management

After the first episode of spontaneous pneumothorax, early pleurodesis is indicated as the risk of recurrence can be as high as 75%.^4,14 Specific pleurodesis modalities have shown promising results, such as total pleural covering with cellulose mesh. In a small retrospective review, cellulose mesh demonstrated a significant reduction in the recurrence rate of pneumothorax at 7.5 years for patients with BHD compared with partial covering.¹⁵ Apart from preventing further pneumothorax episodes in the affected lung, it is also important to highlight patient education and monitoring after initial pleurodesis, as the contralateral lung is also at risk. As demonstrated in this case, the patient had received pleurodesis of his right lung but experienced another pneumothorax of his contralateral lung a few years later.

Lastly, the patient was advised to avoid air travel altogether; however, current data may suggest that air travel may not be an absolute contraindication for patients with BHD. Although the literature on this topic is limited, a retrospective study by Johannesma et al involving 158 patients with BHD surveyed on pneumothorax occurrence after air travel indicated a calculated risk of 0.63% per flight. Notably, only 3 of 13 patients with BHD and recurrent pneumothoraces after travel had undergone pleurodesis in the past.¹⁶ Therefore, counseling patients on the potential risks of air travel and allowing essential flights while diligently monitoring for symptoms during and after travel may be a reasonable, patient-centered approach in contrast to a complete restriction on air travel.

Timing to Diagnosis

Diagnosing BHD is challenging and often delayed. In a 2022 study by Steinlein et al, the average delay in BHD diagnoses in their cohort was 9.3 years, with 4 patients also diagnosed with renal malignancy during the study period.¹⁷ The difficulty in diagnosis can be attributed to the heterogeneous presentation among affected family members, some of whom may exclusively exhibit pulmonary cystic lesions without dermatologic findings.

A lack of longitudinal care for this patient may have contributed to the diagnostic delay. The patient had pneumothorax events across separate care settings and locations, and due to employment-related relocations, he often re-established care at various health care systems. This case highlights the importance of continuity of care, especially in BHD, where monitoring for renal tumors is also essential to long-term management.^17,18

Renal Tumor Monitoring

Finally, once BHD is diagnosed, one of the most important considerations is to begin routine monitoring for renal malignancies. Current recommendations advise starting lifelong renal cancer screening, even as early as age 20 years, with annual MRIs, as renal ultrasound may not be sufficiently sensitive to detect smaller lesions.¹⁹ The screening interval can be extended to every 2 years for patients without a family history of renal tumors or suspicious renal lesions. If tumors are found, then nephron-sparing surgery is recommended, given the potential for the development of chronic renal insufficiency in patients with BHD.²⁰

Conclusions

BHD is a rare and complex syndrome in which early recognition and diagnosis play a pivotal role in preventing potentially severe complications such as renal malignancies. Suspicion of a genetic disorder, such as BHD, LAM, or PLCH, should arise in patients who experience spontaneous pneumothorax, especially in the presence of multiple cystic lesions or a family history of pneumothoraces. Early consideration of pleurodesis after the first spontaneous pneumothorax is advisable. The complex presentation of BHD contributes to the difficulty of diagnosis and may delay recognition, which can be exacerbated by variable continuity of care.

Birt-Hogg-Dubé syndrome (BHD) is an autosomal dominant disease that arises from loss-of-function mutations in the FLCN gene. FLCN encodes folliculin, which is presumed to function as a tumor suppressor, though its precise role is incompletely understood.^1,2 BHD is characterized by multiple pulmonary cysts leading to recurrent spontaneous pneumothoraces, cutaneous lesions—specifically fibrofolliculomas—and an increased risk of renal malignancies. Diagnosing BHD is challenging due to the variable presentation of the disease. Some patients may only have cystic lung diseases, while others may not have characteristic skin lesions.^3-5 It is important to maintain awareness of BHD, especially when the diagnosis dictates the need for genetic counseling.

Case Presentation

A male veteran in his 60s, who was a lifelong nonsmoker with a history of extensive bullous emphysema and recurrent pneumothoraces, presented to the Veterans Affairs Greater Los Angeles Healthcare System pulmonary clinic while transferring care from a separate institution.

According to the patient, the first pneumothorax episode occurred about 20 years before presentation, followed by a recurrence a few years later after he was diagnosed with emphysema. He underwent pleurodesis of the right lung during his service abroad. Another episode nearly a decade after the first pneumothorax necessitated pleurodesis of the left lung (Figure 1). The patient's family history revealed pulmonary cysts in 1 immediate family member but no history of renal tumors. Notably, his mother passed away at a young age due to tuberculosis.

On physical examination, numerous skin tags and acrochordons on the face were observed, which had been stable for > 30 years. Despite a slow decline in exercise capacity following pleurodesis, the patient could still walk multiple miles daily and climb 3 flights of stairs before needing to rest. Pulmonary function testing (PFT) showed a forced expiratory volume in 1 second (FEV₁)/forced vital capacity ratio of 0.84 with reduced FEV₁, total lung capacity (TLC), and diffusion capacity for carbon monoxide (DL_CO), indicating a mild restrictive ventilatory defect and reduced diffusing capacity.

Laboratory results revealed a normal α-1 antitrypsin level: 133 mg/dL (reference, 83-199 mg/dL), with a Pi*MS phenotype and undetectable antinuclear antibodies. The most recent chest computed tomography (CT) in 2019, displayed paraseptal and centrilobular emphysema, scattered blebs, and scarring consistent with prior pleurodesis procedures (Figure 2).

Genetic testing for the FLCN gene revealed heterozygous pathogenic mutation: c.1285del and p.His429Thrfs*39, which confirmed the diagnosis of BHD. A shave biopsy of a postauricular papular lesion confirmed a histologic pattern of fibrofolliculoma/trichodiscoma.

Follow-up and Outcomes

After confirmation of the BHD diagnosis, the patient was referred to genetic counseling and scheduled for annual magnetic resonance imaging (MRI) of the abdomen and pelvis to screen for renal malignancies. As the patient was able to establish care with a new long-term primary care practitioner in the outpatient setting, he continues regular follow-up visits in the pulmonary clinic with stable respiratory symptoms and no recurrent pneumothoraces thus far.

Discussion

Differential Diagnoses of Cystic Pulmonary Lesions

BHD is an important differential diagnosis to consider in the presentation of diffuse cystic lung diseases. Still, 2 other crucial considerations are pulmonary Langerhans cell histiocytosis (PLCH) and lymphangioleiomyomatosis (LAM), which occur at slightly higher frequencies than BHD.⁶

One of the first steps in radiographically evaluating cystic lung diseases is to characterize the cysts. The Fleischner Society defines true cysts as a “round parenchymal lucency or low-attenuating area with a well-defined interface with normal lung.”⁷ Mimics of cystic lesions may include cavitary lung lesions, thick-walled spaces within another area of mass, nodule, or consolidation. Another mimic is a pneumatocele, a pseudocyst that lacks epithelial lining and may be secondary to bacterial pneumonia, pneumocystis infections, trauma, or prior mechanical ventilation.⁸After characterizing true cysts, different patterns of cystic lesions can also be associated with specific diseases. Cysts in PLCH are commonly more uniform and round, whereas the cysts in LAM may be more irregularly shaped. ⁹ Cysts in BHD may be larger and predominantly located in basal and paramediastinal areas.⁴LAM is associated with tuberous sclerosis, which can also present with skin lesions (angiofibromas) and renal tumors (angiomyolipomas), thus creating a very similar picture to BHD. Therefore, tissue biopsies of skin lesions are essential as histopathology can identify characteristic fibrofolliculomas specific to BHD. While genetic testing would also strongly support the diagnosis of BHD, it is essential to note that negative genetic testing does not rule out BHD.⁴Lastly, lymphoid interstitial pneumonia (LIP) is another important consideration in the differential diagnosis of cystic lung diseases. LIP presents with not only perivascular cysts and centrilobular nodules but also diffuse ground-glass attenuation.¹⁰ In contrast to BHD, LIP is associated with autoimmune diseases such as Sjögren syndrome and infectious diseases such as HIV; thus, it may be differentiated from BHD by the presence of underlying disease processes and may warrant serologic testing for potential rheumatologic disorders.

Characteristics and Diagnostic Criteria


Cystic lung disease is the most common presentation of BHD. It presents in > 80% of cases and confers a 50-fold increase in the risk of spontaneous pneumothorax compared with the general population.^4,11 Recurrent pneumothoraces are observed in about 25% to 30% of patients with BHD, typically occurring between the third and fifth decades of life and at significantly decreased rates after 50 years of age.¹² A spontaneous pneumothorax might serve as the initial and perhaps the sole clinical presentation for some patients with BHD, but others may present with other respiratory symptoms such as cough and exertional dyspnea. PFT results may be normal or reveal a mild restrictive ventilatory defect and reduced DL_CO, as reported in a few cases.⁶ The management of pulmonary complications primarily revolves around reducing the risk of pneumothoraces, which includes precautions such as avoiding positive pressure ventilation and air travel. Early pleurodesis with the first occurrence of a spontaneous pneumothorax is considered in some cases.¹³

The distinctive dermatologic features associated with BHD include multiple white papules primarily found on the nose and face. Pathologically, these manifestations have a range of histologic distinctions, from fibrofolliculomas to benign hamartomas of the hair follicles and trichodiscomas.⁵ The diagnostic criteria outlined by Menko et al note that confirmation of BHD requires the presence of either ≥ 5 pathologically confirmed fibrofolliculomas or trichodiscomas, a documented pathogenic FLCN gene mutation, or the fulfillment of 2 minor criteria. These minor criteria include the presence of multiple lung cysts, early-onset renal cancer, or a first-degree relative with BHD.⁵

Recurrent Pneumothoraces Management

After the first episode of spontaneous pneumothorax, early pleurodesis is indicated as the risk of recurrence can be as high as 75%.^4,14 Specific pleurodesis modalities have shown promising results, such as total pleural covering with cellulose mesh. In a small retrospective review, cellulose mesh demonstrated a significant reduction in the recurrence rate of pneumothorax at 7.5 years for patients with BHD compared with partial covering.¹⁵ Apart from preventing further pneumothorax episodes in the affected lung, it is also important to highlight patient education and monitoring after initial pleurodesis, as the contralateral lung is also at risk. As demonstrated in this case, the patient had received pleurodesis of his right lung but experienced another pneumothorax of his contralateral lung a few years later.

Lastly, the patient was advised to avoid air travel altogether; however, current data may suggest that air travel may not be an absolute contraindication for patients with BHD. Although the literature on this topic is limited, a retrospective study by Johannesma et al involving 158 patients with BHD surveyed on pneumothorax occurrence after air travel indicated a calculated risk of 0.63% per flight. Notably, only 3 of 13 patients with BHD and recurrent pneumothoraces after travel had undergone pleurodesis in the past.¹⁶ Therefore, counseling patients on the potential risks of air travel and allowing essential flights while diligently monitoring for symptoms during and after travel may be a reasonable, patient-centered approach in contrast to a complete restriction on air travel.

Timing to Diagnosis

Diagnosing BHD is challenging and often delayed. In a 2022 study by Steinlein et al, the average delay in BHD diagnoses in their cohort was 9.3 years, with 4 patients also diagnosed with renal malignancy during the study period.¹⁷ The difficulty in diagnosis can be attributed to the heterogeneous presentation among affected family members, some of whom may exclusively exhibit pulmonary cystic lesions without dermatologic findings.

A lack of longitudinal care for this patient may have contributed to the diagnostic delay. The patient had pneumothorax events across separate care settings and locations, and due to employment-related relocations, he often re-established care at various health care systems. This case highlights the importance of continuity of care, especially in BHD, where monitoring for renal tumors is also essential to long-term management.^17,18

Renal Tumor Monitoring

Finally, once BHD is diagnosed, one of the most important considerations is to begin routine monitoring for renal malignancies. Current recommendations advise starting lifelong renal cancer screening, even as early as age 20 years, with annual MRIs, as renal ultrasound may not be sufficiently sensitive to detect smaller lesions.¹⁹ The screening interval can be extended to every 2 years for patients without a family history of renal tumors or suspicious renal lesions. If tumors are found, then nephron-sparing surgery is recommended, given the potential for the development of chronic renal insufficiency in patients with BHD.²⁰

Conclusions

BHD is a rare and complex syndrome in which early recognition and diagnosis play a pivotal role in preventing potentially severe complications such as renal malignancies. Suspicion of a genetic disorder, such as BHD, LAM, or PLCH, should arise in patients who experience spontaneous pneumothorax, especially in the presence of multiple cystic lesions or a family history of pneumothoraces. Early consideration of pleurodesis after the first spontaneous pneumothorax is advisable. The complex presentation of BHD contributes to the difficulty of diagnosis and may delay recognition, which can be exacerbated by variable continuity of care.

Patients make unplanned appointments after elective soft tissue hand surgery for real or perceived complications when they experience pain, anxiety, or fear. Unplanned appointments can create travel and financial burdens for patients and families. These appointments take time away from scheduled appointments and can contribute to late arrivals and delays in other clinics. Unscheduled appointments contribute to poor access when staff are diverted from scheduled appointments. If predictive factors can be identified, unplanned appointments may either be ameliorated or avoided with better perioperative risk management or education.

Methods

The US Department of Veterans Affairs (VA) North Florida/South Georgia Veterans Health System (NFSGVAHS) and University of Florida Institutional Review Board approved a retrospective chart review of all plastic surgery cases performed at the Malcom Randall VA Medical Center (MRVAMC) and Lake City VAMC operating rooms from July 1, 2018, through December 31, 2019, and January 1, 2021, through June 30, 2022 (nonurgent surgeries were discouraged during the COVID-19 pandemic). Elective soft tissue hand surgery cases were identified based on the operative description found in the Surgical Service Surgeon Staffing Report reviewed monthly by the Service Chief. Potential indicators of unplanned visits were recorded, including age; sex; diagnosis of diabetes, depression, anxiety, or posttraumatic stress disorder (PTSD); current smoking status; and residential zip code. We used the first 3 digits of the patients’ zip codes, which indicate region, as an estimate of proximity to the MRVAMC, which has a 50-county catchment area across North Florida and South Georgia. Diagnoses were found on the “problem list” from the electronic health record documented in the history and physical examinations before surgery. Clinic notes were examined for 3 months postsurgery to identify unplanned postoperative visits and the reason for the appointment. A χ² analysis was conducted using Excel Version 2402. P < .05 was used to determine whether age (> 60 years), sex, proximity to MRVAMC, diabetes, smoking, depression, anxiety, or PTSD were statistically significant independent risk factors for these appointments.

Results

A total of 1009 elective soft tissue hand surgeries at MRVAMC were reviewed. The patients median age was 61 years. Patients included 173 women (17.1%) and 836 men (82.9%). Eighty-one patients (8.0%) returned for unplanned visits. Age (P = .82); proximity to MRVAMC (P = .34); and diabetes (P = .60), smoking (P = .55), anxiety (P = .33), or PTSD (P = .37) were not statistically significant predictors of unplanned appointments. Depression diagnosis (P = .04) and female sex (P = .03) were found to be independent risk factors for an unplanned appointment (Table 1). The most common indication for the requested appointment was pain-related, followed closely by noninfectious wound concerns and persistent symptoms (Table 2).

Discussion

Improved access, quality, and efficiency for patients are goals for the VA.^1-3 The MRVAMC Plastic and Hand Surgery service provides care for the NFSGVAHS and receives an average of 15 to 20 consultation requests daily. The Veterans Health Administration is frequently challenged by staff shortages, and surgical services struggle to respond to consultation requests and treat patients within reasonable time frames.^4,5

The objective of this study was to identify risk factors for unplanned postoperative appointments following elective hand surgery. Unplanned appointments prevent scheduled patients from being seen on time and contribute to backlogs and delays. When patients schedule multiple appointments on the same day, delays in the first clinic’s scheduled appointments create delays for the second and third clinics. Hand surgery clinics can provide a better experience for patients and staff by identifying and mitigating factors prompting unplanned visits.

We anticipated that wound complications would prompt unscheduled visits. Diabetes is a known risk factor for wound healing complications after plastic and hand surgery.^6,7 A hemoglobin A_1c (HbA_1c) screening protocol used by the NFSGVAHS plastic surgery service since 2015 to identify poorly controlled patients with diabetes before surgery may partially explain this finding.⁸ We did not find a statistically significant difference between patients with diabetes and patients without diabetes for scheduling unplanned appointments. The plastic surgery service does not perform elective hand surgery unless the patient’s HbA_1c level is < 9%, or violate the flexor sheath unless HbA_1c level is < 8%. However, Zhuang et al found an increase in soft tissue infections after hand surgery with HbA_1c levels ≥ 7%.⁹

Smoking is a potential factor in postoperative hand surgery complications.^10,11 Lans et al found an increased incidence of 30-day emergency room visits in current and former smokers after outpatient upper extremity fracture surgery.¹² The MRVAMC Plastic Surgery Service counsels patients about the risk of skin necrosis and delayed wound healing, but does not cancel cases or obtain laboratory values to verify abstinence in patients undergoing hand surgery. The VA has multiple resources available for patients interested in smoking cessation through mental health services.¹³

MRVAMC patients have been known to resist returning for scheduled appointments due to the costs or availability of transportation. We suspected that patients who lived further from MRVAMC would be less likely to return for unscheduled visits. We used the first 3 digits of the patients’ mailing zip code to estimate residential proximity to MRVAMC. An acknowledged limitation to this approach is that some veterans have primary addresses in other regions but still spend significant time in the MRVAMC catchment area and use the facility for their health care during the winter months. These “snowbirds” might reside near the facility despite having official addresses that are more distant. Additionally, there was no increased risk of unplanned visits after hand surgery in patients aged > 61 years (the median age of study participants) (P = .82). Dependence on a third party for transportation in older veterans could impact this finding.

Based on the observation that most patients needed reassurance rather than an intervention when they returned for unscheduled appointments, diagnoses of depression, anxiety, and PTSD were evaluated as separate predictive factors. In previous research, anxiety was found to be a risk factor for problematic recovery following carpal tunnel surgery.¹⁴ In the current study, depression was found to be a statistically significant predictor of unscheduled postoperative appointments (P = .04), while anxiety (P = .33) and PTSD (P = .37) were not statistically significant predictors. This is consistent with other studies that have found preexisting depression can predict complications after hand surgery.^15,16 Vranceanu et al found that depression predicted pain intensity and disability after elective hand surgery.¹⁶ Similarly, Oflazoglu et al found a 12% incidence of depression based on the Patient Health Questionnaire-9 in new and returning hand patients who presented to an academic practice.¹⁷ They suggest patients should be assessed at all levels of care and that those with poor responses to surgical or nonsurgical management should be evaluated for depression. MRVAMC has a large mental health service consisting of psychiatrists, psychologists, addiction specialists, social workers, and homeless outreach, and patients tend to already have a diagnosis and mental health practitioner when they present to the clinic.

Recent studies found that wound problems, pain, and stiffness were the most common reasons for return visits.^18,19 Shetty et al identified younger age, worse preoperative pain scores, and poor access to transportation as predictors of preventable emergency room visits, which generate higher health care expenditures than an office visit.¹⁹ Our study’s top reasons for appointments (pain, wound/scar concerns, persistent symptoms) can be addressed with additional presurgery patient and family education. Additionally, clinicians encourage nonnarcotic pain management strategies including anti-inflammatories, acetaminophen, elevation, splinting, and hand therapy, and the hospital employs experienced, fellowship-trained anesthesia block faculty who help limit perioperative narcotic use. Patients are advised that pain can be used to guide them through the postoperative recovery by preventing overuse and alerting them to a problem that would be masked with narcotics, and long-standing problems such as chronic nerve compressions may continue to cause pain after surgery.

Patients and families can be given consistent and repetitive verbal and written information, instructions, and expectations at the initial consultation, preoperative appointment, and on the day of surgery. Postoperatively, outside their scheduled appointments, patients are encouraged to use the My HealtheVet secure messaging system or call the clinic to access an experienced registered nurse before making a long drive. Access to virtual or phone visits can reduce emergent in-person visits in a VA population.²⁰

Ozdag et al found that 42% of patients who had elective carpal tunnel surgery made unplanned electronic messages or phone contact within 2 weeks postsurgery. The authors point out the uncompensated administrative burden on the staff answering these messages and suggest pre-empting the contacts with more up-front education regarding postoperative pain expectations and management strategies.²¹

Fisher et al found that attending hand therapy reduced the number of emergency department visits in postoperative infection cases.²² At MRVAMC, a postoperative emergency department visit for a patient prompts an urgent unplanned appointment to the plastic surgery clinic, often on the same day. The MRVAMC occupational therapy clinic employed 3 on-site certified hand therapists during the study period. Because all hand surgery patients at the clinic receive hand therapy on the same day as their first postoperative appointment, attendance at hand therapy was not evaluated as a predictor of unplanned visits. Scheduled hand therapy is another point of contact where the clinic can provide reassurance and patient education.

While females made up 17.1% of the patients in this study, they constituted 12.5% of all veterans in Florida in fiscal year 2023.²³ This study found that women were more likely to present for unplanned postoperative appointments (P = .03). This is consistent with existing literature which has found that women are higher users of health care and office-based appointments.^24,25 This finding suggests the need for further study into whether our methods of communicating instructions to female patients undergoing plastic surgery may not be optimal.

Strengths and Limitations

As a retrospective review, the authors used information documented by multiple different health care practitioners, including trainees. The electronic medical record problem lists and templates provide consistency of information; however, less seasoned clinicians may interpret what they see and hear differently from more experienced clinicians in the postoperative setting. This study occurred in one part of the country with demographics that may not mirror other VA systems or the general population. The authors hope this study can be a starting point for other health care facilities to investigate ways to minimize the burden of unscheduled appointments. A strength of the study is that it was conducted within a closed system, as patients tend to stay within the VA system and documentation and communication among clinicians, even outside the immediate facility, are easily accessed through the electronic health record.

Conclusions

This study found that depression diagnosis and female sex are statistically significant predictors of unplanned postoperative visits after elective soft tissue hand surgery. More effective patient education during the preoperative period, particularly in patients with depression, may be warranted.

Patients make unplanned appointments after elective soft tissue hand surgery for real or perceived complications when they experience pain, anxiety, or fear. Unplanned appointments can create travel and financial burdens for patients and families. These appointments take time away from scheduled appointments and can contribute to late arrivals and delays in other clinics. Unscheduled appointments contribute to poor access when staff are diverted from scheduled appointments. If predictive factors can be identified, unplanned appointments may either be ameliorated or avoided with better perioperative risk management or education.

Methods

The US Department of Veterans Affairs (VA) North Florida/South Georgia Veterans Health System (NFSGVAHS) and University of Florida Institutional Review Board approved a retrospective chart review of all plastic surgery cases performed at the Malcom Randall VA Medical Center (MRVAMC) and Lake City VAMC operating rooms from July 1, 2018, through December 31, 2019, and January 1, 2021, through June 30, 2022 (nonurgent surgeries were discouraged during the COVID-19 pandemic). Elective soft tissue hand surgery cases were identified based on the operative description found in the Surgical Service Surgeon Staffing Report reviewed monthly by the Service Chief. Potential indicators of unplanned visits were recorded, including age; sex; diagnosis of diabetes, depression, anxiety, or posttraumatic stress disorder (PTSD); current smoking status; and residential zip code. We used the first 3 digits of the patients’ zip codes, which indicate region, as an estimate of proximity to the MRVAMC, which has a 50-county catchment area across North Florida and South Georgia. Diagnoses were found on the “problem list” from the electronic health record documented in the history and physical examinations before surgery. Clinic notes were examined for 3 months postsurgery to identify unplanned postoperative visits and the reason for the appointment. A χ² analysis was conducted using Excel Version 2402. P < .05 was used to determine whether age (> 60 years), sex, proximity to MRVAMC, diabetes, smoking, depression, anxiety, or PTSD were statistically significant independent risk factors for these appointments.

Results

A total of 1009 elective soft tissue hand surgeries at MRVAMC were reviewed. The patients median age was 61 years. Patients included 173 women (17.1%) and 836 men (82.9%). Eighty-one patients (8.0%) returned for unplanned visits. Age (P = .82); proximity to MRVAMC (P = .34); and diabetes (P = .60), smoking (P = .55), anxiety (P = .33), or PTSD (P = .37) were not statistically significant predictors of unplanned appointments. Depression diagnosis (P = .04) and female sex (P = .03) were found to be independent risk factors for an unplanned appointment (Table 1). The most common indication for the requested appointment was pain-related, followed closely by noninfectious wound concerns and persistent symptoms (Table 2).

Discussion

Improved access, quality, and efficiency for patients are goals for the VA.^1-3 The MRVAMC Plastic and Hand Surgery service provides care for the NFSGVAHS and receives an average of 15 to 20 consultation requests daily. The Veterans Health Administration is frequently challenged by staff shortages, and surgical services struggle to respond to consultation requests and treat patients within reasonable time frames.^4,5

The objective of this study was to identify risk factors for unplanned postoperative appointments following elective hand surgery. Unplanned appointments prevent scheduled patients from being seen on time and contribute to backlogs and delays. When patients schedule multiple appointments on the same day, delays in the first clinic’s scheduled appointments create delays for the second and third clinics. Hand surgery clinics can provide a better experience for patients and staff by identifying and mitigating factors prompting unplanned visits.

We anticipated that wound complications would prompt unscheduled visits. Diabetes is a known risk factor for wound healing complications after plastic and hand surgery.^6,7 A hemoglobin A_1c (HbA_1c) screening protocol used by the NFSGVAHS plastic surgery service since 2015 to identify poorly controlled patients with diabetes before surgery may partially explain this finding.⁸ We did not find a statistically significant difference between patients with diabetes and patients without diabetes for scheduling unplanned appointments. The plastic surgery service does not perform elective hand surgery unless the patient’s HbA_1c level is < 9%, or violate the flexor sheath unless HbA_1c level is < 8%. However, Zhuang et al found an increase in soft tissue infections after hand surgery with HbA_1c levels ≥ 7%.⁹

Smoking is a potential factor in postoperative hand surgery complications.^10,11 Lans et al found an increased incidence of 30-day emergency room visits in current and former smokers after outpatient upper extremity fracture surgery.¹² The MRVAMC Plastic Surgery Service counsels patients about the risk of skin necrosis and delayed wound healing, but does not cancel cases or obtain laboratory values to verify abstinence in patients undergoing hand surgery. The VA has multiple resources available for patients interested in smoking cessation through mental health services.¹³

MRVAMC patients have been known to resist returning for scheduled appointments due to the costs or availability of transportation. We suspected that patients who lived further from MRVAMC would be less likely to return for unscheduled visits. We used the first 3 digits of the patients’ mailing zip code to estimate residential proximity to MRVAMC. An acknowledged limitation to this approach is that some veterans have primary addresses in other regions but still spend significant time in the MRVAMC catchment area and use the facility for their health care during the winter months. These “snowbirds” might reside near the facility despite having official addresses that are more distant. Additionally, there was no increased risk of unplanned visits after hand surgery in patients aged > 61 years (the median age of study participants) (P = .82). Dependence on a third party for transportation in older veterans could impact this finding.

Based on the observation that most patients needed reassurance rather than an intervention when they returned for unscheduled appointments, diagnoses of depression, anxiety, and PTSD were evaluated as separate predictive factors. In previous research, anxiety was found to be a risk factor for problematic recovery following carpal tunnel surgery.¹⁴ In the current study, depression was found to be a statistically significant predictor of unscheduled postoperative appointments (P = .04), while anxiety (P = .33) and PTSD (P = .37) were not statistically significant predictors. This is consistent with other studies that have found preexisting depression can predict complications after hand surgery.^15,16 Vranceanu et al found that depression predicted pain intensity and disability after elective hand surgery.¹⁶ Similarly, Oflazoglu et al found a 12% incidence of depression based on the Patient Health Questionnaire-9 in new and returning hand patients who presented to an academic practice.¹⁷ They suggest patients should be assessed at all levels of care and that those with poor responses to surgical or nonsurgical management should be evaluated for depression. MRVAMC has a large mental health service consisting of psychiatrists, psychologists, addiction specialists, social workers, and homeless outreach, and patients tend to already have a diagnosis and mental health practitioner when they present to the clinic.

Recent studies found that wound problems, pain, and stiffness were the most common reasons for return visits.^18,19 Shetty et al identified younger age, worse preoperative pain scores, and poor access to transportation as predictors of preventable emergency room visits, which generate higher health care expenditures than an office visit.¹⁹ Our study’s top reasons for appointments (pain, wound/scar concerns, persistent symptoms) can be addressed with additional presurgery patient and family education. Additionally, clinicians encourage nonnarcotic pain management strategies including anti-inflammatories, acetaminophen, elevation, splinting, and hand therapy, and the hospital employs experienced, fellowship-trained anesthesia block faculty who help limit perioperative narcotic use. Patients are advised that pain can be used to guide them through the postoperative recovery by preventing overuse and alerting them to a problem that would be masked with narcotics, and long-standing problems such as chronic nerve compressions may continue to cause pain after surgery.

Patients and families can be given consistent and repetitive verbal and written information, instructions, and expectations at the initial consultation, preoperative appointment, and on the day of surgery. Postoperatively, outside their scheduled appointments, patients are encouraged to use the My HealtheVet secure messaging system or call the clinic to access an experienced registered nurse before making a long drive. Access to virtual or phone visits can reduce emergent in-person visits in a VA population.²⁰

Ozdag et al found that 42% of patients who had elective carpal tunnel surgery made unplanned electronic messages or phone contact within 2 weeks postsurgery. The authors point out the uncompensated administrative burden on the staff answering these messages and suggest pre-empting the contacts with more up-front education regarding postoperative pain expectations and management strategies.²¹

Fisher et al found that attending hand therapy reduced the number of emergency department visits in postoperative infection cases.²² At MRVAMC, a postoperative emergency department visit for a patient prompts an urgent unplanned appointment to the plastic surgery clinic, often on the same day. The MRVAMC occupational therapy clinic employed 3 on-site certified hand therapists during the study period. Because all hand surgery patients at the clinic receive hand therapy on the same day as their first postoperative appointment, attendance at hand therapy was not evaluated as a predictor of unplanned visits. Scheduled hand therapy is another point of contact where the clinic can provide reassurance and patient education.

While females made up 17.1% of the patients in this study, they constituted 12.5% of all veterans in Florida in fiscal year 2023.²³ This study found that women were more likely to present for unplanned postoperative appointments (P = .03). This is consistent with existing literature which has found that women are higher users of health care and office-based appointments.^24,25 This finding suggests the need for further study into whether our methods of communicating instructions to female patients undergoing plastic surgery may not be optimal.

Strengths and Limitations

As a retrospective review, the authors used information documented by multiple different health care practitioners, including trainees. The electronic medical record problem lists and templates provide consistency of information; however, less seasoned clinicians may interpret what they see and hear differently from more experienced clinicians in the postoperative setting. This study occurred in one part of the country with demographics that may not mirror other VA systems or the general population. The authors hope this study can be a starting point for other health care facilities to investigate ways to minimize the burden of unscheduled appointments. A strength of the study is that it was conducted within a closed system, as patients tend to stay within the VA system and documentation and communication among clinicians, even outside the immediate facility, are easily accessed through the electronic health record.

Conclusions

This study found that depression diagnosis and female sex are statistically significant predictors of unplanned postoperative visits after elective soft tissue hand surgery. More effective patient education during the preoperative period, particularly in patients with depression, may be warranted.

Patients make unplanned appointments after elective soft tissue hand surgery for real or perceived complications when they experience pain, anxiety, or fear. Unplanned appointments can create travel and financial burdens for patients and families. These appointments take time away from scheduled appointments and can contribute to late arrivals and delays in other clinics. Unscheduled appointments contribute to poor access when staff are diverted from scheduled appointments. If predictive factors can be identified, unplanned appointments may either be ameliorated or avoided with better perioperative risk management or education.

Methods

The US Department of Veterans Affairs (VA) North Florida/South Georgia Veterans Health System (NFSGVAHS) and University of Florida Institutional Review Board approved a retrospective chart review of all plastic surgery cases performed at the Malcom Randall VA Medical Center (MRVAMC) and Lake City VAMC operating rooms from July 1, 2018, through December 31, 2019, and January 1, 2021, through June 30, 2022 (nonurgent surgeries were discouraged during the COVID-19 pandemic). Elective soft tissue hand surgery cases were identified based on the operative description found in the Surgical Service Surgeon Staffing Report reviewed monthly by the Service Chief. Potential indicators of unplanned visits were recorded, including age; sex; diagnosis of diabetes, depression, anxiety, or posttraumatic stress disorder (PTSD); current smoking status; and residential zip code. We used the first 3 digits of the patients’ zip codes, which indicate region, as an estimate of proximity to the MRVAMC, which has a 50-county catchment area across North Florida and South Georgia. Diagnoses were found on the “problem list” from the electronic health record documented in the history and physical examinations before surgery. Clinic notes were examined for 3 months postsurgery to identify unplanned postoperative visits and the reason for the appointment. A χ² analysis was conducted using Excel Version 2402. P < .05 was used to determine whether age (> 60 years), sex, proximity to MRVAMC, diabetes, smoking, depression, anxiety, or PTSD were statistically significant independent risk factors for these appointments.

Results

A total of 1009 elective soft tissue hand surgeries at MRVAMC were reviewed. The patients median age was 61 years. Patients included 173 women (17.1%) and 836 men (82.9%). Eighty-one patients (8.0%) returned for unplanned visits. Age (P = .82); proximity to MRVAMC (P = .34); and diabetes (P = .60), smoking (P = .55), anxiety (P = .33), or PTSD (P = .37) were not statistically significant predictors of unplanned appointments. Depression diagnosis (P = .04) and female sex (P = .03) were found to be independent risk factors for an unplanned appointment (Table 1). The most common indication for the requested appointment was pain-related, followed closely by noninfectious wound concerns and persistent symptoms (Table 2).

Discussion

Improved access, quality, and efficiency for patients are goals for the VA.^1-3 The MRVAMC Plastic and Hand Surgery service provides care for the NFSGVAHS and receives an average of 15 to 20 consultation requests daily. The Veterans Health Administration is frequently challenged by staff shortages, and surgical services struggle to respond to consultation requests and treat patients within reasonable time frames.^4,5

The objective of this study was to identify risk factors for unplanned postoperative appointments following elective hand surgery. Unplanned appointments prevent scheduled patients from being seen on time and contribute to backlogs and delays. When patients schedule multiple appointments on the same day, delays in the first clinic’s scheduled appointments create delays for the second and third clinics. Hand surgery clinics can provide a better experience for patients and staff by identifying and mitigating factors prompting unplanned visits.

We anticipated that wound complications would prompt unscheduled visits. Diabetes is a known risk factor for wound healing complications after plastic and hand surgery.^6,7 A hemoglobin A_1c (HbA_1c) screening protocol used by the NFSGVAHS plastic surgery service since 2015 to identify poorly controlled patients with diabetes before surgery may partially explain this finding.⁸ We did not find a statistically significant difference between patients with diabetes and patients without diabetes for scheduling unplanned appointments. The plastic surgery service does not perform elective hand surgery unless the patient’s HbA_1c level is < 9%, or violate the flexor sheath unless HbA_1c level is < 8%. However, Zhuang et al found an increase in soft tissue infections after hand surgery with HbA_1c levels ≥ 7%.⁹

Smoking is a potential factor in postoperative hand surgery complications.^10,11 Lans et al found an increased incidence of 30-day emergency room visits in current and former smokers after outpatient upper extremity fracture surgery.¹² The MRVAMC Plastic Surgery Service counsels patients about the risk of skin necrosis and delayed wound healing, but does not cancel cases or obtain laboratory values to verify abstinence in patients undergoing hand surgery. The VA has multiple resources available for patients interested in smoking cessation through mental health services.¹³

MRVAMC patients have been known to resist returning for scheduled appointments due to the costs or availability of transportation. We suspected that patients who lived further from MRVAMC would be less likely to return for unscheduled visits. We used the first 3 digits of the patients’ mailing zip code to estimate residential proximity to MRVAMC. An acknowledged limitation to this approach is that some veterans have primary addresses in other regions but still spend significant time in the MRVAMC catchment area and use the facility for their health care during the winter months. These “snowbirds” might reside near the facility despite having official addresses that are more distant. Additionally, there was no increased risk of unplanned visits after hand surgery in patients aged > 61 years (the median age of study participants) (P = .82). Dependence on a third party for transportation in older veterans could impact this finding.

Based on the observation that most patients needed reassurance rather than an intervention when they returned for unscheduled appointments, diagnoses of depression, anxiety, and PTSD were evaluated as separate predictive factors. In previous research, anxiety was found to be a risk factor for problematic recovery following carpal tunnel surgery.¹⁴ In the current study, depression was found to be a statistically significant predictor of unscheduled postoperative appointments (P = .04), while anxiety (P = .33) and PTSD (P = .37) were not statistically significant predictors. This is consistent with other studies that have found preexisting depression can predict complications after hand surgery.^15,16 Vranceanu et al found that depression predicted pain intensity and disability after elective hand surgery.¹⁶ Similarly, Oflazoglu et al found a 12% incidence of depression based on the Patient Health Questionnaire-9 in new and returning hand patients who presented to an academic practice.¹⁷ They suggest patients should be assessed at all levels of care and that those with poor responses to surgical or nonsurgical management should be evaluated for depression. MRVAMC has a large mental health service consisting of psychiatrists, psychologists, addiction specialists, social workers, and homeless outreach, and patients tend to already have a diagnosis and mental health practitioner when they present to the clinic.

Recent studies found that wound problems, pain, and stiffness were the most common reasons for return visits.^18,19 Shetty et al identified younger age, worse preoperative pain scores, and poor access to transportation as predictors of preventable emergency room visits, which generate higher health care expenditures than an office visit.¹⁹ Our study’s top reasons for appointments (pain, wound/scar concerns, persistent symptoms) can be addressed with additional presurgery patient and family education. Additionally, clinicians encourage nonnarcotic pain management strategies including anti-inflammatories, acetaminophen, elevation, splinting, and hand therapy, and the hospital employs experienced, fellowship-trained anesthesia block faculty who help limit perioperative narcotic use. Patients are advised that pain can be used to guide them through the postoperative recovery by preventing overuse and alerting them to a problem that would be masked with narcotics, and long-standing problems such as chronic nerve compressions may continue to cause pain after surgery.

Patients and families can be given consistent and repetitive verbal and written information, instructions, and expectations at the initial consultation, preoperative appointment, and on the day of surgery. Postoperatively, outside their scheduled appointments, patients are encouraged to use the My HealtheVet secure messaging system or call the clinic to access an experienced registered nurse before making a long drive. Access to virtual or phone visits can reduce emergent in-person visits in a VA population.²⁰

Ozdag et al found that 42% of patients who had elective carpal tunnel surgery made unplanned electronic messages or phone contact within 2 weeks postsurgery. The authors point out the uncompensated administrative burden on the staff answering these messages and suggest pre-empting the contacts with more up-front education regarding postoperative pain expectations and management strategies.²¹

Fisher et al found that attending hand therapy reduced the number of emergency department visits in postoperative infection cases.²² At MRVAMC, a postoperative emergency department visit for a patient prompts an urgent unplanned appointment to the plastic surgery clinic, often on the same day. The MRVAMC occupational therapy clinic employed 3 on-site certified hand therapists during the study period. Because all hand surgery patients at the clinic receive hand therapy on the same day as their first postoperative appointment, attendance at hand therapy was not evaluated as a predictor of unplanned visits. Scheduled hand therapy is another point of contact where the clinic can provide reassurance and patient education.

While females made up 17.1% of the patients in this study, they constituted 12.5% of all veterans in Florida in fiscal year 2023.²³ This study found that women were more likely to present for unplanned postoperative appointments (P = .03). This is consistent with existing literature which has found that women are higher users of health care and office-based appointments.^24,25 This finding suggests the need for further study into whether our methods of communicating instructions to female patients undergoing plastic surgery may not be optimal.

Strengths and Limitations

As a retrospective review, the authors used information documented by multiple different health care practitioners, including trainees. The electronic medical record problem lists and templates provide consistency of information; however, less seasoned clinicians may interpret what they see and hear differently from more experienced clinicians in the postoperative setting. This study occurred in one part of the country with demographics that may not mirror other VA systems or the general population. The authors hope this study can be a starting point for other health care facilities to investigate ways to minimize the burden of unscheduled appointments. A strength of the study is that it was conducted within a closed system, as patients tend to stay within the VA system and documentation and communication among clinicians, even outside the immediate facility, are easily accessed through the electronic health record.

Conclusions

This study found that depression diagnosis and female sex are statistically significant predictors of unplanned postoperative visits after elective soft tissue hand surgery. More effective patient education during the preoperative period, particularly in patients with depression, may be warranted.

TOPLINE:

In a meta-analysis, patients with hidradenitis suppurativa (HS) faced a more than 80% higher risk for cancer overall than the general population, with particularly elevated risks for gastrointestinal, head and neck, hematologic, and respiratory system cancers.

METHODOLOGY:

• Researchers conducted a meta-analysis including 11 studies from PubMed, Embase, and Web of Science databases published between 2001 and 2024; these studies examined the risk for cancer in patients with HS compared with that in the general population.
• These studies included 624,721 patients diagnosed with HS (mean age, 33.6-43.8 years) and 393,691,636 control individuals from the general population.
• Researchers performed an inverse variance-weighted random-effects analysis to calculate pooled odds ratios (ORs) for cancer overall and specific cancer subtypes.
• Cancer types were categorized into 11 groups for subgroup analysis: bone and soft tissue cancers, breast cancer, central nervous system cancers, endocrine-related cancers, gastrointestinal cancers, head and neck cancers, hematologic cancers, respiratory system cancers, skin cancers, urogenital cancers, and unspecified cancers.

TAKEAWAY:

• Patients with HS demonstrated a significantly higher risk for cancer overall than control individuals (crude OR, 1.82; P = .018).
• Patients with HS showed an increased risk for gastrointestinal cancers (crude OR, 1.61; P = .0002), head and neck cancers (crude OR, 2.41; P = .00001), hematologic cancers (crude OR, 1.71; P = .00005), and respiratory system cancers (crude OR, 1.81; P = .04).
• Patients with HS demonstrated significantly elevated risks for both Hodgkin lymphoma (OR, 2.44; P = .0001) and non-Hodgkin lymphoma (OR, 1.15; P = .012).
• A non-significant increased risk for skin cancer was observed in patients with HS (crude OR, 1.48; P = .08). No increased risks for bone and soft tissue cancers, central nervous system cancers, breast cancer, or urogenital cancers were observed in patients with HS.

IN PRACTICE:

"HS was associated with an increased overall risk of cancer, including several specific subtypes, compared with controls," the authors wrote, suggesting that "studies are adjusting for confounders and assess long-term associations between HS and cancer risk are highly needed to investigate which factors contribute to this cancer risk."

SOURCE:

This study was led by Daniel Isufi, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark. It was published online on March 11, 2026, in Dermatology and Therapy.

LIMITATIONS:

Limited data on cancer subtypes hindered meta-analyses of rare cancers, and the lack of reporting on anti‑inflammatory treatment and disease severity prevented subgroup analyses. Most studies originated from North America, introducing potential geographic bias. No study reported BMI, and ethnicity was poorly documented. Only few studies adjusted for key confounders (smoking, obesity, and alcohol intake), limiting the determination of whether the increased risk for cancer was due to HS itself or shared lifestyle and metabolic factors.

DISCLOSURES:

This study did not receive any funding or sponsorship. Two authors reported receiving research grant funding from the LEO Foundation and having other ties with various other sources.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

TOPLINE:

In a meta-analysis, patients with hidradenitis suppurativa (HS) faced a more than 80% higher risk for cancer overall than the general population, with particularly elevated risks for gastrointestinal, head and neck, hematologic, and respiratory system cancers.

METHODOLOGY:

• Researchers conducted a meta-analysis including 11 studies from PubMed, Embase, and Web of Science databases published between 2001 and 2024; these studies examined the risk for cancer in patients with HS compared with that in the general population.
• These studies included 624,721 patients diagnosed with HS (mean age, 33.6-43.8 years) and 393,691,636 control individuals from the general population.
• Researchers performed an inverse variance-weighted random-effects analysis to calculate pooled odds ratios (ORs) for cancer overall and specific cancer subtypes.
• Cancer types were categorized into 11 groups for subgroup analysis: bone and soft tissue cancers, breast cancer, central nervous system cancers, endocrine-related cancers, gastrointestinal cancers, head and neck cancers, hematologic cancers, respiratory system cancers, skin cancers, urogenital cancers, and unspecified cancers.

TAKEAWAY:

• Patients with HS demonstrated a significantly higher risk for cancer overall than control individuals (crude OR, 1.82; P = .018).
• Patients with HS showed an increased risk for gastrointestinal cancers (crude OR, 1.61; P = .0002), head and neck cancers (crude OR, 2.41; P = .00001), hematologic cancers (crude OR, 1.71; P = .00005), and respiratory system cancers (crude OR, 1.81; P = .04).
• Patients with HS demonstrated significantly elevated risks for both Hodgkin lymphoma (OR, 2.44; P = .0001) and non-Hodgkin lymphoma (OR, 1.15; P = .012).
• A non-significant increased risk for skin cancer was observed in patients with HS (crude OR, 1.48; P = .08). No increased risks for bone and soft tissue cancers, central nervous system cancers, breast cancer, or urogenital cancers were observed in patients with HS.

IN PRACTICE:

"HS was associated with an increased overall risk of cancer, including several specific subtypes, compared with controls," the authors wrote, suggesting that "studies are adjusting for confounders and assess long-term associations between HS and cancer risk are highly needed to investigate which factors contribute to this cancer risk."

SOURCE:

This study was led by Daniel Isufi, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark. It was published online on March 11, 2026, in Dermatology and Therapy.

LIMITATIONS:

Limited data on cancer subtypes hindered meta-analyses of rare cancers, and the lack of reporting on anti‑inflammatory treatment and disease severity prevented subgroup analyses. Most studies originated from North America, introducing potential geographic bias. No study reported BMI, and ethnicity was poorly documented. Only few studies adjusted for key confounders (smoking, obesity, and alcohol intake), limiting the determination of whether the increased risk for cancer was due to HS itself or shared lifestyle and metabolic factors.

DISCLOSURES:

This study did not receive any funding or sponsorship. Two authors reported receiving research grant funding from the LEO Foundation and having other ties with various other sources.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

TOPLINE:

In a meta-analysis, patients with hidradenitis suppurativa (HS) faced a more than 80% higher risk for cancer overall than the general population, with particularly elevated risks for gastrointestinal, head and neck, hematologic, and respiratory system cancers.

METHODOLOGY:

• Researchers conducted a meta-analysis including 11 studies from PubMed, Embase, and Web of Science databases published between 2001 and 2024; these studies examined the risk for cancer in patients with HS compared with that in the general population.
• These studies included 624,721 patients diagnosed with HS (mean age, 33.6-43.8 years) and 393,691,636 control individuals from the general population.
• Researchers performed an inverse variance-weighted random-effects analysis to calculate pooled odds ratios (ORs) for cancer overall and specific cancer subtypes.
• Cancer types were categorized into 11 groups for subgroup analysis: bone and soft tissue cancers, breast cancer, central nervous system cancers, endocrine-related cancers, gastrointestinal cancers, head and neck cancers, hematologic cancers, respiratory system cancers, skin cancers, urogenital cancers, and unspecified cancers.

TAKEAWAY:

• Patients with HS demonstrated a significantly higher risk for cancer overall than control individuals (crude OR, 1.82; P = .018).
• Patients with HS showed an increased risk for gastrointestinal cancers (crude OR, 1.61; P = .0002), head and neck cancers (crude OR, 2.41; P = .00001), hematologic cancers (crude OR, 1.71; P = .00005), and respiratory system cancers (crude OR, 1.81; P = .04).
• Patients with HS demonstrated significantly elevated risks for both Hodgkin lymphoma (OR, 2.44; P = .0001) and non-Hodgkin lymphoma (OR, 1.15; P = .012).
• A non-significant increased risk for skin cancer was observed in patients with HS (crude OR, 1.48; P = .08). No increased risks for bone and soft tissue cancers, central nervous system cancers, breast cancer, or urogenital cancers were observed in patients with HS.

IN PRACTICE:

"HS was associated with an increased overall risk of cancer, including several specific subtypes, compared with controls," the authors wrote, suggesting that "studies are adjusting for confounders and assess long-term associations between HS and cancer risk are highly needed to investigate which factors contribute to this cancer risk."

SOURCE:

This study was led by Daniel Isufi, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark. It was published online on March 11, 2026, in Dermatology and Therapy.

LIMITATIONS:

Limited data on cancer subtypes hindered meta-analyses of rare cancers, and the lack of reporting on anti‑inflammatory treatment and disease severity prevented subgroup analyses. Most studies originated from North America, introducing potential geographic bias. No study reported BMI, and ethnicity was poorly documented. Only few studies adjusted for key confounders (smoking, obesity, and alcohol intake), limiting the determination of whether the increased risk for cancer was due to HS itself or shared lifestyle and metabolic factors.

DISCLOSURES:

This study did not receive any funding or sponsorship. Two authors reported receiving research grant funding from the LEO Foundation and having other ties with various other sources.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

About half of the > 9 million veterans served by the Veterans Health Administration (VHA) are aged ≥ 65 years.¹ Veterans are at a higher risk for comorbidities, which may contribute to increased health care costs, mobility limitations and disability, poor quality of life, and mortality. ^2-5 Programs and policies that promote health maintenance, independent living, and quality of life are needed among older veterans. To support veterans’ overall health and well-being, the VHA has shifted to whole health, a patient-centered care model.⁶

The whole health paradigm employs personalized, proactive, and patient-driven care, emphasizing complementary and integrative health practices, and prioritizing health promotion and disease prevention over disease treatment.⁷ The veteran is empowered to decide “what matters to [me],” reflect on life and health, and define mission, aspiration, and purpose. This approach gives veterans a more active and direct role in their care, distinguishing it from traditional care models. In turn, it helps reduce the burden on clinicians and fosters a more collaborative environment in which both the clinician and veteran work together to shape the care process.⁷ Veterans utilize the Circle of Health to identify skills and support needed to implement changes in self-care. The Circle of Health includes 8 self-care components: moving the body; surroundings; personal development; food and drink; recharge; family, friends, and coworkers; spirit and soul; and power of the mind.⁶ This process drives the creation of a personal health plan, creating opportunities for individuals to engage in well-being programs that matter to them and help them meet their goals.

Gerofit is a VHA best practice and whole health outpatient exercise program for veterans aged ≥65 years.⁸ Gerofit has focused primarily on exercise within the moving the body self-care component.⁹ A longitudinal study followed 691 Gerofit participants across 6 US Department of Veterans Affairs (VA) medical centers who on average were 73 years old, had 16 different medical conditions, and took 10 medications. Most were obese and had a mean gait speed of 1.04 m/s, suggesting functional impairment.¹⁰ Prior studies have shown that Gerofit participation is associated with a range of health benefits. Two studies reported improvements in psychological well-being and sustained gains in endurance, strength, and flexibility following early Gerofit program participation. ^11,12 A 10-year analysis of 115 veterans found that long-term Gerofit participation reduced mortality risk, while another study of 452 veterans showed decreased medication use following 1 year in the program.^13,14

The VHA whole health model comprises 3 components: (1) The Pathway, (2) well-being programs, and (3) whole health clinical care.⁶ The Pathway engages veterans in identifying personal health goals, while well-being programs offer selfcare and skill-building activities. Traditional clinical settings often focus primarily on the third component due to time and resource constraints. The Gerofit platform addresses all 3 components. Its existing infrastructure, including a supportive community and dedicated facilities, provides a setting for implementing The Pathway and well-being programs. The Gerofit structure allows for the time and continuity necessary for these components, which are often limited during standard clinical visits.

By expanding the Gerofit exercise regimen to include additional wellness activities, it can holistically support older veterans. Research supports this integrative approach. For example, a 2020 study found that incorporating a holistic health program into an existing exercise program within a church setting led to improved physical activity and overall health among women participants.¹⁵ This article describes the integration of Whole Health(y) Aging with Gerofit (WHAG), a pilot program in Baltimore, Maryland, that integrates whole health components into the established Gerofit framework to enhance the overall well-being of participating veterans (Figure 1).

WHOLE HEALTH(Y) AGING WITH GEROFIT

Gerofit enrollment has been described elsewhere in detail.¹⁶ Patients aged ≥ 65 years are eligible to participate with clinician approval if they are medically stable. Following VHA clinician referral and primary care approval, veterans completed a telephone visit to determine eligibility and discuss their exercise history, goals, and preferences. Veterans dependent in activities of daily living and those with cognitive impairment, unstable angina, active proliferative diabetic retinopathy, oxygen dependence, frank incontinence, active open wounds, active substance abuse, volatile behavioral issues, or who are experiencing homelessness are not eligible for Gerofit.

The exercise physiologist identified veteran barriers and incentives to participation and assisted with a plan to maximize SMART goals (specific, measurable, achievable, relevant, and time-bound). Veterans then completed an assessment visit, either in person or virtually, depending on the selected programming. Functional assessments conducted by trained Gerofit exercise physiologists include testing of lower and upper body strength and submaximal endurance.^9,17,18 Participation in Gerofit is voluntary and not time limited.

Prior to these newly expanded offerings, veterans could only enroll in a personalized, structured exercise program. Based on feedback from Gerofit participants indicating areas of interest, WHAG was developed to provide additional wellness offerings aligned with other Circle of Health components.⁶ This included virtual group nutrition education and cooking interventions with optional fresh produce delivery; wellness classes, the Companion Dog Fostering & Adoption program, and Gerofit in the Mind, which included mindfulness classes and relaxation seminars (Figure 1). Programs were virtual (except dog fostering and adoption) and rotated throughout the year. Not all programs are offered simultaneously.

Attendance, completion of selected questions from the individual Personal Health Inventory (PHI) Short Form, measured physical function, self-reported physical activity levels, physical and mental health status, and program satisfaction were measured for all WHAG subprograms.¹⁸ Selected questions from the PHI Short Form use a 5-point Likert scale to rate the following whole health components: physical activity; sleep, relaxation, and recovery; healthy eating habits; and positive outlook, healthy relationships, and caring for mental health. Physical function was assessed using 30-second arm curls (upper body strength), 30-second chair stands (lower body strength), and the 2-minute step test (virtual) or 6-minute walk test (in person) (submaximal cardiovascular endurance).

Self-reported physical activity was assessed by asking frequency (days per week) and duration (minutes per session) of cardiovascular and strength exercises to calculate total minutes per week. Physical and mental health status was assessed using the Patient Reported Outcomes Measurement Information System (PROMIS) Global Health Scale.¹⁹ Demographic data included sex, race and ethnicity, and age at baseline visit. Mean (SD) was calculated for continuous variables and presented unless otherwise specified, and frequencies were calculated for categorical variables. Subsequent reports will describe additional assessments and detailed outcomes unique to individual programs.

Overview

Veterans chose the programs that best suited their needs without limitations.⁷ Staff provided guidance on newly available programs based on an individual’s specified goals. Gerofit staff assisted veterans with development of individualized personal health plans, monitoring progress towards their goals, supporting program participation, and connecting veterans with additional whole health resources.

Gerofit Exercise Group. Exercise was designed to address the Moving the Body component of whole health. Veterans could elect to schedule 1-hour, 3-times-weekly in-person gym appointments, participate in 3-times-weekly livestreamed virtual group exercise classes through VA Video Connect, or receive a self-directed at-home exercise plan.

Gerofit Learning Opportunities for Wellness Classes. These virtual health education sessions addressed the personal development component of whole health and were designed to increase self-efficacy and empower veterans to take an active role in their health care. Topics focused broadly on issues related to healthy aging (eg, importance of sleep, goal setting, self-care, and comorbidity education). Veterans could participate in any classes of interest, which were led by health care professionals and offered twice monthly. Sessions encouraged participant questions and peer interaction.

Nutrition. Improving dietary quality is a frequently reported goal of Gerofit participants. WHAG incorporated multiple strategies to assist veterans in meeting these goals. For example, through a partnership with Therapeutic Alternative of Maryland Farm, Gerofit provided veterans free, locally grown fresh produce. This initiative addressed barriers to healthy eating by improving access to fresh produce, which has been shown to influence cooking frequency and diet quality.^20-22 Participation in nutrition classes was not required. In 2021, veterans received produce weekly; however, many reported excess quantities. Beginning in 2022, veterans could select both produce items and quantities desired.

In addition, a registered dietitian led a 14-week virtual nutrition education program guided by the social cognitive theory framework and focused on self-regulation skills such as goal setting, overcoming barriers, and identifying triggers.²³ Prior research highlighted low health literacy as a common barrier among older veterans, which informed several key components of the curriculum.²⁴ These included how to read and interpret nutrition labels, define balanced meals and snacks, and understand the classification of various food groups such as fats, carbohydrates, and proteins. The online program curriculum included an instructor guide and participant materials for each individual lesson, including an educational handout on the specific week’s topic, applied activity (group or individual), and recipes related to the produce shares. Structured group discussion promoted camaraderie and recipe sharing, and additional instruction on produce preparation and storage.

Reported lack of self-efficacy and knowledge regarding produce preparation prompted a 5-week virtual cooking series, led by a medical student and supervised by a registered dietitian. Sessions combined brief nutrition education with live cooking demonstrations adapted from the VA Healthy Teaching Kitchen curriculum. Recipes emphasized low-cost, commonly found food items. The Healthy Teaching Kitchen modifications focused on Dietary Approaches to Stop Hypertension diets, diabetes, and the importance of protein for older adults. Participants were allowed time to discuss recipes and food preparation tips, and other household members were allowed to observe.

Dog Fostering and Adoption. Veterans could foster or adopt a rescue dog through a partnership with local rescue groups. This program allowed participating veterans to have a companion, which addressed the surroundings, moving the body, and spirit and soul whole health components. The Companion Dog Fostering and Adoption Program and results on physical function and daily physical activity from the first 3 months were recently published. Positive effects on physical activity, physical function, and quality of life were observed at 3 months as compared to baseline in veterans who received a companion dog.²⁵

Gerofit in the Garden. Veterans could opt to receive an EarthBox containing soil and seedlings for 1 vegetable and 1 herb. The boxes are designed to fit on a small tabletop, regardless of home type or availability of backyard. In-person instruction for veterans on care and maintenance was provided by a farm employee with experience in gardening and farming practices.

Gerofit in the Mind. Online relaxation seminars were offered twice monthly for 4 months. Led by a certified sound health guide, sessions incorporated sound baths, crystal bowls, Tibetan bowls, tuning forks, and breath work. Virtual mindfulness classes led by a certified yoga instructor were offered weekly for 1 month. Veterans could drop in and participate based on their availability. Classes were designed to introduce veterans to the practice of mindfulness, improve mood, and lower stress and anxiety.

Pilot Program Outcomes

Sixteen male veterans participated in WHAG. Participants were 62% Black, with a mean age of 76 years. Veterans collaborated with Gerofit staff to develop personal health plans, which ultimately guided program participation (Figure 2).

Five participants enrolled in 1 WHAG program, 11 enrolled in 2, and 8 enrolled in ≥ 3 (Table 1). Sixteen veterans completed baseline testing and 12 completed 3-month follow-up assessments (Table 2). At baseline, participants were below the reference range for physical functioning and physical activity levels. After 3 months, improvements were observed in endurance self-reported physical activity, and strength with many values in the reference range. However, physical and mental global health scores did not change.

Ten veterans completed the PHI Short Form. Veterans most frequently identified multiple areas they wished to improve, including moving the body (n = 10), recharge (n = 10), food and drink (n = 9), and power of the mind (n = 7). Baseline self-ratings on each whole health component, along with follow-up ratings at the program’s conclusion, are presented in Figure 3. Some participants aimed to maintain current levels rather than seek improvement. At the 3-month mark, most veterans perceived themselves as improving in ≥1 health component.

Discussion Programs that target holistic wellness are needed to ensure the health of a rapidly aging population. The WHAG pilot program is an example of a comprehensive, patient-centered wellness program that supports participants in defining personal wellness goals to promote healthy aging. Gerofit addresses the continuum by beginning with goal-oriented discussions with veterans to guide program participation and support desired outcomes.

Gerofit provided a strong pre-existing framework of virtual social support and physical infrastructure for the addition of WHAG. Gerofit staff were responsible for recruitment and engagement, program oversight, and outcome data collection. Additionally, VHA facilities provide physical space for in-person and virtual programming. Integrating WHAG into Gerofit allows veterans to prioritize “what matters” and engage with peers in a nontraditional way, such as the dog fostering and adoption program provides veterans with an opportunity to increase physical activity levels and improve mental and physical health through the human-animal bond.²⁵

By providing virtual options, WHAG enhances access to health care in medically underserved areas. WHAG also improves the veteran experience with the VA, building on Gerofit’s track record of high patient satisfaction, strong adherence, high retention, and consistent consults for veterans to join.¹⁰ The program allows veterans to be at the forefront of their VHA care, choosing to participate in the various offerings based on their personal preferences.

In this population of older veterans from Baltimore, Maryland, the majority of whom reside in disadvantaged areas, we observed that the programs with the highest participation were related to diet, stress reduction, and physical activity. These 3 areas align with common barriers faced by individuals in underserved communities. Many of these communities are food deserts, lack space or resources for gardening, and have limited or unsafe access to opportunities for physical activity, making gyms or even neighborhood exercise difficult to access.^26-28 Offering produce delivery and virtual nutrition classes may potentially alleviate this barrier by providing economic stability by increasing access to healthy foods paired with nutrition education to promote use of free, fresh food. Teaching older adults with impaired mobility how to overcome barriers to consuming a healthy diet may improve their dietary intake.^23,29,30 Future evaluations aim to examine how these various nutrition programs impact dietary intake and how changes in dietary intake may impact functional outcomes among this group.

Group classes provide opportunities for social connection and mutual support, both of which are powerful motivators for older adults. Frequent contact with others may help reduce the risk of depression, loneliness, and social isolation.²⁸ Routine contact with staff allows for observation of short-term changes in behavior and mood, giving staff the chance to follow up when needed. The addition of these new programs gives participants more opportunities to engage with Gerofit staff and fellow veterans beyond traditional exercise sessions. This WHAG model could expand to other Gerofit sites; however, future whole health programs should take into account the unique needs and barriers specific to each location. Doing so will help ensure offerings align with participant preferences. Programs should be thoughtfully selected and designed to directly address local challenges to promote optimal engagement and support the greatest potential for success.

CONCLUSIONS

Programs that promote and support functional independence in older adults are needed, particularly given the rapidly growing and aging population. Identifying comprehensive strategies that promote healthy aging is likely to be beneficial not only for chronic disease management and social engagement but may also promote functional independence and reduce the risk of further functional decline.

About half of the > 9 million veterans served by the Veterans Health Administration (VHA) are aged ≥ 65 years.¹ Veterans are at a higher risk for comorbidities, which may contribute to increased health care costs, mobility limitations and disability, poor quality of life, and mortality. ^2-5 Programs and policies that promote health maintenance, independent living, and quality of life are needed among older veterans. To support veterans’ overall health and well-being, the VHA has shifted to whole health, a patient-centered care model.⁶

The whole health paradigm employs personalized, proactive, and patient-driven care, emphasizing complementary and integrative health practices, and prioritizing health promotion and disease prevention over disease treatment.⁷ The veteran is empowered to decide “what matters to [me],” reflect on life and health, and define mission, aspiration, and purpose. This approach gives veterans a more active and direct role in their care, distinguishing it from traditional care models. In turn, it helps reduce the burden on clinicians and fosters a more collaborative environment in which both the clinician and veteran work together to shape the care process.⁷ Veterans utilize the Circle of Health to identify skills and support needed to implement changes in self-care. The Circle of Health includes 8 self-care components: moving the body; surroundings; personal development; food and drink; recharge; family, friends, and coworkers; spirit and soul; and power of the mind.⁶ This process drives the creation of a personal health plan, creating opportunities for individuals to engage in well-being programs that matter to them and help them meet their goals.

Gerofit is a VHA best practice and whole health outpatient exercise program for veterans aged ≥65 years.⁸ Gerofit has focused primarily on exercise within the moving the body self-care component.⁹ A longitudinal study followed 691 Gerofit participants across 6 US Department of Veterans Affairs (VA) medical centers who on average were 73 years old, had 16 different medical conditions, and took 10 medications. Most were obese and had a mean gait speed of 1.04 m/s, suggesting functional impairment.¹⁰ Prior studies have shown that Gerofit participation is associated with a range of health benefits. Two studies reported improvements in psychological well-being and sustained gains in endurance, strength, and flexibility following early Gerofit program participation. ^11,12 A 10-year analysis of 115 veterans found that long-term Gerofit participation reduced mortality risk, while another study of 452 veterans showed decreased medication use following 1 year in the program.^13,14

The VHA whole health model comprises 3 components: (1) The Pathway, (2) well-being programs, and (3) whole health clinical care.⁶ The Pathway engages veterans in identifying personal health goals, while well-being programs offer selfcare and skill-building activities. Traditional clinical settings often focus primarily on the third component due to time and resource constraints. The Gerofit platform addresses all 3 components. Its existing infrastructure, including a supportive community and dedicated facilities, provides a setting for implementing The Pathway and well-being programs. The Gerofit structure allows for the time and continuity necessary for these components, which are often limited during standard clinical visits.

By expanding the Gerofit exercise regimen to include additional wellness activities, it can holistically support older veterans. Research supports this integrative approach. For example, a 2020 study found that incorporating a holistic health program into an existing exercise program within a church setting led to improved physical activity and overall health among women participants.¹⁵ This article describes the integration of Whole Health(y) Aging with Gerofit (WHAG), a pilot program in Baltimore, Maryland, that integrates whole health components into the established Gerofit framework to enhance the overall well-being of participating veterans (Figure 1).

WHOLE HEALTH(Y) AGING WITH GEROFIT

Gerofit enrollment has been described elsewhere in detail.¹⁶ Patients aged ≥ 65 years are eligible to participate with clinician approval if they are medically stable. Following VHA clinician referral and primary care approval, veterans completed a telephone visit to determine eligibility and discuss their exercise history, goals, and preferences. Veterans dependent in activities of daily living and those with cognitive impairment, unstable angina, active proliferative diabetic retinopathy, oxygen dependence, frank incontinence, active open wounds, active substance abuse, volatile behavioral issues, or who are experiencing homelessness are not eligible for Gerofit.

The exercise physiologist identified veteran barriers and incentives to participation and assisted with a plan to maximize SMART goals (specific, measurable, achievable, relevant, and time-bound). Veterans then completed an assessment visit, either in person or virtually, depending on the selected programming. Functional assessments conducted by trained Gerofit exercise physiologists include testing of lower and upper body strength and submaximal endurance.^9,17,18 Participation in Gerofit is voluntary and not time limited.

Prior to these newly expanded offerings, veterans could only enroll in a personalized, structured exercise program. Based on feedback from Gerofit participants indicating areas of interest, WHAG was developed to provide additional wellness offerings aligned with other Circle of Health components.⁶ This included virtual group nutrition education and cooking interventions with optional fresh produce delivery; wellness classes, the Companion Dog Fostering & Adoption program, and Gerofit in the Mind, which included mindfulness classes and relaxation seminars (Figure 1). Programs were virtual (except dog fostering and adoption) and rotated throughout the year. Not all programs are offered simultaneously.

Attendance, completion of selected questions from the individual Personal Health Inventory (PHI) Short Form, measured physical function, self-reported physical activity levels, physical and mental health status, and program satisfaction were measured for all WHAG subprograms.¹⁸ Selected questions from the PHI Short Form use a 5-point Likert scale to rate the following whole health components: physical activity; sleep, relaxation, and recovery; healthy eating habits; and positive outlook, healthy relationships, and caring for mental health. Physical function was assessed using 30-second arm curls (upper body strength), 30-second chair stands (lower body strength), and the 2-minute step test (virtual) or 6-minute walk test (in person) (submaximal cardiovascular endurance).

Self-reported physical activity was assessed by asking frequency (days per week) and duration (minutes per session) of cardiovascular and strength exercises to calculate total minutes per week. Physical and mental health status was assessed using the Patient Reported Outcomes Measurement Information System (PROMIS) Global Health Scale.¹⁹ Demographic data included sex, race and ethnicity, and age at baseline visit. Mean (SD) was calculated for continuous variables and presented unless otherwise specified, and frequencies were calculated for categorical variables. Subsequent reports will describe additional assessments and detailed outcomes unique to individual programs.

Overview

Veterans chose the programs that best suited their needs without limitations.⁷ Staff provided guidance on newly available programs based on an individual’s specified goals. Gerofit staff assisted veterans with development of individualized personal health plans, monitoring progress towards their goals, supporting program participation, and connecting veterans with additional whole health resources.

Gerofit Exercise Group. Exercise was designed to address the Moving the Body component of whole health. Veterans could elect to schedule 1-hour, 3-times-weekly in-person gym appointments, participate in 3-times-weekly livestreamed virtual group exercise classes through VA Video Connect, or receive a self-directed at-home exercise plan.

Gerofit Learning Opportunities for Wellness Classes. These virtual health education sessions addressed the personal development component of whole health and were designed to increase self-efficacy and empower veterans to take an active role in their health care. Topics focused broadly on issues related to healthy aging (eg, importance of sleep, goal setting, self-care, and comorbidity education). Veterans could participate in any classes of interest, which were led by health care professionals and offered twice monthly. Sessions encouraged participant questions and peer interaction.

Nutrition. Improving dietary quality is a frequently reported goal of Gerofit participants. WHAG incorporated multiple strategies to assist veterans in meeting these goals. For example, through a partnership with Therapeutic Alternative of Maryland Farm, Gerofit provided veterans free, locally grown fresh produce. This initiative addressed barriers to healthy eating by improving access to fresh produce, which has been shown to influence cooking frequency and diet quality.^20-22 Participation in nutrition classes was not required. In 2021, veterans received produce weekly; however, many reported excess quantities. Beginning in 2022, veterans could select both produce items and quantities desired.

In addition, a registered dietitian led a 14-week virtual nutrition education program guided by the social cognitive theory framework and focused on self-regulation skills such as goal setting, overcoming barriers, and identifying triggers.²³ Prior research highlighted low health literacy as a common barrier among older veterans, which informed several key components of the curriculum.²⁴ These included how to read and interpret nutrition labels, define balanced meals and snacks, and understand the classification of various food groups such as fats, carbohydrates, and proteins. The online program curriculum included an instructor guide and participant materials for each individual lesson, including an educational handout on the specific week’s topic, applied activity (group or individual), and recipes related to the produce shares. Structured group discussion promoted camaraderie and recipe sharing, and additional instruction on produce preparation and storage.

Reported lack of self-efficacy and knowledge regarding produce preparation prompted a 5-week virtual cooking series, led by a medical student and supervised by a registered dietitian. Sessions combined brief nutrition education with live cooking demonstrations adapted from the VA Healthy Teaching Kitchen curriculum. Recipes emphasized low-cost, commonly found food items. The Healthy Teaching Kitchen modifications focused on Dietary Approaches to Stop Hypertension diets, diabetes, and the importance of protein for older adults. Participants were allowed time to discuss recipes and food preparation tips, and other household members were allowed to observe.

Dog Fostering and Adoption. Veterans could foster or adopt a rescue dog through a partnership with local rescue groups. This program allowed participating veterans to have a companion, which addressed the surroundings, moving the body, and spirit and soul whole health components. The Companion Dog Fostering and Adoption Program and results on physical function and daily physical activity from the first 3 months were recently published. Positive effects on physical activity, physical function, and quality of life were observed at 3 months as compared to baseline in veterans who received a companion dog.²⁵

Gerofit in the Garden. Veterans could opt to receive an EarthBox containing soil and seedlings for 1 vegetable and 1 herb. The boxes are designed to fit on a small tabletop, regardless of home type or availability of backyard. In-person instruction for veterans on care and maintenance was provided by a farm employee with experience in gardening and farming practices.

Gerofit in the Mind. Online relaxation seminars were offered twice monthly for 4 months. Led by a certified sound health guide, sessions incorporated sound baths, crystal bowls, Tibetan bowls, tuning forks, and breath work. Virtual mindfulness classes led by a certified yoga instructor were offered weekly for 1 month. Veterans could drop in and participate based on their availability. Classes were designed to introduce veterans to the practice of mindfulness, improve mood, and lower stress and anxiety.

Pilot Program Outcomes

Sixteen male veterans participated in WHAG. Participants were 62% Black, with a mean age of 76 years. Veterans collaborated with Gerofit staff to develop personal health plans, which ultimately guided program participation (Figure 2).

Five participants enrolled in 1 WHAG program, 11 enrolled in 2, and 8 enrolled in ≥ 3 (Table 1). Sixteen veterans completed baseline testing and 12 completed 3-month follow-up assessments (Table 2). At baseline, participants were below the reference range for physical functioning and physical activity levels. After 3 months, improvements were observed in endurance self-reported physical activity, and strength with many values in the reference range. However, physical and mental global health scores did not change.

Ten veterans completed the PHI Short Form. Veterans most frequently identified multiple areas they wished to improve, including moving the body (n = 10), recharge (n = 10), food and drink (n = 9), and power of the mind (n = 7). Baseline self-ratings on each whole health component, along with follow-up ratings at the program’s conclusion, are presented in Figure 3. Some participants aimed to maintain current levels rather than seek improvement. At the 3-month mark, most veterans perceived themselves as improving in ≥1 health component.

Discussion Programs that target holistic wellness are needed to ensure the health of a rapidly aging population. The WHAG pilot program is an example of a comprehensive, patient-centered wellness program that supports participants in defining personal wellness goals to promote healthy aging. Gerofit addresses the continuum by beginning with goal-oriented discussions with veterans to guide program participation and support desired outcomes.

Gerofit provided a strong pre-existing framework of virtual social support and physical infrastructure for the addition of WHAG. Gerofit staff were responsible for recruitment and engagement, program oversight, and outcome data collection. Additionally, VHA facilities provide physical space for in-person and virtual programming. Integrating WHAG into Gerofit allows veterans to prioritize “what matters” and engage with peers in a nontraditional way, such as the dog fostering and adoption program provides veterans with an opportunity to increase physical activity levels and improve mental and physical health through the human-animal bond.²⁵

By providing virtual options, WHAG enhances access to health care in medically underserved areas. WHAG also improves the veteran experience with the VA, building on Gerofit’s track record of high patient satisfaction, strong adherence, high retention, and consistent consults for veterans to join.¹⁰ The program allows veterans to be at the forefront of their VHA care, choosing to participate in the various offerings based on their personal preferences.

In this population of older veterans from Baltimore, Maryland, the majority of whom reside in disadvantaged areas, we observed that the programs with the highest participation were related to diet, stress reduction, and physical activity. These 3 areas align with common barriers faced by individuals in underserved communities. Many of these communities are food deserts, lack space or resources for gardening, and have limited or unsafe access to opportunities for physical activity, making gyms or even neighborhood exercise difficult to access.^26-28 Offering produce delivery and virtual nutrition classes may potentially alleviate this barrier by providing economic stability by increasing access to healthy foods paired with nutrition education to promote use of free, fresh food. Teaching older adults with impaired mobility how to overcome barriers to consuming a healthy diet may improve their dietary intake.^23,29,30 Future evaluations aim to examine how these various nutrition programs impact dietary intake and how changes in dietary intake may impact functional outcomes among this group.

Group classes provide opportunities for social connection and mutual support, both of which are powerful motivators for older adults. Frequent contact with others may help reduce the risk of depression, loneliness, and social isolation.²⁸ Routine contact with staff allows for observation of short-term changes in behavior and mood, giving staff the chance to follow up when needed. The addition of these new programs gives participants more opportunities to engage with Gerofit staff and fellow veterans beyond traditional exercise sessions. This WHAG model could expand to other Gerofit sites; however, future whole health programs should take into account the unique needs and barriers specific to each location. Doing so will help ensure offerings align with participant preferences. Programs should be thoughtfully selected and designed to directly address local challenges to promote optimal engagement and support the greatest potential for success.

CONCLUSIONS

Programs that promote and support functional independence in older adults are needed, particularly given the rapidly growing and aging population. Identifying comprehensive strategies that promote healthy aging is likely to be beneficial not only for chronic disease management and social engagement but may also promote functional independence and reduce the risk of further functional decline.

About half of the > 9 million veterans served by the Veterans Health Administration (VHA) are aged ≥ 65 years.¹ Veterans are at a higher risk for comorbidities, which may contribute to increased health care costs, mobility limitations and disability, poor quality of life, and mortality. ^2-5 Programs and policies that promote health maintenance, independent living, and quality of life are needed among older veterans. To support veterans’ overall health and well-being, the VHA has shifted to whole health, a patient-centered care model.⁶

The whole health paradigm employs personalized, proactive, and patient-driven care, emphasizing complementary and integrative health practices, and prioritizing health promotion and disease prevention over disease treatment.⁷ The veteran is empowered to decide “what matters to [me],” reflect on life and health, and define mission, aspiration, and purpose. This approach gives veterans a more active and direct role in their care, distinguishing it from traditional care models. In turn, it helps reduce the burden on clinicians and fosters a more collaborative environment in which both the clinician and veteran work together to shape the care process.⁷ Veterans utilize the Circle of Health to identify skills and support needed to implement changes in self-care. The Circle of Health includes 8 self-care components: moving the body; surroundings; personal development; food and drink; recharge; family, friends, and coworkers; spirit and soul; and power of the mind.⁶ This process drives the creation of a personal health plan, creating opportunities for individuals to engage in well-being programs that matter to them and help them meet their goals.

Gerofit is a VHA best practice and whole health outpatient exercise program for veterans aged ≥65 years.⁸ Gerofit has focused primarily on exercise within the moving the body self-care component.⁹ A longitudinal study followed 691 Gerofit participants across 6 US Department of Veterans Affairs (VA) medical centers who on average were 73 years old, had 16 different medical conditions, and took 10 medications. Most were obese and had a mean gait speed of 1.04 m/s, suggesting functional impairment.¹⁰ Prior studies have shown that Gerofit participation is associated with a range of health benefits. Two studies reported improvements in psychological well-being and sustained gains in endurance, strength, and flexibility following early Gerofit program participation. ^11,12 A 10-year analysis of 115 veterans found that long-term Gerofit participation reduced mortality risk, while another study of 452 veterans showed decreased medication use following 1 year in the program.^13,14

The VHA whole health model comprises 3 components: (1) The Pathway, (2) well-being programs, and (3) whole health clinical care.⁶ The Pathway engages veterans in identifying personal health goals, while well-being programs offer selfcare and skill-building activities. Traditional clinical settings often focus primarily on the third component due to time and resource constraints. The Gerofit platform addresses all 3 components. Its existing infrastructure, including a supportive community and dedicated facilities, provides a setting for implementing The Pathway and well-being programs. The Gerofit structure allows for the time and continuity necessary for these components, which are often limited during standard clinical visits.

By expanding the Gerofit exercise regimen to include additional wellness activities, it can holistically support older veterans. Research supports this integrative approach. For example, a 2020 study found that incorporating a holistic health program into an existing exercise program within a church setting led to improved physical activity and overall health among women participants.¹⁵ This article describes the integration of Whole Health(y) Aging with Gerofit (WHAG), a pilot program in Baltimore, Maryland, that integrates whole health components into the established Gerofit framework to enhance the overall well-being of participating veterans (Figure 1).

WHOLE HEALTH(Y) AGING WITH GEROFIT

Gerofit enrollment has been described elsewhere in detail.¹⁶ Patients aged ≥ 65 years are eligible to participate with clinician approval if they are medically stable. Following VHA clinician referral and primary care approval, veterans completed a telephone visit to determine eligibility and discuss their exercise history, goals, and preferences. Veterans dependent in activities of daily living and those with cognitive impairment, unstable angina, active proliferative diabetic retinopathy, oxygen dependence, frank incontinence, active open wounds, active substance abuse, volatile behavioral issues, or who are experiencing homelessness are not eligible for Gerofit.

The exercise physiologist identified veteran barriers and incentives to participation and assisted with a plan to maximize SMART goals (specific, measurable, achievable, relevant, and time-bound). Veterans then completed an assessment visit, either in person or virtually, depending on the selected programming. Functional assessments conducted by trained Gerofit exercise physiologists include testing of lower and upper body strength and submaximal endurance.^9,17,18 Participation in Gerofit is voluntary and not time limited.

Prior to these newly expanded offerings, veterans could only enroll in a personalized, structured exercise program. Based on feedback from Gerofit participants indicating areas of interest, WHAG was developed to provide additional wellness offerings aligned with other Circle of Health components.⁶ This included virtual group nutrition education and cooking interventions with optional fresh produce delivery; wellness classes, the Companion Dog Fostering & Adoption program, and Gerofit in the Mind, which included mindfulness classes and relaxation seminars (Figure 1). Programs were virtual (except dog fostering and adoption) and rotated throughout the year. Not all programs are offered simultaneously.

Attendance, completion of selected questions from the individual Personal Health Inventory (PHI) Short Form, measured physical function, self-reported physical activity levels, physical and mental health status, and program satisfaction were measured for all WHAG subprograms.¹⁸ Selected questions from the PHI Short Form use a 5-point Likert scale to rate the following whole health components: physical activity; sleep, relaxation, and recovery; healthy eating habits; and positive outlook, healthy relationships, and caring for mental health. Physical function was assessed using 30-second arm curls (upper body strength), 30-second chair stands (lower body strength), and the 2-minute step test (virtual) or 6-minute walk test (in person) (submaximal cardiovascular endurance).

Self-reported physical activity was assessed by asking frequency (days per week) and duration (minutes per session) of cardiovascular and strength exercises to calculate total minutes per week. Physical and mental health status was assessed using the Patient Reported Outcomes Measurement Information System (PROMIS) Global Health Scale.¹⁹ Demographic data included sex, race and ethnicity, and age at baseline visit. Mean (SD) was calculated for continuous variables and presented unless otherwise specified, and frequencies were calculated for categorical variables. Subsequent reports will describe additional assessments and detailed outcomes unique to individual programs.

Overview

Veterans chose the programs that best suited their needs without limitations.⁷ Staff provided guidance on newly available programs based on an individual’s specified goals. Gerofit staff assisted veterans with development of individualized personal health plans, monitoring progress towards their goals, supporting program participation, and connecting veterans with additional whole health resources.

Gerofit Exercise Group. Exercise was designed to address the Moving the Body component of whole health. Veterans could elect to schedule 1-hour, 3-times-weekly in-person gym appointments, participate in 3-times-weekly livestreamed virtual group exercise classes through VA Video Connect, or receive a self-directed at-home exercise plan.

Gerofit Learning Opportunities for Wellness Classes. These virtual health education sessions addressed the personal development component of whole health and were designed to increase self-efficacy and empower veterans to take an active role in their health care. Topics focused broadly on issues related to healthy aging (eg, importance of sleep, goal setting, self-care, and comorbidity education). Veterans could participate in any classes of interest, which were led by health care professionals and offered twice monthly. Sessions encouraged participant questions and peer interaction.

Nutrition. Improving dietary quality is a frequently reported goal of Gerofit participants. WHAG incorporated multiple strategies to assist veterans in meeting these goals. For example, through a partnership with Therapeutic Alternative of Maryland Farm, Gerofit provided veterans free, locally grown fresh produce. This initiative addressed barriers to healthy eating by improving access to fresh produce, which has been shown to influence cooking frequency and diet quality.^20-22 Participation in nutrition classes was not required. In 2021, veterans received produce weekly; however, many reported excess quantities. Beginning in 2022, veterans could select both produce items and quantities desired.

In addition, a registered dietitian led a 14-week virtual nutrition education program guided by the social cognitive theory framework and focused on self-regulation skills such as goal setting, overcoming barriers, and identifying triggers.²³ Prior research highlighted low health literacy as a common barrier among older veterans, which informed several key components of the curriculum.²⁴ These included how to read and interpret nutrition labels, define balanced meals and snacks, and understand the classification of various food groups such as fats, carbohydrates, and proteins. The online program curriculum included an instructor guide and participant materials for each individual lesson, including an educational handout on the specific week’s topic, applied activity (group or individual), and recipes related to the produce shares. Structured group discussion promoted camaraderie and recipe sharing, and additional instruction on produce preparation and storage.

Reported lack of self-efficacy and knowledge regarding produce preparation prompted a 5-week virtual cooking series, led by a medical student and supervised by a registered dietitian. Sessions combined brief nutrition education with live cooking demonstrations adapted from the VA Healthy Teaching Kitchen curriculum. Recipes emphasized low-cost, commonly found food items. The Healthy Teaching Kitchen modifications focused on Dietary Approaches to Stop Hypertension diets, diabetes, and the importance of protein for older adults. Participants were allowed time to discuss recipes and food preparation tips, and other household members were allowed to observe.

Dog Fostering and Adoption. Veterans could foster or adopt a rescue dog through a partnership with local rescue groups. This program allowed participating veterans to have a companion, which addressed the surroundings, moving the body, and spirit and soul whole health components. The Companion Dog Fostering and Adoption Program and results on physical function and daily physical activity from the first 3 months were recently published. Positive effects on physical activity, physical function, and quality of life were observed at 3 months as compared to baseline in veterans who received a companion dog.²⁵

Gerofit in the Garden. Veterans could opt to receive an EarthBox containing soil and seedlings for 1 vegetable and 1 herb. The boxes are designed to fit on a small tabletop, regardless of home type or availability of backyard. In-person instruction for veterans on care and maintenance was provided by a farm employee with experience in gardening and farming practices.

Gerofit in the Mind. Online relaxation seminars were offered twice monthly for 4 months. Led by a certified sound health guide, sessions incorporated sound baths, crystal bowls, Tibetan bowls, tuning forks, and breath work. Virtual mindfulness classes led by a certified yoga instructor were offered weekly for 1 month. Veterans could drop in and participate based on their availability. Classes were designed to introduce veterans to the practice of mindfulness, improve mood, and lower stress and anxiety.

Pilot Program Outcomes

Sixteen male veterans participated in WHAG. Participants were 62% Black, with a mean age of 76 years. Veterans collaborated with Gerofit staff to develop personal health plans, which ultimately guided program participation (Figure 2).

Five participants enrolled in 1 WHAG program, 11 enrolled in 2, and 8 enrolled in ≥ 3 (Table 1). Sixteen veterans completed baseline testing and 12 completed 3-month follow-up assessments (Table 2). At baseline, participants were below the reference range for physical functioning and physical activity levels. After 3 months, improvements were observed in endurance self-reported physical activity, and strength with many values in the reference range. However, physical and mental global health scores did not change.

Ten veterans completed the PHI Short Form. Veterans most frequently identified multiple areas they wished to improve, including moving the body (n = 10), recharge (n = 10), food and drink (n = 9), and power of the mind (n = 7). Baseline self-ratings on each whole health component, along with follow-up ratings at the program’s conclusion, are presented in Figure 3. Some participants aimed to maintain current levels rather than seek improvement. At the 3-month mark, most veterans perceived themselves as improving in ≥1 health component.

Discussion Programs that target holistic wellness are needed to ensure the health of a rapidly aging population. The WHAG pilot program is an example of a comprehensive, patient-centered wellness program that supports participants in defining personal wellness goals to promote healthy aging. Gerofit addresses the continuum by beginning with goal-oriented discussions with veterans to guide program participation and support desired outcomes.

Gerofit provided a strong pre-existing framework of virtual social support and physical infrastructure for the addition of WHAG. Gerofit staff were responsible for recruitment and engagement, program oversight, and outcome data collection. Additionally, VHA facilities provide physical space for in-person and virtual programming. Integrating WHAG into Gerofit allows veterans to prioritize “what matters” and engage with peers in a nontraditional way, such as the dog fostering and adoption program provides veterans with an opportunity to increase physical activity levels and improve mental and physical health through the human-animal bond.²⁵

By providing virtual options, WHAG enhances access to health care in medically underserved areas. WHAG also improves the veteran experience with the VA, building on Gerofit’s track record of high patient satisfaction, strong adherence, high retention, and consistent consults for veterans to join.¹⁰ The program allows veterans to be at the forefront of their VHA care, choosing to participate in the various offerings based on their personal preferences.

In this population of older veterans from Baltimore, Maryland, the majority of whom reside in disadvantaged areas, we observed that the programs with the highest participation were related to diet, stress reduction, and physical activity. These 3 areas align with common barriers faced by individuals in underserved communities. Many of these communities are food deserts, lack space or resources for gardening, and have limited or unsafe access to opportunities for physical activity, making gyms or even neighborhood exercise difficult to access.^26-28 Offering produce delivery and virtual nutrition classes may potentially alleviate this barrier by providing economic stability by increasing access to healthy foods paired with nutrition education to promote use of free, fresh food. Teaching older adults with impaired mobility how to overcome barriers to consuming a healthy diet may improve their dietary intake.^23,29,30 Future evaluations aim to examine how these various nutrition programs impact dietary intake and how changes in dietary intake may impact functional outcomes among this group.

Group classes provide opportunities for social connection and mutual support, both of which are powerful motivators for older adults. Frequent contact with others may help reduce the risk of depression, loneliness, and social isolation.²⁸ Routine contact with staff allows for observation of short-term changes in behavior and mood, giving staff the chance to follow up when needed. The addition of these new programs gives participants more opportunities to engage with Gerofit staff and fellow veterans beyond traditional exercise sessions. This WHAG model could expand to other Gerofit sites; however, future whole health programs should take into account the unique needs and barriers specific to each location. Doing so will help ensure offerings align with participant preferences. Programs should be thoughtfully selected and designed to directly address local challenges to promote optimal engagement and support the greatest potential for success.

CONCLUSIONS

Programs that promote and support functional independence in older adults are needed, particularly given the rapidly growing and aging population. Identifying comprehensive strategies that promote healthy aging is likely to be beneficial not only for chronic disease management and social engagement but may also promote functional independence and reduce the risk of further functional decline.

Hidradenitis suppurativa (HS) is a chronic, inflammatory skin disorder characterized by painful nodules, abscesses, and tunnels predominantly affecting intertriginous areas of the body.^1,2 The condition poses significant challenges in terms of diagnosis, treatment, and quality of life for affected individuals. Various systemic therapies have been explored to manage this debilitating condition, with the emergence of biologic agents offering hope for improved outcomes. In 2015, adalimumab (ADA) was the first biologic approved by the US Food and Drug Administration (FDA) for the treatment of HS, followed by secukinumab in 2023 and bimekizumab in 2024. However, the off-label use of other biologics and/or tumor necrosis factor inhibitors such as infliximab (IFX) has become common practice.³

Although these therapies have demonstrated promising results in the treatment of HS, their widespread use may be hindered by accessibility and cost barriers. Orenstein et al analyzed data from the IBM Explorys platform from 2015 to 2020 and found that only 1.8% of patients diagnosed with HS had been prescribed ADA or IFX.⁴ More recently, Garg et al examined IBM MarketScan and IBM US Medicaid data from 2015 to 2018 to evaluate trends in clinical care and treatment. The prevalence of ADA and IFX prescriptions among patients with HS ranged from 2.3% to 8.0% (ADA) and 0.7% to 0.9% (IFX) for patients with commercial insurance, and 1.4% to 4.8% (ADA) and 0.5% to 0.7% (IFX) for patients with Medicaid.⁵ Biologics are often expensive, and the high cost associated with these therapies has been identified as a significant barrier to access for patients with HS, particularly those who lack adequate insurance coverage or face financial constraints.⁶

Furthermore, these barriers, particularly the financial barriers, are potentially compounded by the demographics of patients most notably affected by HS. In the US, a disproportionate incidence of HS has been noted in specific groups and age ranges, including women, individuals aged 18 to 29 years, and Black individuals.⁴ Orenstein et al found a statistically significant difference in use of ADA and IFX biologics based on age, sex, and race.⁴

The aim of this study was to examine the use of 2 biologics (ADA and IFX) in the Veterans Health Administration (VHA), a unique population in which financial barriers are reduced due to the single-payer government health care system structure. This design allowed for improved isolation and evaluation of variation in ADA and/or IFX prescription rates by demographics and health-related factors among patients with HS. To our knowledge, no studies have analyzed these metrics within the VHA.

Methods

This retrospective, cross-sectional analysis of VHA patients used data from the US Department of Veterans Affairs (VA) Corporate Data Warehouse, a data repository that provides access to longitudinal national electronic health record data for all veterans receiving care through VHA facilities. This study received ethical approval from institutional review boards at the Minneapolis Veterans Affairs Health Care System and VA Salt Lake City Healthcare System. Patient information was deidentified, and patient consent was not required.

Patients with HS were identified using ≥ 1 International Classification of Diseases (ICD) diagnostic code: (ICD-9 [705.83] or ICD-10 [L73.2]) between January 1, 2011, and December 31, 2021. The study included patients aged ≥ 18 years as of January 1, 2011, with ≥ 2 patient encounters during the postdiagnosis follow-up period, and with ≥ 1 encounter 6 months postindex. Patients with a biologic prescription prior to HS diagnosis were excluded. For this study, the term biologics refers to ADA and/or IFX prescriptions, unless otherwise specified. Only ADA and IFX were included in this analysis because ADA, a tumor necrosis factor (TNF)-á inhibitor, was the only FDA-approved medication at the time of the search, and IFX is another common TNF-α inhibitor used for the treatment of HS.

Statistical Analysis

We calculated logistic regression using SAS 9.4 (SAS Institute, Cary, NC). For each variable, the univariate relationship with biologic prescriptions was examined first, followed by the multivariate relationship controlling for all other variables. The following variables were controlled for in the multivariate models and were chosen a priori: sex, age, race, ethnicity, US region, hospital setting, current or previous tobacco use, obesity (defined as body mass index [BMI] ≥ 30), and Charlson Comorbidity Index (CCI).⁷

Results

Using ICD codes, we identified 29,483 individuals with ≥ 1 HS diagnosis (Figure 1). Of those identified, 1537 patients (5.21%) had been prescribed ≥ 1 biologic. The cohort was predominantly White (60.56%), male (75.27%), obese (59.34%), and had a history of current or previous tobacco use (73.47%) (Table 1). There were significant adjusted differences in prescription rates among veterans with HS based on age, race, and BMI. Notably, there was an age-dependent reduction in the odds of being prescribed a biologic in patients with HS. Compared with patients aged 18 to 44 years, patients aged 45 to 64 years (adjusted odds ratio [aOR], 0.63; 95% CI, 0.54–0.74; P < .001) and patients aged ≥ 65 years (aOR, 0.36; 95% CI, 0.27–0.48; P < .001) had significantly lower odds of receiving a biologic prescription (Table 2). Compared with White patients with HS, Native Hawaiian (NH) or Pacific Islander (PI) patients were less likely to be prescribed a biologic (aOR, 0.23; 95% CI, 0.06–0.92; P = .04). Patients with obesity had significantly higher odds of receiving a biologic prescription compared with patients without obesity (aOR, 1.47; 95% CI, 1.27– 1.71; P < .001).

After adjusting for the variables listed in Table 1, there were no significant differences in biologic prescription rates for men compared with women (aOR, 0.97; 95% CI, 0.83-1.12; P = .68). We observed slight variations in biologic prescriptions between US regions (Midwest 5.0%, East 4.2%, South 5.8%, West 4.6%), none of which were significantly different in the fully adjusted model. No statistically significant differences were found in biologic prescriptions between urban and rural VA settings (5.4% vs 4.8%; aOR, 1.06; 95% CI, 0.90–1.24; P = .47). Tobacco use was not associated with the rate of biologic prescription receipt (aOR, 1.14; 95% CI, 0.97–1.34; P = .11). After adjusting for other variables (as outlined in Table 2), no significant differences were found between CCI of 0 and 1 (aOR, 0.97; 95% CI, 0.82–1.16; P = .77) or between CCI of 0 and 2 (aOR, 0.89; 95% CI, 0.74–1.07; P = .22).⁷

Discussion

The aim of the study was to ascertain potential discrepancies in biologic prescription patterns among patients with HS in the VHA by demographic and lifestyle behavior modifiers. Veteran cohorts are unique in composition, consisting predominantly of older White men within a single-payer health care system. The prevalence of biologic prescriptions in this population was low (5.2%), consistent with prior studies (1.8%–8.9%).^4,5

We found a significant difference in ADA/IFX prescription patterns between White patients and NH/PI patients (aOR, 0.23; 95% CI, 0.06-0.92; P = .04). Further replication of this result is needed due to the small number of NH/PI patients included in the study (n = 241). Notably, we did not find a significant difference in the odds of Black patients being prescribed a biologic compared with White patients (aOR, 1.07; 95% CI, 0.92–1.25; P = .38), consistent with prior studies.⁴

In line with prior studies, age was associated with the likelihood of receiving a biologic prescription.⁴ Using the multivariate model adjusting for variables listed in Table 1, including CCI, patients aged 45 to 64 years and > 64 years were less likely to be prescribed a biologic than patients aged 18 to 44 years. HS disease activity could be a potential confounding variable, as HS severity may subside in some people with increasing age or menopause.⁸

Because different regions in the US have different sociopolitical ideologies and governing legislation, we hypothesized that there may be dissimilarities in the prevalence rates of biologic prescribing across various US regions. However, no significant differences were found in prescription patterns among US regions or between rural and urban settings. Previous research has demonstrated discernible disparities in both dermatologic care and clinical outcomes based on hospital setting (ie, urban vs rural).^9-11

Tobacco use has been demonstrated to be associated with the development of HS.¹² In a large retrospective analysis, Garg et al reported increased odds of receiving a new HS diagnosis in known tobacco users (aOR, 1.9; 95% CI, 1.8–2.0).¹³ The extent to which tobacco use affects HS severity is less understood. While some studies have found an association between smoking and HS severity, other analyses have failed to find this association.^14,15 The effects of smoking cessation on the disease course of HS are unknown.¹⁶ This analysis, found no significant difference in prescriptions for biologics among patients with HS comparing current or previous tobacco users with nonusers.

There is a known positive correlation between increasing BMI and HS prevalence and severity that may be explained by the downstream effects of adipose tissue secretion of proinflammatory mediators and insulin resistance in the setting of chronic inflammation.¹² This analysis found that patients with HS and obesity were 1.47 times more likely to be prescribed a biologic than patients with HS without obesity, which may be confounded by increased HS severity among patients with obesity. The initial concern when analyzing tobacco use and obesity was that clinician bias may result in a decrease in the prevalence of biologic use in these demographics, which was not supported in this study.

Although we identified few disparities, the results demonstrated a substantial underutilization of biologic therapies (5.2%), similar to the other US civilian studies (1.8-8.9%).^4,5 While there is no current universal, standardized severity scoring system to evaluate HS (it is difficult to objectively define moderate to severe HS), estimates have shown that 40.3% to 65.8% of patients with HS have Hurley stage II or III.^17-19 Therefore, only a small percentage of patients with moderate to severe disease were prescribed the only FDA-approved medication during this time period. The persistence of this underutilization within a medical system that reduces financial barriers suggests that nonfinancial barriers have a notable role in the underutilization of biologics.

For instance, risk of adverse events, particularly lymphoma and infection, has been cited by patients as a reason to avoid biologics. Additionally, treatment fatigue reduced some patients’ willingness to try new treatments, as did lack of knowledge about treatment options.^6,20 Other reported barriers included the frequency of injections and fear of needles.⁶ Additionally, within the VA, ADA may require prior authorization at the local facility level.²¹ An established relationship with a dermatologist has been shown to significantly increase the odds of being prescribed a biologic medication in the face of these barriers.⁴ Future system-wide quality improvement initiatives could be implemented to identify patients with HS not followed by dermatology, with the goal of establishing care with a dermatologist.

Limitations

Limitations to this study include an inability to categorize HS disease severity and assess the degree to which disease severity confounded study findings, particularly in relation to tobacco use and obesity. The generalizability of this study is also limited because of the demographic characteristics of the veteran patient population, which is predominantly older, White, and male, whereas HS disproportionately affects younger, Black, and female individuals in the US.²² Despite these limitations, this study contributes valuable insights into the use of biologic therapies for veteran populations with HS using a national dataset.

Conclusions

This study was performed within a single-payer government medical system, likely reducing or removing the financial barriers that some patient populations may face when pursuing biologics for HS treatment. However, the prevalence of biologic use in this population was low overall (5.2%), suggesting that other factors play a role in the underutilization of biologics in HS. Consistent with previous studies, younger individuals were more likely to be prescribed a biologic, and no difference in prescription rates between Black and White patients was observed. Unlike previous studies, no significant difference in prescription rates between men and women was observed.

Hidradenitis suppurativa (HS) is a chronic, inflammatory skin disorder characterized by painful nodules, abscesses, and tunnels predominantly affecting intertriginous areas of the body.^1,2 The condition poses significant challenges in terms of diagnosis, treatment, and quality of life for affected individuals. Various systemic therapies have been explored to manage this debilitating condition, with the emergence of biologic agents offering hope for improved outcomes. In 2015, adalimumab (ADA) was the first biologic approved by the US Food and Drug Administration (FDA) for the treatment of HS, followed by secukinumab in 2023 and bimekizumab in 2024. However, the off-label use of other biologics and/or tumor necrosis factor inhibitors such as infliximab (IFX) has become common practice.³

Although these therapies have demonstrated promising results in the treatment of HS, their widespread use may be hindered by accessibility and cost barriers. Orenstein et al analyzed data from the IBM Explorys platform from 2015 to 2020 and found that only 1.8% of patients diagnosed with HS had been prescribed ADA or IFX.⁴ More recently, Garg et al examined IBM MarketScan and IBM US Medicaid data from 2015 to 2018 to evaluate trends in clinical care and treatment. The prevalence of ADA and IFX prescriptions among patients with HS ranged from 2.3% to 8.0% (ADA) and 0.7% to 0.9% (IFX) for patients with commercial insurance, and 1.4% to 4.8% (ADA) and 0.5% to 0.7% (IFX) for patients with Medicaid.⁵ Biologics are often expensive, and the high cost associated with these therapies has been identified as a significant barrier to access for patients with HS, particularly those who lack adequate insurance coverage or face financial constraints.⁶

Furthermore, these barriers, particularly the financial barriers, are potentially compounded by the demographics of patients most notably affected by HS. In the US, a disproportionate incidence of HS has been noted in specific groups and age ranges, including women, individuals aged 18 to 29 years, and Black individuals.⁴ Orenstein et al found a statistically significant difference in use of ADA and IFX biologics based on age, sex, and race.⁴

The aim of this study was to examine the use of 2 biologics (ADA and IFX) in the Veterans Health Administration (VHA), a unique population in which financial barriers are reduced due to the single-payer government health care system structure. This design allowed for improved isolation and evaluation of variation in ADA and/or IFX prescription rates by demographics and health-related factors among patients with HS. To our knowledge, no studies have analyzed these metrics within the VHA.

Methods

This retrospective, cross-sectional analysis of VHA patients used data from the US Department of Veterans Affairs (VA) Corporate Data Warehouse, a data repository that provides access to longitudinal national electronic health record data for all veterans receiving care through VHA facilities. This study received ethical approval from institutional review boards at the Minneapolis Veterans Affairs Health Care System and VA Salt Lake City Healthcare System. Patient information was deidentified, and patient consent was not required.

Patients with HS were identified using ≥ 1 International Classification of Diseases (ICD) diagnostic code: (ICD-9 [705.83] or ICD-10 [L73.2]) between January 1, 2011, and December 31, 2021. The study included patients aged ≥ 18 years as of January 1, 2011, with ≥ 2 patient encounters during the postdiagnosis follow-up period, and with ≥ 1 encounter 6 months postindex. Patients with a biologic prescription prior to HS diagnosis were excluded. For this study, the term biologics refers to ADA and/or IFX prescriptions, unless otherwise specified. Only ADA and IFX were included in this analysis because ADA, a tumor necrosis factor (TNF)-á inhibitor, was the only FDA-approved medication at the time of the search, and IFX is another common TNF-α inhibitor used for the treatment of HS.

Statistical Analysis

We calculated logistic regression using SAS 9.4 (SAS Institute, Cary, NC). For each variable, the univariate relationship with biologic prescriptions was examined first, followed by the multivariate relationship controlling for all other variables. The following variables were controlled for in the multivariate models and were chosen a priori: sex, age, race, ethnicity, US region, hospital setting, current or previous tobacco use, obesity (defined as body mass index [BMI] ≥ 30), and Charlson Comorbidity Index (CCI).⁷

Results

Using ICD codes, we identified 29,483 individuals with ≥ 1 HS diagnosis (Figure 1). Of those identified, 1537 patients (5.21%) had been prescribed ≥ 1 biologic. The cohort was predominantly White (60.56%), male (75.27%), obese (59.34%), and had a history of current or previous tobacco use (73.47%) (Table 1). There were significant adjusted differences in prescription rates among veterans with HS based on age, race, and BMI. Notably, there was an age-dependent reduction in the odds of being prescribed a biologic in patients with HS. Compared with patients aged 18 to 44 years, patients aged 45 to 64 years (adjusted odds ratio [aOR], 0.63; 95% CI, 0.54–0.74; P < .001) and patients aged ≥ 65 years (aOR, 0.36; 95% CI, 0.27–0.48; P < .001) had significantly lower odds of receiving a biologic prescription (Table 2). Compared with White patients with HS, Native Hawaiian (NH) or Pacific Islander (PI) patients were less likely to be prescribed a biologic (aOR, 0.23; 95% CI, 0.06–0.92; P = .04). Patients with obesity had significantly higher odds of receiving a biologic prescription compared with patients without obesity (aOR, 1.47; 95% CI, 1.27– 1.71; P < .001).

After adjusting for the variables listed in Table 1, there were no significant differences in biologic prescription rates for men compared with women (aOR, 0.97; 95% CI, 0.83-1.12; P = .68). We observed slight variations in biologic prescriptions between US regions (Midwest 5.0%, East 4.2%, South 5.8%, West 4.6%), none of which were significantly different in the fully adjusted model. No statistically significant differences were found in biologic prescriptions between urban and rural VA settings (5.4% vs 4.8%; aOR, 1.06; 95% CI, 0.90–1.24; P = .47). Tobacco use was not associated with the rate of biologic prescription receipt (aOR, 1.14; 95% CI, 0.97–1.34; P = .11). After adjusting for other variables (as outlined in Table 2), no significant differences were found between CCI of 0 and 1 (aOR, 0.97; 95% CI, 0.82–1.16; P = .77) or between CCI of 0 and 2 (aOR, 0.89; 95% CI, 0.74–1.07; P = .22).⁷

Discussion

The aim of the study was to ascertain potential discrepancies in biologic prescription patterns among patients with HS in the VHA by demographic and lifestyle behavior modifiers. Veteran cohorts are unique in composition, consisting predominantly of older White men within a single-payer health care system. The prevalence of biologic prescriptions in this population was low (5.2%), consistent with prior studies (1.8%–8.9%).^4,5

We found a significant difference in ADA/IFX prescription patterns between White patients and NH/PI patients (aOR, 0.23; 95% CI, 0.06-0.92; P = .04). Further replication of this result is needed due to the small number of NH/PI patients included in the study (n = 241). Notably, we did not find a significant difference in the odds of Black patients being prescribed a biologic compared with White patients (aOR, 1.07; 95% CI, 0.92–1.25; P = .38), consistent with prior studies.⁴

In line with prior studies, age was associated with the likelihood of receiving a biologic prescription.⁴ Using the multivariate model adjusting for variables listed in Table 1, including CCI, patients aged 45 to 64 years and > 64 years were less likely to be prescribed a biologic than patients aged 18 to 44 years. HS disease activity could be a potential confounding variable, as HS severity may subside in some people with increasing age or menopause.⁸

Because different regions in the US have different sociopolitical ideologies and governing legislation, we hypothesized that there may be dissimilarities in the prevalence rates of biologic prescribing across various US regions. However, no significant differences were found in prescription patterns among US regions or between rural and urban settings. Previous research has demonstrated discernible disparities in both dermatologic care and clinical outcomes based on hospital setting (ie, urban vs rural).^9-11

Tobacco use has been demonstrated to be associated with the development of HS.¹² In a large retrospective analysis, Garg et al reported increased odds of receiving a new HS diagnosis in known tobacco users (aOR, 1.9; 95% CI, 1.8–2.0).¹³ The extent to which tobacco use affects HS severity is less understood. While some studies have found an association between smoking and HS severity, other analyses have failed to find this association.^14,15 The effects of smoking cessation on the disease course of HS are unknown.¹⁶ This analysis, found no significant difference in prescriptions for biologics among patients with HS comparing current or previous tobacco users with nonusers.

There is a known positive correlation between increasing BMI and HS prevalence and severity that may be explained by the downstream effects of adipose tissue secretion of proinflammatory mediators and insulin resistance in the setting of chronic inflammation.¹² This analysis found that patients with HS and obesity were 1.47 times more likely to be prescribed a biologic than patients with HS without obesity, which may be confounded by increased HS severity among patients with obesity. The initial concern when analyzing tobacco use and obesity was that clinician bias may result in a decrease in the prevalence of biologic use in these demographics, which was not supported in this study.

Although we identified few disparities, the results demonstrated a substantial underutilization of biologic therapies (5.2%), similar to the other US civilian studies (1.8-8.9%).^4,5 While there is no current universal, standardized severity scoring system to evaluate HS (it is difficult to objectively define moderate to severe HS), estimates have shown that 40.3% to 65.8% of patients with HS have Hurley stage II or III.^17-19 Therefore, only a small percentage of patients with moderate to severe disease were prescribed the only FDA-approved medication during this time period. The persistence of this underutilization within a medical system that reduces financial barriers suggests that nonfinancial barriers have a notable role in the underutilization of biologics.

For instance, risk of adverse events, particularly lymphoma and infection, has been cited by patients as a reason to avoid biologics. Additionally, treatment fatigue reduced some patients’ willingness to try new treatments, as did lack of knowledge about treatment options.^6,20 Other reported barriers included the frequency of injections and fear of needles.⁶ Additionally, within the VA, ADA may require prior authorization at the local facility level.²¹ An established relationship with a dermatologist has been shown to significantly increase the odds of being prescribed a biologic medication in the face of these barriers.⁴ Future system-wide quality improvement initiatives could be implemented to identify patients with HS not followed by dermatology, with the goal of establishing care with a dermatologist.

Limitations

Limitations to this study include an inability to categorize HS disease severity and assess the degree to which disease severity confounded study findings, particularly in relation to tobacco use and obesity. The generalizability of this study is also limited because of the demographic characteristics of the veteran patient population, which is predominantly older, White, and male, whereas HS disproportionately affects younger, Black, and female individuals in the US.²² Despite these limitations, this study contributes valuable insights into the use of biologic therapies for veteran populations with HS using a national dataset.

Conclusions

This study was performed within a single-payer government medical system, likely reducing or removing the financial barriers that some patient populations may face when pursuing biologics for HS treatment. However, the prevalence of biologic use in this population was low overall (5.2%), suggesting that other factors play a role in the underutilization of biologics in HS. Consistent with previous studies, younger individuals were more likely to be prescribed a biologic, and no difference in prescription rates between Black and White patients was observed. Unlike previous studies, no significant difference in prescription rates between men and women was observed.

Hidradenitis suppurativa (HS) is a chronic, inflammatory skin disorder characterized by painful nodules, abscesses, and tunnels predominantly affecting intertriginous areas of the body.^1,2 The condition poses significant challenges in terms of diagnosis, treatment, and quality of life for affected individuals. Various systemic therapies have been explored to manage this debilitating condition, with the emergence of biologic agents offering hope for improved outcomes. In 2015, adalimumab (ADA) was the first biologic approved by the US Food and Drug Administration (FDA) for the treatment of HS, followed by secukinumab in 2023 and bimekizumab in 2024. However, the off-label use of other biologics and/or tumor necrosis factor inhibitors such as infliximab (IFX) has become common practice.³

Although these therapies have demonstrated promising results in the treatment of HS, their widespread use may be hindered by accessibility and cost barriers. Orenstein et al analyzed data from the IBM Explorys platform from 2015 to 2020 and found that only 1.8% of patients diagnosed with HS had been prescribed ADA or IFX.⁴ More recently, Garg et al examined IBM MarketScan and IBM US Medicaid data from 2015 to 2018 to evaluate trends in clinical care and treatment. The prevalence of ADA and IFX prescriptions among patients with HS ranged from 2.3% to 8.0% (ADA) and 0.7% to 0.9% (IFX) for patients with commercial insurance, and 1.4% to 4.8% (ADA) and 0.5% to 0.7% (IFX) for patients with Medicaid.⁵ Biologics are often expensive, and the high cost associated with these therapies has been identified as a significant barrier to access for patients with HS, particularly those who lack adequate insurance coverage or face financial constraints.⁶

Furthermore, these barriers, particularly the financial barriers, are potentially compounded by the demographics of patients most notably affected by HS. In the US, a disproportionate incidence of HS has been noted in specific groups and age ranges, including women, individuals aged 18 to 29 years, and Black individuals.⁴ Orenstein et al found a statistically significant difference in use of ADA and IFX biologics based on age, sex, and race.⁴

The aim of this study was to examine the use of 2 biologics (ADA and IFX) in the Veterans Health Administration (VHA), a unique population in which financial barriers are reduced due to the single-payer government health care system structure. This design allowed for improved isolation and evaluation of variation in ADA and/or IFX prescription rates by demographics and health-related factors among patients with HS. To our knowledge, no studies have analyzed these metrics within the VHA.

Methods

This retrospective, cross-sectional analysis of VHA patients used data from the US Department of Veterans Affairs (VA) Corporate Data Warehouse, a data repository that provides access to longitudinal national electronic health record data for all veterans receiving care through VHA facilities. This study received ethical approval from institutional review boards at the Minneapolis Veterans Affairs Health Care System and VA Salt Lake City Healthcare System. Patient information was deidentified, and patient consent was not required.

Patients with HS were identified using ≥ 1 International Classification of Diseases (ICD) diagnostic code: (ICD-9 [705.83] or ICD-10 [L73.2]) between January 1, 2011, and December 31, 2021. The study included patients aged ≥ 18 years as of January 1, 2011, with ≥ 2 patient encounters during the postdiagnosis follow-up period, and with ≥ 1 encounter 6 months postindex. Patients with a biologic prescription prior to HS diagnosis were excluded. For this study, the term biologics refers to ADA and/or IFX prescriptions, unless otherwise specified. Only ADA and IFX were included in this analysis because ADA, a tumor necrosis factor (TNF)-á inhibitor, was the only FDA-approved medication at the time of the search, and IFX is another common TNF-α inhibitor used for the treatment of HS.

Statistical Analysis

We calculated logistic regression using SAS 9.4 (SAS Institute, Cary, NC). For each variable, the univariate relationship with biologic prescriptions was examined first, followed by the multivariate relationship controlling for all other variables. The following variables were controlled for in the multivariate models and were chosen a priori: sex, age, race, ethnicity, US region, hospital setting, current or previous tobacco use, obesity (defined as body mass index [BMI] ≥ 30), and Charlson Comorbidity Index (CCI).⁷

Results

Using ICD codes, we identified 29,483 individuals with ≥ 1 HS diagnosis (Figure 1). Of those identified, 1537 patients (5.21%) had been prescribed ≥ 1 biologic. The cohort was predominantly White (60.56%), male (75.27%), obese (59.34%), and had a history of current or previous tobacco use (73.47%) (Table 1). There were significant adjusted differences in prescription rates among veterans with HS based on age, race, and BMI. Notably, there was an age-dependent reduction in the odds of being prescribed a biologic in patients with HS. Compared with patients aged 18 to 44 years, patients aged 45 to 64 years (adjusted odds ratio [aOR], 0.63; 95% CI, 0.54–0.74; P < .001) and patients aged ≥ 65 years (aOR, 0.36; 95% CI, 0.27–0.48; P < .001) had significantly lower odds of receiving a biologic prescription (Table 2). Compared with White patients with HS, Native Hawaiian (NH) or Pacific Islander (PI) patients were less likely to be prescribed a biologic (aOR, 0.23; 95% CI, 0.06–0.92; P = .04). Patients with obesity had significantly higher odds of receiving a biologic prescription compared with patients without obesity (aOR, 1.47; 95% CI, 1.27– 1.71; P < .001).

After adjusting for the variables listed in Table 1, there were no significant differences in biologic prescription rates for men compared with women (aOR, 0.97; 95% CI, 0.83-1.12; P = .68). We observed slight variations in biologic prescriptions between US regions (Midwest 5.0%, East 4.2%, South 5.8%, West 4.6%), none of which were significantly different in the fully adjusted model. No statistically significant differences were found in biologic prescriptions between urban and rural VA settings (5.4% vs 4.8%; aOR, 1.06; 95% CI, 0.90–1.24; P = .47). Tobacco use was not associated with the rate of biologic prescription receipt (aOR, 1.14; 95% CI, 0.97–1.34; P = .11). After adjusting for other variables (as outlined in Table 2), no significant differences were found between CCI of 0 and 1 (aOR, 0.97; 95% CI, 0.82–1.16; P = .77) or between CCI of 0 and 2 (aOR, 0.89; 95% CI, 0.74–1.07; P = .22).⁷

Discussion

The aim of the study was to ascertain potential discrepancies in biologic prescription patterns among patients with HS in the VHA by demographic and lifestyle behavior modifiers. Veteran cohorts are unique in composition, consisting predominantly of older White men within a single-payer health care system. The prevalence of biologic prescriptions in this population was low (5.2%), consistent with prior studies (1.8%–8.9%).^4,5

We found a significant difference in ADA/IFX prescription patterns between White patients and NH/PI patients (aOR, 0.23; 95% CI, 0.06-0.92; P = .04). Further replication of this result is needed due to the small number of NH/PI patients included in the study (n = 241). Notably, we did not find a significant difference in the odds of Black patients being prescribed a biologic compared with White patients (aOR, 1.07; 95% CI, 0.92–1.25; P = .38), consistent with prior studies.⁴

In line with prior studies, age was associated with the likelihood of receiving a biologic prescription.⁴ Using the multivariate model adjusting for variables listed in Table 1, including CCI, patients aged 45 to 64 years and > 64 years were less likely to be prescribed a biologic than patients aged 18 to 44 years. HS disease activity could be a potential confounding variable, as HS severity may subside in some people with increasing age or menopause.⁸

Because different regions in the US have different sociopolitical ideologies and governing legislation, we hypothesized that there may be dissimilarities in the prevalence rates of biologic prescribing across various US regions. However, no significant differences were found in prescription patterns among US regions or between rural and urban settings. Previous research has demonstrated discernible disparities in both dermatologic care and clinical outcomes based on hospital setting (ie, urban vs rural).^9-11

Tobacco use has been demonstrated to be associated with the development of HS.¹² In a large retrospective analysis, Garg et al reported increased odds of receiving a new HS diagnosis in known tobacco users (aOR, 1.9; 95% CI, 1.8–2.0).¹³ The extent to which tobacco use affects HS severity is less understood. While some studies have found an association between smoking and HS severity, other analyses have failed to find this association.^14,15 The effects of smoking cessation on the disease course of HS are unknown.¹⁶ This analysis, found no significant difference in prescriptions for biologics among patients with HS comparing current or previous tobacco users with nonusers.

There is a known positive correlation between increasing BMI and HS prevalence and severity that may be explained by the downstream effects of adipose tissue secretion of proinflammatory mediators and insulin resistance in the setting of chronic inflammation.¹² This analysis found that patients with HS and obesity were 1.47 times more likely to be prescribed a biologic than patients with HS without obesity, which may be confounded by increased HS severity among patients with obesity. The initial concern when analyzing tobacco use and obesity was that clinician bias may result in a decrease in the prevalence of biologic use in these demographics, which was not supported in this study.

Although we identified few disparities, the results demonstrated a substantial underutilization of biologic therapies (5.2%), similar to the other US civilian studies (1.8-8.9%).^4,5 While there is no current universal, standardized severity scoring system to evaluate HS (it is difficult to objectively define moderate to severe HS), estimates have shown that 40.3% to 65.8% of patients with HS have Hurley stage II or III.^17-19 Therefore, only a small percentage of patients with moderate to severe disease were prescribed the only FDA-approved medication during this time period. The persistence of this underutilization within a medical system that reduces financial barriers suggests that nonfinancial barriers have a notable role in the underutilization of biologics.

For instance, risk of adverse events, particularly lymphoma and infection, has been cited by patients as a reason to avoid biologics. Additionally, treatment fatigue reduced some patients’ willingness to try new treatments, as did lack of knowledge about treatment options.^6,20 Other reported barriers included the frequency of injections and fear of needles.⁶ Additionally, within the VA, ADA may require prior authorization at the local facility level.²¹ An established relationship with a dermatologist has been shown to significantly increase the odds of being prescribed a biologic medication in the face of these barriers.⁴ Future system-wide quality improvement initiatives could be implemented to identify patients with HS not followed by dermatology, with the goal of establishing care with a dermatologist.

Limitations

Limitations to this study include an inability to categorize HS disease severity and assess the degree to which disease severity confounded study findings, particularly in relation to tobacco use and obesity. The generalizability of this study is also limited because of the demographic characteristics of the veteran patient population, which is predominantly older, White, and male, whereas HS disproportionately affects younger, Black, and female individuals in the US.²² Despite these limitations, this study contributes valuable insights into the use of biologic therapies for veteran populations with HS using a national dataset.

Conclusions

This study was performed within a single-payer government medical system, likely reducing or removing the financial barriers that some patient populations may face when pursuing biologics for HS treatment. However, the prevalence of biologic use in this population was low overall (5.2%), suggesting that other factors play a role in the underutilization of biologics in HS. Consistent with previous studies, younger individuals were more likely to be prescribed a biologic, and no difference in prescription rates between Black and White patients was observed. Unlike previous studies, no significant difference in prescription rates between men and women was observed.

To improve safety performance, many health care organizations have embarked on the journey to becoming high reliability organizations (HROs). HROs operate in complex, high-risk, constantly changing environments and avoid catastrophic events despite the inherent risks.¹ HROs maintain high levels of safety and reliability by adhering to core principles, foundational practices, rigorous processes, a strong organizational culture, and continuous learning and process improvement.^1-3

Becoming an HRO requires understanding what makes systems safer for patients and staff at all levels by taking ownership of 5 principles: (1) sensitivity to operations (increased awareness of the current status of systems); (2) reluctance to simplify (avoiding oversimplification of the cause[s] of problems); (3) preoccupation with failure (anticipating risks that might be symptomatic of a larger problem); (4) deference to expertise (relying on the most qualified individuals to make decisions); and (5) commitment to resilience (planning for potential failure and being prepared to respond).^1,2,4 In addition to these, the Veterans Health Administration has identified 3 pillars of HROs: leadership commitment (safety and reliability are central to leadership vision, decision-making, and action-oriented behaviors), safety culture (across the organization, safety values are key to preventing harm and learning from mistakes), and continuous process improvement (promoting constant learning and improvement with evidence-based tools and methodologies).⁵

Implementing these principles is not enough to achieve high reliability. This transition requires significant change, which can be met with resistance. Without attending to organizational change, implementation of HRO principles can be superficial, scattered, and isolated.⁶ Large organizations often struggle with change as it conflicts with the fundamental human need for stability and security.⁷ Consequently, the journey to becoming an HRO requires an understanding of the reasons for resistance to change (RtC) as well as evidence-based strategies.

REASONS FOR RESISTANCE TO CHANGE

RtC is the informal and covert behavior of an individual or group to a particular change. RtC is commonly recognized as the failure of employees to do anything requested by managers and is a main reason change initiatives fail.⁸ While some staff see change as opportunities for learning and growth, others resist based on uncertainty about how the changes will impact their current work situation, or fear, frustration, confusion, and distrust.^8,9 Resistance can overtly manifest with some staff publicly expressing their discontent in public without offering solutions, or covertly by ignoring the change or avoiding participation in any aspect of the change process. Both forms of RtC are equally detrimental.⁸

Frequent changes in organizations can also cause cynicism. Employees will view the change as something initially popular, but will only last until another change comes along.^8,9 Resistance can result in the failure to achieve desired objectives, wasted time, effort, and resources, decreased momentum, and loss of confidence and trust in leaders to effectively manage the change process.⁹ To understand RtC, 3 main factors must be considered: individual, interpersonal, and organizational.

Individual

An individual’s personality can be an important indicator for how they will respond to change. Some individuals welcome and thrive on change while others resist in preference for the status quo.^8,10 Individuals will also resist change if they believe their position, power, or prestige within the organization are in jeopardy or that the change is contrary to current personal or organizational values, principles, and objectives.^8-12 Resistance can also be the result of uncertainty about what the change means, lack of information regarding the change, or questioning motives for the change.⁹

Interpersonal

Another influence on RtC is the interpersonal factors of employees. The personal satisfaction individuals receive from their work and the type of interactions they experience with colleagues can impact RtC. When communication with colleagues is lacking before and during change implementation, negative reactions to the change can fuel resistance.¹¹ Cross-functional and bidirectional communication is vital; its absence can leave staff feeling inadequately informed and less supportive of the change.⁸ Employees’ understanding of changes through communication between other members of the organization is critical to success.¹¹

Organizational

How organizational leaders introduce change affects the extent to which staff respond.¹⁰ RtC can emerge if staff feel change is imposed on them. Change is better received when people are actively engaged in the process and adopt a sense of ownership that will ultimately affect them and their role within the organization.^12,13 Organizations are also better equipped to address potential RtC when leadership is respected and have a genuine concern for the overall well-being of staff members. Organizational leaders who mainly focus on the bottom line and have little regard for staff are more likely to be perceived as untrustworthy, which contributes to RtC.^9,13 Lack of proper education and guidance from organizational leaders, as well as poor communication, can lead to RtC.^8,13

MANAGING RESISTANCE TO CHANGE

RtC can be a significant factor in the success or failure of the change process. Poorly managed change can exponentially increase resistance, necessitating a multifaceted approach to managing RtC, while well-managed change can result in a high success rate. Evidence-based strategies to counter RtC focus on communication, employee participation, education and training, and engaging managers.⁸

Communication

Open and effective communication is critical to managing RtC, as uncertainty often exaggerates the negative aspects of change. Effective communication involves active listening, with leadership and management addressing employee concerns in a clear and concise manner. A psychologically safe culture for open dialogue is essential when addressing RtC.^9,14,15 Psychological safety empowers staff to speak up, ask questions, and offer ideas, forming a solid basis for open and effective communication and participation. Leaders and managers should create opportunities for open dialogue for all members of the organization throughout the process. This can be accomplished with one-on-one meetings, open forums, town hall meetings, electronic mail, newsletters, and social media. Topics should cover the reasons for change, details of what is changing, the individual, organizational, and patient risks of not changing, as well as the benefits of changing.⁹ Encouraging staff to ask questions and provide feedback to promote bidirectional and closed-loop communication is essential to avoid misunderstandings.^9,15 While open communication is essential, leaders must carefully plan what information to share, how much to share, and how to avoid information overload. Information about the change should be timely, adequate, applicable, and informative.¹⁵ The HRO practice of leader rounding for high reliability can be instrumental to ensure effective, bidirectional communication and collaboration among all disciplines across a health care organization through improving leadership visibility during times of change and enhancing interactions and communication with staff.³

Employee Participation

Involving staff in the change process significantly reduces RtC. Engagement fosters ownership in the change process, increasing the likelihood employees will support and even champion it. Health care professionals welcome opportunities to be involved in helping with aspects of organizational change, especially when invited to participate in the change early in the process and throughout the course of change.^7,14,15

Leaders should encourage staff to provide feedback to understand the impact the change is having on them and their roles and responsibilities within the organization. This exemplifies the HRO principle of deference to expertise as the employee often has the most in-depth knowledge of their work setting. Employee perspectives can significantly influence the success of change initatives.^7,14 Participation is impactful in providing employees with a sense of agency facilitating acceptance and improving desire to adopt the change.¹⁴

Tiered safety huddles and visual management systems (VMSs) also can engage staff. Tiered safety huddles provide a forum for transparent communication, increasing situational awareness, and improving a health care organization’s ability to appropriately respond to staff questions, suggestions, and concerns. VMSs display the status and progress toward organizational goals during the change process, and are highly effective in creating environments where staff feel empowered to voice concerns related to the change process.³

Education and Training

Educating employees on the value of change is crucial to overcome RtC. RtC often stems from employees not feeling prepared to adapt or adopt new processes. Health care professionals who do not receive information about change are less likely to support it.^7,12,15 Staff are more likely to accept change when they understand why it is needed and how it impacts the organization’s long-term mission.^11,15 Timely, compelling, and informative education on how to adapt to the change will promote more positive appraisal of the change and reduce RtC.^8,15 Employees must feel confident they will receive the appropriate training, resources, and support to successfully adapt to the change. This requires leaders and managers taking time to clarify expectations, conduct a gap analysis to identify the skills and knowledge needed to support the planned change, and provide sufficient educational opportunities to fill those gaps.⁸ For example, the US Department of Veterans Affairs offers classes to employees on the Prosci ADKAR (Awareness, Desire, Knowledge, Ability, and Reinforcement) Model. This training provides individuals with the information and skills needed for change to be successful.¹⁶

Safety forums can be influential and allow leadership to educate staff on updates related to change processes and promote bidirectional communication.³ In safety forums, staff have an opportunity to ask questions, especially as they relate to learning about available resources to become more informed about the organizational changes.

Engaging Managers

Managers are pivotal to the successful implementation of organizational change.⁸ They serve as the bridge between senior leadership and frontline employees and are positioned to influence the adoption and success of change initiatives. Often the first point of contact for employees, managers can effectively communicate the need for change, and act as the liaison to align it with individual employee motivations. Since they are often the first to encounter resistance among employees, managers serve as advocates through the process. Through a coaching role, managers can help employees develop the knowledge and ability to be successful and thrive in the new environment. The Table summarizes the evidence-based strategies.

CONCLUSIONS

Implementing change in health care organizations can be challenging, especially on the journey to high reliability. RtC is the result of factors at the individual, interpersonal, and organizational levels that leaders must address to increase chances for success. Organizational changes in health care are more likely to succeed when staff understand why the change is needed through open and continuous communication, can influence the change by sharing their own perspectives, and have the knowledge, skills, and resources to prepare for and participate in the process.

To improve safety performance, many health care organizations have embarked on the journey to becoming high reliability organizations (HROs). HROs operate in complex, high-risk, constantly changing environments and avoid catastrophic events despite the inherent risks.¹ HROs maintain high levels of safety and reliability by adhering to core principles, foundational practices, rigorous processes, a strong organizational culture, and continuous learning and process improvement.^1-3

Becoming an HRO requires understanding what makes systems safer for patients and staff at all levels by taking ownership of 5 principles: (1) sensitivity to operations (increased awareness of the current status of systems); (2) reluctance to simplify (avoiding oversimplification of the cause[s] of problems); (3) preoccupation with failure (anticipating risks that might be symptomatic of a larger problem); (4) deference to expertise (relying on the most qualified individuals to make decisions); and (5) commitment to resilience (planning for potential failure and being prepared to respond).^1,2,4 In addition to these, the Veterans Health Administration has identified 3 pillars of HROs: leadership commitment (safety and reliability are central to leadership vision, decision-making, and action-oriented behaviors), safety culture (across the organization, safety values are key to preventing harm and learning from mistakes), and continuous process improvement (promoting constant learning and improvement with evidence-based tools and methodologies).⁵

Implementing these principles is not enough to achieve high reliability. This transition requires significant change, which can be met with resistance. Without attending to organizational change, implementation of HRO principles can be superficial, scattered, and isolated.⁶ Large organizations often struggle with change as it conflicts with the fundamental human need for stability and security.⁷ Consequently, the journey to becoming an HRO requires an understanding of the reasons for resistance to change (RtC) as well as evidence-based strategies.

REASONS FOR RESISTANCE TO CHANGE

RtC is the informal and covert behavior of an individual or group to a particular change. RtC is commonly recognized as the failure of employees to do anything requested by managers and is a main reason change initiatives fail.⁸ While some staff see change as opportunities for learning and growth, others resist based on uncertainty about how the changes will impact their current work situation, or fear, frustration, confusion, and distrust.^8,9 Resistance can overtly manifest with some staff publicly expressing their discontent in public without offering solutions, or covertly by ignoring the change or avoiding participation in any aspect of the change process. Both forms of RtC are equally detrimental.⁸

Frequent changes in organizations can also cause cynicism. Employees will view the change as something initially popular, but will only last until another change comes along.^8,9 Resistance can result in the failure to achieve desired objectives, wasted time, effort, and resources, decreased momentum, and loss of confidence and trust in leaders to effectively manage the change process.⁹ To understand RtC, 3 main factors must be considered: individual, interpersonal, and organizational.

Individual

An individual’s personality can be an important indicator for how they will respond to change. Some individuals welcome and thrive on change while others resist in preference for the status quo.^8,10 Individuals will also resist change if they believe their position, power, or prestige within the organization are in jeopardy or that the change is contrary to current personal or organizational values, principles, and objectives.^8-12 Resistance can also be the result of uncertainty about what the change means, lack of information regarding the change, or questioning motives for the change.⁹

Interpersonal

Another influence on RtC is the interpersonal factors of employees. The personal satisfaction individuals receive from their work and the type of interactions they experience with colleagues can impact RtC. When communication with colleagues is lacking before and during change implementation, negative reactions to the change can fuel resistance.¹¹ Cross-functional and bidirectional communication is vital; its absence can leave staff feeling inadequately informed and less supportive of the change.⁸ Employees’ understanding of changes through communication between other members of the organization is critical to success.¹¹

Organizational

How organizational leaders introduce change affects the extent to which staff respond.¹⁰ RtC can emerge if staff feel change is imposed on them. Change is better received when people are actively engaged in the process and adopt a sense of ownership that will ultimately affect them and their role within the organization.^12,13 Organizations are also better equipped to address potential RtC when leadership is respected and have a genuine concern for the overall well-being of staff members. Organizational leaders who mainly focus on the bottom line and have little regard for staff are more likely to be perceived as untrustworthy, which contributes to RtC.^9,13 Lack of proper education and guidance from organizational leaders, as well as poor communication, can lead to RtC.^8,13

MANAGING RESISTANCE TO CHANGE

RtC can be a significant factor in the success or failure of the change process. Poorly managed change can exponentially increase resistance, necessitating a multifaceted approach to managing RtC, while well-managed change can result in a high success rate. Evidence-based strategies to counter RtC focus on communication, employee participation, education and training, and engaging managers.⁸

Communication

Open and effective communication is critical to managing RtC, as uncertainty often exaggerates the negative aspects of change. Effective communication involves active listening, with leadership and management addressing employee concerns in a clear and concise manner. A psychologically safe culture for open dialogue is essential when addressing RtC.^9,14,15 Psychological safety empowers staff to speak up, ask questions, and offer ideas, forming a solid basis for open and effective communication and participation. Leaders and managers should create opportunities for open dialogue for all members of the organization throughout the process. This can be accomplished with one-on-one meetings, open forums, town hall meetings, electronic mail, newsletters, and social media. Topics should cover the reasons for change, details of what is changing, the individual, organizational, and patient risks of not changing, as well as the benefits of changing.⁹ Encouraging staff to ask questions and provide feedback to promote bidirectional and closed-loop communication is essential to avoid misunderstandings.^9,15 While open communication is essential, leaders must carefully plan what information to share, how much to share, and how to avoid information overload. Information about the change should be timely, adequate, applicable, and informative.¹⁵ The HRO practice of leader rounding for high reliability can be instrumental to ensure effective, bidirectional communication and collaboration among all disciplines across a health care organization through improving leadership visibility during times of change and enhancing interactions and communication with staff.³

Employee Participation

Involving staff in the change process significantly reduces RtC. Engagement fosters ownership in the change process, increasing the likelihood employees will support and even champion it. Health care professionals welcome opportunities to be involved in helping with aspects of organizational change, especially when invited to participate in the change early in the process and throughout the course of change.^7,14,15

Leaders should encourage staff to provide feedback to understand the impact the change is having on them and their roles and responsibilities within the organization. This exemplifies the HRO principle of deference to expertise as the employee often has the most in-depth knowledge of their work setting. Employee perspectives can significantly influence the success of change initatives.^7,14 Participation is impactful in providing employees with a sense of agency facilitating acceptance and improving desire to adopt the change.¹⁴

Tiered safety huddles and visual management systems (VMSs) also can engage staff. Tiered safety huddles provide a forum for transparent communication, increasing situational awareness, and improving a health care organization’s ability to appropriately respond to staff questions, suggestions, and concerns. VMSs display the status and progress toward organizational goals during the change process, and are highly effective in creating environments where staff feel empowered to voice concerns related to the change process.³

Education and Training

Educating employees on the value of change is crucial to overcome RtC. RtC often stems from employees not feeling prepared to adapt or adopt new processes. Health care professionals who do not receive information about change are less likely to support it.^7,12,15 Staff are more likely to accept change when they understand why it is needed and how it impacts the organization’s long-term mission.^11,15 Timely, compelling, and informative education on how to adapt to the change will promote more positive appraisal of the change and reduce RtC.^8,15 Employees must feel confident they will receive the appropriate training, resources, and support to successfully adapt to the change. This requires leaders and managers taking time to clarify expectations, conduct a gap analysis to identify the skills and knowledge needed to support the planned change, and provide sufficient educational opportunities to fill those gaps.⁸ For example, the US Department of Veterans Affairs offers classes to employees on the Prosci ADKAR (Awareness, Desire, Knowledge, Ability, and Reinforcement) Model. This training provides individuals with the information and skills needed for change to be successful.¹⁶

Safety forums can be influential and allow leadership to educate staff on updates related to change processes and promote bidirectional communication.³ In safety forums, staff have an opportunity to ask questions, especially as they relate to learning about available resources to become more informed about the organizational changes.

Engaging Managers

Managers are pivotal to the successful implementation of organizational change.⁸ They serve as the bridge between senior leadership and frontline employees and are positioned to influence the adoption and success of change initiatives. Often the first point of contact for employees, managers can effectively communicate the need for change, and act as the liaison to align it with individual employee motivations. Since they are often the first to encounter resistance among employees, managers serve as advocates through the process. Through a coaching role, managers can help employees develop the knowledge and ability to be successful and thrive in the new environment. The Table summarizes the evidence-based strategies.

CONCLUSIONS

Implementing change in health care organizations can be challenging, especially on the journey to high reliability. RtC is the result of factors at the individual, interpersonal, and organizational levels that leaders must address to increase chances for success. Organizational changes in health care are more likely to succeed when staff understand why the change is needed through open and continuous communication, can influence the change by sharing their own perspectives, and have the knowledge, skills, and resources to prepare for and participate in the process.

To improve safety performance, many health care organizations have embarked on the journey to becoming high reliability organizations (HROs). HROs operate in complex, high-risk, constantly changing environments and avoid catastrophic events despite the inherent risks.¹ HROs maintain high levels of safety and reliability by adhering to core principles, foundational practices, rigorous processes, a strong organizational culture, and continuous learning and process improvement.^1-3

Becoming an HRO requires understanding what makes systems safer for patients and staff at all levels by taking ownership of 5 principles: (1) sensitivity to operations (increased awareness of the current status of systems); (2) reluctance to simplify (avoiding oversimplification of the cause[s] of problems); (3) preoccupation with failure (anticipating risks that might be symptomatic of a larger problem); (4) deference to expertise (relying on the most qualified individuals to make decisions); and (5) commitment to resilience (planning for potential failure and being prepared to respond).^1,2,4 In addition to these, the Veterans Health Administration has identified 3 pillars of HROs: leadership commitment (safety and reliability are central to leadership vision, decision-making, and action-oriented behaviors), safety culture (across the organization, safety values are key to preventing harm and learning from mistakes), and continuous process improvement (promoting constant learning and improvement with evidence-based tools and methodologies).⁵

Implementing these principles is not enough to achieve high reliability. This transition requires significant change, which can be met with resistance. Without attending to organizational change, implementation of HRO principles can be superficial, scattered, and isolated.⁶ Large organizations often struggle with change as it conflicts with the fundamental human need for stability and security.⁷ Consequently, the journey to becoming an HRO requires an understanding of the reasons for resistance to change (RtC) as well as evidence-based strategies.

REASONS FOR RESISTANCE TO CHANGE

RtC is the informal and covert behavior of an individual or group to a particular change. RtC is commonly recognized as the failure of employees to do anything requested by managers and is a main reason change initiatives fail.⁸ While some staff see change as opportunities for learning and growth, others resist based on uncertainty about how the changes will impact their current work situation, or fear, frustration, confusion, and distrust.^8,9 Resistance can overtly manifest with some staff publicly expressing their discontent in public without offering solutions, or covertly by ignoring the change or avoiding participation in any aspect of the change process. Both forms of RtC are equally detrimental.⁸

Frequent changes in organizations can also cause cynicism. Employees will view the change as something initially popular, but will only last until another change comes along.^8,9 Resistance can result in the failure to achieve desired objectives, wasted time, effort, and resources, decreased momentum, and loss of confidence and trust in leaders to effectively manage the change process.⁹ To understand RtC, 3 main factors must be considered: individual, interpersonal, and organizational.

Individual

An individual’s personality can be an important indicator for how they will respond to change. Some individuals welcome and thrive on change while others resist in preference for the status quo.^8,10 Individuals will also resist change if they believe their position, power, or prestige within the organization are in jeopardy or that the change is contrary to current personal or organizational values, principles, and objectives.^8-12 Resistance can also be the result of uncertainty about what the change means, lack of information regarding the change, or questioning motives for the change.⁹

Interpersonal

Another influence on RtC is the interpersonal factors of employees. The personal satisfaction individuals receive from their work and the type of interactions they experience with colleagues can impact RtC. When communication with colleagues is lacking before and during change implementation, negative reactions to the change can fuel resistance.¹¹ Cross-functional and bidirectional communication is vital; its absence can leave staff feeling inadequately informed and less supportive of the change.⁸ Employees’ understanding of changes through communication between other members of the organization is critical to success.¹¹

Organizational

How organizational leaders introduce change affects the extent to which staff respond.¹⁰ RtC can emerge if staff feel change is imposed on them. Change is better received when people are actively engaged in the process and adopt a sense of ownership that will ultimately affect them and their role within the organization.^12,13 Organizations are also better equipped to address potential RtC when leadership is respected and have a genuine concern for the overall well-being of staff members. Organizational leaders who mainly focus on the bottom line and have little regard for staff are more likely to be perceived as untrustworthy, which contributes to RtC.^9,13 Lack of proper education and guidance from organizational leaders, as well as poor communication, can lead to RtC.^8,13

MANAGING RESISTANCE TO CHANGE

RtC can be a significant factor in the success or failure of the change process. Poorly managed change can exponentially increase resistance, necessitating a multifaceted approach to managing RtC, while well-managed change can result in a high success rate. Evidence-based strategies to counter RtC focus on communication, employee participation, education and training, and engaging managers.⁸

Communication

Open and effective communication is critical to managing RtC, as uncertainty often exaggerates the negative aspects of change. Effective communication involves active listening, with leadership and management addressing employee concerns in a clear and concise manner. A psychologically safe culture for open dialogue is essential when addressing RtC.^9,14,15 Psychological safety empowers staff to speak up, ask questions, and offer ideas, forming a solid basis for open and effective communication and participation. Leaders and managers should create opportunities for open dialogue for all members of the organization throughout the process. This can be accomplished with one-on-one meetings, open forums, town hall meetings, electronic mail, newsletters, and social media. Topics should cover the reasons for change, details of what is changing, the individual, organizational, and patient risks of not changing, as well as the benefits of changing.⁹ Encouraging staff to ask questions and provide feedback to promote bidirectional and closed-loop communication is essential to avoid misunderstandings.^9,15 While open communication is essential, leaders must carefully plan what information to share, how much to share, and how to avoid information overload. Information about the change should be timely, adequate, applicable, and informative.¹⁵ The HRO practice of leader rounding for high reliability can be instrumental to ensure effective, bidirectional communication and collaboration among all disciplines across a health care organization through improving leadership visibility during times of change and enhancing interactions and communication with staff.³

Employee Participation

Involving staff in the change process significantly reduces RtC. Engagement fosters ownership in the change process, increasing the likelihood employees will support and even champion it. Health care professionals welcome opportunities to be involved in helping with aspects of organizational change, especially when invited to participate in the change early in the process and throughout the course of change.^7,14,15

Leaders should encourage staff to provide feedback to understand the impact the change is having on them and their roles and responsibilities within the organization. This exemplifies the HRO principle of deference to expertise as the employee often has the most in-depth knowledge of their work setting. Employee perspectives can significantly influence the success of change initatives.^7,14 Participation is impactful in providing employees with a sense of agency facilitating acceptance and improving desire to adopt the change.¹⁴

Tiered safety huddles and visual management systems (VMSs) also can engage staff. Tiered safety huddles provide a forum for transparent communication, increasing situational awareness, and improving a health care organization’s ability to appropriately respond to staff questions, suggestions, and concerns. VMSs display the status and progress toward organizational goals during the change process, and are highly effective in creating environments where staff feel empowered to voice concerns related to the change process.³

Education and Training

Educating employees on the value of change is crucial to overcome RtC. RtC often stems from employees not feeling prepared to adapt or adopt new processes. Health care professionals who do not receive information about change are less likely to support it.^7,12,15 Staff are more likely to accept change when they understand why it is needed and how it impacts the organization’s long-term mission.^11,15 Timely, compelling, and informative education on how to adapt to the change will promote more positive appraisal of the change and reduce RtC.^8,15 Employees must feel confident they will receive the appropriate training, resources, and support to successfully adapt to the change. This requires leaders and managers taking time to clarify expectations, conduct a gap analysis to identify the skills and knowledge needed to support the planned change, and provide sufficient educational opportunities to fill those gaps.⁸ For example, the US Department of Veterans Affairs offers classes to employees on the Prosci ADKAR (Awareness, Desire, Knowledge, Ability, and Reinforcement) Model. This training provides individuals with the information and skills needed for change to be successful.¹⁶

Safety forums can be influential and allow leadership to educate staff on updates related to change processes and promote bidirectional communication.³ In safety forums, staff have an opportunity to ask questions, especially as they relate to learning about available resources to become more informed about the organizational changes.

Engaging Managers

Managers are pivotal to the successful implementation of organizational change.⁸ They serve as the bridge between senior leadership and frontline employees and are positioned to influence the adoption and success of change initiatives. Often the first point of contact for employees, managers can effectively communicate the need for change, and act as the liaison to align it with individual employee motivations. Since they are often the first to encounter resistance among employees, managers serve as advocates through the process. Through a coaching role, managers can help employees develop the knowledge and ability to be successful and thrive in the new environment. The Table summarizes the evidence-based strategies.

CONCLUSIONS

Implementing change in health care organizations can be challenging, especially on the journey to high reliability. RtC is the result of factors at the individual, interpersonal, and organizational levels that leaders must address to increase chances for success. Organizational changes in health care are more likely to succeed when staff understand why the change is needed through open and continuous communication, can influence the change by sharing their own perspectives, and have the knowledge, skills, and resources to prepare for and participate in the process.