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.