More than 20% of the U.S. population will be aged ≥ 65 years by 2030, an increase from 13% in 2012.¹ The likelihood of needing assistance with activities of daily living (ADLs) increases with age.² People who need such assistance often depend on informal and unpaid assistance from friends and family. In 2009, about 65.7 million Americans (28.5%) provided informal care for people with an illness or disability, and that number only is expected to rise.³ These informal caregivers provide up to 80% of the total care hours needed by community-dwelling older adults—an estimated economic value of $450 billion in unpaid contributions in 2009.^4,5

Caregiving can lead to significant physical, psychological, social, and financial burdens.⁶ The caregiving burden is associated with a host of adverse health behaviors and outcomes such as poor diet, lack of exercise and sleep, smoking, decreased participation in preventive health care, anxiety, depression, relationship difficulties, employment disruption, financial hardship, suicide, and higher mortality compared with that of noncaregivers.^6-10 Additionally, care recipients are at increased risk for abuse or neglect when the caregiver is experiencing a significant burden.¹¹ Therefore, efforts to improve caregiver support are important for both partners in the caregiver/care recipient dyad.

Caregiver support is beneficial to the health of caregivers and care recipients.^10,12 For example, the Resources for Enhancing Alzheimer’s Caregiver Health (REACH) program has been shown to reduce the stress of informal caregiving and the risk of depression in caregivers.^13,14 This program showed similar effects when implemented within the VHA.¹⁴ In the Partners in Dementia Care project, the VHA and Alzheimer’s Association coordinated care and support for veterans with dementia and their family and friends. This intervention resulted in lower caregiver strain and depression scores among participants.¹⁵

With a growing medical literature that shows the benefits of caregiver support interventions, the VHA developed a robust support program for informal caregivers of veterans. The VA caregiver support website (www.caregiver.va.gov) provides information and resources targeted to caregivers for veterans, including psychosocial and functional support for caregivers. The psychosocial support provided by the VA includes caregiver education, counseling, access to caregiver support coordinators, a caregiver support line, support groups, and referral to community support organizations.¹⁶ Functional support on the site includes financial assistance toward skilled home care, home hospice care, adult day care, home-based primary care, homemaker and home health aide services, telehealth, and respite care.¹⁶ Veterans who are caregiving for nonveterans have access to VHA psychosocial support but not to functional support services. For these veterans, functional caregiver support must come from family or referral to community organizations.

Background

In the U.S., about 11% of caregivers are veterans, but the availability of data about these caregivers is limited to veteran subgroups.³ For example, a 2011 study reported that 20% of veterans aged ≥ 60 years are caregivers.¹⁷ However, this estimate included child care for unimpaired children, which is not commonly included in other caregiving estimates. In another study, 30% of middle-aged active-duty officers reported helping their parents with instrumental ADLs (IADLs).¹⁸ These data suggest a significant proportion of veterans may be caregivers; however, the estimates do not identify prevalence of caregiving among a population of VHA enrolled veterans.

Likewise, few studies discuss the burden veterans experience from caregiving. A study of the 2009/2010 CDC Behavioral Risk Factor Surveillance System data found that female caregivers were more likely to report problems with sleep and mental health if they were veterans vs nonveterans.¹⁹ In a second study, caregiving veterans frequently reported physical (39%) and emotional (53%) strain, with emotional strain relating to depressive symptoms. The study of active-duty officers noted that worry was prevalent among military officers caregiving for parents from a distance.¹⁸ In contrast to the negative outcomes of caregiving, Monin and colleagues found that many veterans perceived caregiving as rewarding. Since caregiving may be a positive experience, veterans may benefit and be a potential resource for care to elderly and disabled citizens.¹⁷

Project Rationale and Goals

Social workers are the cornerstone of caregiver support at the George E. Wahlen VA Salt Lake City Health Care System (VASLCHCS) in Utah. They educate veterans and caregivers about VA resources to support caregivers of veterans. For those veterans who are caregiving for a nonveteran, the VASLCHCS social workers provide psychosocial support and help veterans connect to a local area agency on aging (AAA) for access to functional support. In practice, primary care clinic (PCC) providers have observed that directing a veteran to call the AAA does not usually result in a phone call. Therefore, an aim of this quality improvement (QI) project was to determine the most effective means of completing a successful AAA referral.

The VASLCHCS Geriatric Research Education and Clinical Center collaborates with the Utah Aging and Disability Resource Connection (ADRC) to improve awareness of available resources for veterans. Building on this collaborative project, the authors created a formal referral process for veterans needing local AAA services. This QI project had 3 aims: (1) estimate the prevalence of caregiving among veterans in the VASLCHCS primary care clinic; (2) identify perceived caregiving difficulties and resource use difficulty in caregiving tasks; and (3) test different strategies to connect veterans with a referral to community resources through the AAA.

The authors hypothesized that a veteran would be more likely to connect with the AAA if contact was initiated by the AAA rather than the standard practice of asking the veteran to make the call. However, the authors also hypothesized that a veteran who took the time to make the call would be more likely to use AAA resources compared with veterans who were called by the AAA.

Methods

The VASLCHCS Research and Development Office reviewed this project and determined that it met the definition of QI. Therefore, it did not require IRB approval.

The study drew from a convenience sample of veterans who were waiting for appointments in the PCC and who were referred by their health care provider (HCP). To identify caregivers, veterans were asked: “People may provide regular care or assistance to a friend or family member who has a health problem, long-term illness, or disability. During the past month, did you provide any such care or assistance to a friend or family member?” Referrals from HCPs were included in all calculations except the prevalence estimate.

The authors interviewed veterans over a 3-month period in 2015. As of November 2014, the clinic was serving about 11,000 veterans, of which 6,589 lived in Salt Lake County. The clinic also serves veterans who live in other counties in Utah, Nevada, Wyoming, Idaho, and Colorado. 

Intervention and Partnering With Community Resources

All willing caregivers were provided a referral to a local AAA (Figure). Salt Lake County veterans interested in referral to the AAA were randomized to 1 of 2 referral methods: veteran-initiated referral (VIR), in which the veteran was given a handout with the phone number of the Salt Lake County caregiver support program (CSP), or provider-initiated referral (PIR), in which the veteran’s phone number was given to the CSP. Caregiving veterans living outside Salt Lake County were provided the AAA phone number in their area and instructed to call for information.

The interview form was randomized using an even or odd number before the interview. Some veterans who were randomized to a PIR needed to be moved into the VIR intervention arm because of the following reasons: the veteran’s care recipient was aged < 18 years (3); the veteran lived outside of Salt Lake County (20); the veteran did not want his/her name given to an outside agency (5); or the interviewer mistakenly gave the veteran the AAA contact information (4).

The primary author called caregivers in the PIR and VIR groups 2 to 4 weeks after the referral to determine whether they had contacted or were contacted by the AAA. Ten call attempts were made before participants were considered lost to follow-up. Caregivers that had been in contact with the AAA reported in open-ended fashion the resources to which they had been referred and whether those resources had been helpful.

Analysis

In this evaluation, the primary outcome of interest was whether contact between the veteran and AAA occurred. For the VIR group, contact was defined as the veteran having called the AAA, regardless of whether he or she actually spoke to someone. For the PIR group, contact occurred if the veteran reported receiving a phone call from AAA regardless of whether he or she had actually spoken with someone (eg, if the veteran reported that the AAA had left a voice mail, this was considered contact). Veterans also were asked whether connecting with the AAA led to resource referrals and whether these referrals were useful.

To achieve a power of 80% with a 95% confidence interval, 20 people were needed in each intervention group to detect a 40% difference in the rate of contact between the 2 groups. STATA12 (College Station, TX) was used to calculate Fisher exact and chi-square values to evaluate differences between groups.

Results

For the study, 433 PCC veterans were interviewed, and 157 (36%) self-identified as a caregiver. An additional 22 referrals were included for a total of 179 caregivers. Caregiver and care recipient characteristics, caregiver burden, and resource utilization were calculated for all 179 caregivers; however, all caregivers did not answer every question. Ninety-eight percent (176) of caregivers were men; 64% (109/170) were from Salt Lake County, and 5% were from outside Utah (8). Twelve percent (21) of the 179 caregivers were providing care for > 1 person. Of 177 caregivers, 3% (5) were caring for both a veteran and a nonveteran, 69% (122) were caring for a nonveteran only, and 28% (49) were caring for another veteran only (Table 1).

The most common burden reported by caregivers was stress (63%); 70% endorsed family/friends as a resource (Table 2). Just 6% (10) of caregivers used the AAA, whereas 26% (45) received VHA support. Of the 54 veterans who were caring for a veteran, 40 reported using the VHA as a resource. Five people caring for nonveterans reported using the VHA as a resource; however, data about which resources those caregivers were accessing were not collected (Table 3).

AAA Referral and Randomization

Sixty-five percent of caregivers accepted AAA referrals. Of 109 Salt Lake County caregivers, 70% accepted referral to the AAA. There was no statistically significant difference in referral acceptance rates when comparing Salt Lake County residents with nonresidents (P = .09).The authors were unable to obtain the phone number for 1 caregiver who had accepted a referral, and 1 caregiver who accepted referral did not want a follow-up. This left 111 caregivers available for follow-up, 75 in Salt Lake County. Fifty Salt Lake County veterans were randomly assigned to the VIR group and 25 to the PIR group. The 36 caregivers who accepted referrals outside Salt Lake County also were placed in the VIR group, for a total of 86 caregivers.

Follow-up

Ninety-eight percent of caregivers were reached for follow-up. Both people lost to follow-up were in Salt Lake County (1 in each group).

In Salt Lake County, 12% (6) of the VIR group and 64% (16) of the PIR group had connected with the AAA (P < .01). Although 64% of those in the PIR group reported having been called by the AAA, the AAA representative reported all 25 had been called. The AAA records showed 9 of those called were reached by voice mail, 6 were provided information about caregiving resources, 2 formally joined the support program, 5 declined help, 1 was no longer caregiving, 1 was too busy to talk, and 1 was the wrong phone number (and was lost to follow-up as well).

Outside of Salt Lake County 19% (7) reported calling the local AAA. There was no difference in referral completion between the Salt Lake County/non-Salt Lake County VIR groups (P = .4).

Fifteen percent of all VIR caregivers reported calling the AAA. There were no statistical differences between Salt Lake County VIR and non-Salt Lake County VIR for reasons why the veteran had not called the AAA (Table 4).

Of 28 people who connected with the AAA, 16 (57%) said they had received access to a needed resource as a result of the phone call. Seven caregivers (25%) said they had not been referred to other resources as a result of the call. The VIR group was more likely to be referred to other resources after contacting the AAA than was the PIR group, although this difference did not reach significance (69% vs 47%, P = .28).

Discussion

More than one-third (36%) of veterans seen in the VASLCHCS PCC are caregivers. This prevalence is higher than that reported for the general U.S. population and higher than that reported in other veteran groups.^5,17,18 Most caregivers in this project were caring for nonveterans and only had access to VHA psychosocial caregiver support programs because VHA functional caregiver support (eg, respite, homemaker services) is not available to veterans who care for nonveterans. A majority (78%) of caregiving veterans reported some caregiver burden. Despite the burden, most are not using community resources. However when offered, more than half the caregivers were interested in an AAA referral.

Although the VHA does not provide functional caregiver support resources to veterans caring for nonveterans, there are other agencies that can assist veterans: AAAs for care recipients aged ≥ 60 years and the ADRCs for younger veterans. Through AAAs, caregivers can access a variety of support services, including transportation, adult day care, caregiver support, and health promotion programs. Partnership between agencies such as the VHA and the AAAs could benefit caregiving veterans. This QI project suggests ways to strengthen interagency cooperation.

This study also suggests that a provider or clinic-initiated referral is more likely to connect veterans with information and resources than the current practice of recommending that the veteran initiate the referral. Once in contact with the AAA, most caregivers were referred to needed resources. The next step will be to establish an efficient way for clinic staff to identify caregiving veterans and make referrals to community programs. Referrals could be made by any member of the patient aligned care team (PACT) to further standardize and streamline the process.

Thirty-one percent of veterans in this project were eligible for the VHA caregiver support program because they cared for a veteran. However, 25% of these caregiving veterans were not accessing this resource. Increasing awareness of the VHA caregiver support program among veterans caring for other veterans would improve caregiver support to both caregiving and care recipient veterans.

Limitations

One limitation of this project was the intentional exclusion of the women’s clinic from the sampling process. For consistency, the authors wanted to limit the intervention to 1 PCC and so they chose the clinic that serves the majority of the veterans who receive primary care at VASLCHCS. Additionally, the literature showed that male caregivers compared with women caregivers^20,21 have different characteristics in regards to caregiver burden, and a well-designed study of women caregivers already has been published.¹⁹

Also, this study did not obtain data on age, health problems, or socioeconomic status of the caregivers to avoid identifying information. Last, the authors did not ask about time spent caregiving or type of care provided. These questions may be important for future studies. Future investigations should evaluate health care use and health of caregivers vs noncaregivers in the veteran population. It also could be important to determine methods for building bridges between the VHA, AAAs, and other community services.

Conclusion

To minimize the disruption that a research study might have caused to normal clinical workflow, the primary author played the role that a medical social worker or other PACT member might play in the future. This project sheds light on how to improve outcomes for community referrals and an important future step in this research would be to develop and test a process that would integrate the PACT into the referral process.

More than one-third of veterans seen in the VASLCHCS PCC are caregivers. To the authors’ knowledge, this is the first estimate of prevalence of caregiving in veterans who receive primary care from the VHA. About 63% of caregiving veterans perceived some burden due to caregiving, and 66% accepted referral to community resources. However, only 12% who were asked to self-refer made contact with the AAA compared with 64% when a provider made the referral for them. Provider referral is more effective in connecting caregiving veterans with resources. Development of interagency partnerships should be fostered to help veterans decrease caregiving burden.

This project is one of the few studies looking at this special group of caregivers: veterans who serve as caregivers. It highlights the need for the VHA to establish policies and partnerships to improve caregiver support to this valuable group of veterans.

More than 20% of the U.S. population will be aged ≥ 65 years by 2030, an increase from 13% in 2012.¹ The likelihood of needing assistance with activities of daily living (ADLs) increases with age.² People who need such assistance often depend on informal and unpaid assistance from friends and family. In 2009, about 65.7 million Americans (28.5%) provided informal care for people with an illness or disability, and that number only is expected to rise.³ These informal caregivers provide up to 80% of the total care hours needed by community-dwelling older adults—an estimated economic value of $450 billion in unpaid contributions in 2009.^4,5

Caregiving can lead to significant physical, psychological, social, and financial burdens.⁶ The caregiving burden is associated with a host of adverse health behaviors and outcomes such as poor diet, lack of exercise and sleep, smoking, decreased participation in preventive health care, anxiety, depression, relationship difficulties, employment disruption, financial hardship, suicide, and higher mortality compared with that of noncaregivers.^6-10 Additionally, care recipients are at increased risk for abuse or neglect when the caregiver is experiencing a significant burden.¹¹ Therefore, efforts to improve caregiver support are important for both partners in the caregiver/care recipient dyad.

Caregiver support is beneficial to the health of caregivers and care recipients.^10,12 For example, the Resources for Enhancing Alzheimer’s Caregiver Health (REACH) program has been shown to reduce the stress of informal caregiving and the risk of depression in caregivers.^13,14 This program showed similar effects when implemented within the VHA.¹⁴ In the Partners in Dementia Care project, the VHA and Alzheimer’s Association coordinated care and support for veterans with dementia and their family and friends. This intervention resulted in lower caregiver strain and depression scores among participants.¹⁵

With a growing medical literature that shows the benefits of caregiver support interventions, the VHA developed a robust support program for informal caregivers of veterans. The VA caregiver support website (www.caregiver.va.gov) provides information and resources targeted to caregivers for veterans, including psychosocial and functional support for caregivers. The psychosocial support provided by the VA includes caregiver education, counseling, access to caregiver support coordinators, a caregiver support line, support groups, and referral to community support organizations.¹⁶ Functional support on the site includes financial assistance toward skilled home care, home hospice care, adult day care, home-based primary care, homemaker and home health aide services, telehealth, and respite care.¹⁶ Veterans who are caregiving for nonveterans have access to VHA psychosocial support but not to functional support services. For these veterans, functional caregiver support must come from family or referral to community organizations.

Background

In the U.S., about 11% of caregivers are veterans, but the availability of data about these caregivers is limited to veteran subgroups.³ For example, a 2011 study reported that 20% of veterans aged ≥ 60 years are caregivers.¹⁷ However, this estimate included child care for unimpaired children, which is not commonly included in other caregiving estimates. In another study, 30% of middle-aged active-duty officers reported helping their parents with instrumental ADLs (IADLs).¹⁸ These data suggest a significant proportion of veterans may be caregivers; however, the estimates do not identify prevalence of caregiving among a population of VHA enrolled veterans.

Likewise, few studies discuss the burden veterans experience from caregiving. A study of the 2009/2010 CDC Behavioral Risk Factor Surveillance System data found that female caregivers were more likely to report problems with sleep and mental health if they were veterans vs nonveterans.¹⁹ In a second study, caregiving veterans frequently reported physical (39%) and emotional (53%) strain, with emotional strain relating to depressive symptoms. The study of active-duty officers noted that worry was prevalent among military officers caregiving for parents from a distance.¹⁸ In contrast to the negative outcomes of caregiving, Monin and colleagues found that many veterans perceived caregiving as rewarding. Since caregiving may be a positive experience, veterans may benefit and be a potential resource for care to elderly and disabled citizens.¹⁷

Project Rationale and Goals

Social workers are the cornerstone of caregiver support at the George E. Wahlen VA Salt Lake City Health Care System (VASLCHCS) in Utah. They educate veterans and caregivers about VA resources to support caregivers of veterans. For those veterans who are caregiving for a nonveteran, the VASLCHCS social workers provide psychosocial support and help veterans connect to a local area agency on aging (AAA) for access to functional support. In practice, primary care clinic (PCC) providers have observed that directing a veteran to call the AAA does not usually result in a phone call. Therefore, an aim of this quality improvement (QI) project was to determine the most effective means of completing a successful AAA referral.

The VASLCHCS Geriatric Research Education and Clinical Center collaborates with the Utah Aging and Disability Resource Connection (ADRC) to improve awareness of available resources for veterans. Building on this collaborative project, the authors created a formal referral process for veterans needing local AAA services. This QI project had 3 aims: (1) estimate the prevalence of caregiving among veterans in the VASLCHCS primary care clinic; (2) identify perceived caregiving difficulties and resource use difficulty in caregiving tasks; and (3) test different strategies to connect veterans with a referral to community resources through the AAA.

The authors hypothesized that a veteran would be more likely to connect with the AAA if contact was initiated by the AAA rather than the standard practice of asking the veteran to make the call. However, the authors also hypothesized that a veteran who took the time to make the call would be more likely to use AAA resources compared with veterans who were called by the AAA.

Methods

The VASLCHCS Research and Development Office reviewed this project and determined that it met the definition of QI. Therefore, it did not require IRB approval.

The study drew from a convenience sample of veterans who were waiting for appointments in the PCC and who were referred by their health care provider (HCP). To identify caregivers, veterans were asked: “People may provide regular care or assistance to a friend or family member who has a health problem, long-term illness, or disability. During the past month, did you provide any such care or assistance to a friend or family member?” Referrals from HCPs were included in all calculations except the prevalence estimate.

The authors interviewed veterans over a 3-month period in 2015. As of November 2014, the clinic was serving about 11,000 veterans, of which 6,589 lived in Salt Lake County. The clinic also serves veterans who live in other counties in Utah, Nevada, Wyoming, Idaho, and Colorado. 

Intervention and Partnering With Community Resources

All willing caregivers were provided a referral to a local AAA (Figure). Salt Lake County veterans interested in referral to the AAA were randomized to 1 of 2 referral methods: veteran-initiated referral (VIR), in which the veteran was given a handout with the phone number of the Salt Lake County caregiver support program (CSP), or provider-initiated referral (PIR), in which the veteran’s phone number was given to the CSP. Caregiving veterans living outside Salt Lake County were provided the AAA phone number in their area and instructed to call for information.

The interview form was randomized using an even or odd number before the interview. Some veterans who were randomized to a PIR needed to be moved into the VIR intervention arm because of the following reasons: the veteran’s care recipient was aged < 18 years (3); the veteran lived outside of Salt Lake County (20); the veteran did not want his/her name given to an outside agency (5); or the interviewer mistakenly gave the veteran the AAA contact information (4).

The primary author called caregivers in the PIR and VIR groups 2 to 4 weeks after the referral to determine whether they had contacted or were contacted by the AAA. Ten call attempts were made before participants were considered lost to follow-up. Caregivers that had been in contact with the AAA reported in open-ended fashion the resources to which they had been referred and whether those resources had been helpful.

Analysis

In this evaluation, the primary outcome of interest was whether contact between the veteran and AAA occurred. For the VIR group, contact was defined as the veteran having called the AAA, regardless of whether he or she actually spoke to someone. For the PIR group, contact occurred if the veteran reported receiving a phone call from AAA regardless of whether he or she had actually spoken with someone (eg, if the veteran reported that the AAA had left a voice mail, this was considered contact). Veterans also were asked whether connecting with the AAA led to resource referrals and whether these referrals were useful.

To achieve a power of 80% with a 95% confidence interval, 20 people were needed in each intervention group to detect a 40% difference in the rate of contact between the 2 groups. STATA12 (College Station, TX) was used to calculate Fisher exact and chi-square values to evaluate differences between groups.

Results

For the study, 433 PCC veterans were interviewed, and 157 (36%) self-identified as a caregiver. An additional 22 referrals were included for a total of 179 caregivers. Caregiver and care recipient characteristics, caregiver burden, and resource utilization were calculated for all 179 caregivers; however, all caregivers did not answer every question. Ninety-eight percent (176) of caregivers were men; 64% (109/170) were from Salt Lake County, and 5% were from outside Utah (8). Twelve percent (21) of the 179 caregivers were providing care for > 1 person. Of 177 caregivers, 3% (5) were caring for both a veteran and a nonveteran, 69% (122) were caring for a nonveteran only, and 28% (49) were caring for another veteran only (Table 1).

The most common burden reported by caregivers was stress (63%); 70% endorsed family/friends as a resource (Table 2). Just 6% (10) of caregivers used the AAA, whereas 26% (45) received VHA support. Of the 54 veterans who were caring for a veteran, 40 reported using the VHA as a resource. Five people caring for nonveterans reported using the VHA as a resource; however, data about which resources those caregivers were accessing were not collected (Table 3).

AAA Referral and Randomization

Sixty-five percent of caregivers accepted AAA referrals. Of 109 Salt Lake County caregivers, 70% accepted referral to the AAA. There was no statistically significant difference in referral acceptance rates when comparing Salt Lake County residents with nonresidents (P = .09).The authors were unable to obtain the phone number for 1 caregiver who had accepted a referral, and 1 caregiver who accepted referral did not want a follow-up. This left 111 caregivers available for follow-up, 75 in Salt Lake County. Fifty Salt Lake County veterans were randomly assigned to the VIR group and 25 to the PIR group. The 36 caregivers who accepted referrals outside Salt Lake County also were placed in the VIR group, for a total of 86 caregivers.

Follow-up

Ninety-eight percent of caregivers were reached for follow-up. Both people lost to follow-up were in Salt Lake County (1 in each group).

In Salt Lake County, 12% (6) of the VIR group and 64% (16) of the PIR group had connected with the AAA (P < .01). Although 64% of those in the PIR group reported having been called by the AAA, the AAA representative reported all 25 had been called. The AAA records showed 9 of those called were reached by voice mail, 6 were provided information about caregiving resources, 2 formally joined the support program, 5 declined help, 1 was no longer caregiving, 1 was too busy to talk, and 1 was the wrong phone number (and was lost to follow-up as well).

Outside of Salt Lake County 19% (7) reported calling the local AAA. There was no difference in referral completion between the Salt Lake County/non-Salt Lake County VIR groups (P = .4).

Fifteen percent of all VIR caregivers reported calling the AAA. There were no statistical differences between Salt Lake County VIR and non-Salt Lake County VIR for reasons why the veteran had not called the AAA (Table 4).

Of 28 people who connected with the AAA, 16 (57%) said they had received access to a needed resource as a result of the phone call. Seven caregivers (25%) said they had not been referred to other resources as a result of the call. The VIR group was more likely to be referred to other resources after contacting the AAA than was the PIR group, although this difference did not reach significance (69% vs 47%, P = .28).

Discussion

More than one-third (36%) of veterans seen in the VASLCHCS PCC are caregivers. This prevalence is higher than that reported for the general U.S. population and higher than that reported in other veteran groups.^5,17,18 Most caregivers in this project were caring for nonveterans and only had access to VHA psychosocial caregiver support programs because VHA functional caregiver support (eg, respite, homemaker services) is not available to veterans who care for nonveterans. A majority (78%) of caregiving veterans reported some caregiver burden. Despite the burden, most are not using community resources. However when offered, more than half the caregivers were interested in an AAA referral.

Although the VHA does not provide functional caregiver support resources to veterans caring for nonveterans, there are other agencies that can assist veterans: AAAs for care recipients aged ≥ 60 years and the ADRCs for younger veterans. Through AAAs, caregivers can access a variety of support services, including transportation, adult day care, caregiver support, and health promotion programs. Partnership between agencies such as the VHA and the AAAs could benefit caregiving veterans. This QI project suggests ways to strengthen interagency cooperation.

This study also suggests that a provider or clinic-initiated referral is more likely to connect veterans with information and resources than the current practice of recommending that the veteran initiate the referral. Once in contact with the AAA, most caregivers were referred to needed resources. The next step will be to establish an efficient way for clinic staff to identify caregiving veterans and make referrals to community programs. Referrals could be made by any member of the patient aligned care team (PACT) to further standardize and streamline the process.

Thirty-one percent of veterans in this project were eligible for the VHA caregiver support program because they cared for a veteran. However, 25% of these caregiving veterans were not accessing this resource. Increasing awareness of the VHA caregiver support program among veterans caring for other veterans would improve caregiver support to both caregiving and care recipient veterans.

Limitations

One limitation of this project was the intentional exclusion of the women’s clinic from the sampling process. For consistency, the authors wanted to limit the intervention to 1 PCC and so they chose the clinic that serves the majority of the veterans who receive primary care at VASLCHCS. Additionally, the literature showed that male caregivers compared with women caregivers^20,21 have different characteristics in regards to caregiver burden, and a well-designed study of women caregivers already has been published.¹⁹

Also, this study did not obtain data on age, health problems, or socioeconomic status of the caregivers to avoid identifying information. Last, the authors did not ask about time spent caregiving or type of care provided. These questions may be important for future studies. Future investigations should evaluate health care use and health of caregivers vs noncaregivers in the veteran population. It also could be important to determine methods for building bridges between the VHA, AAAs, and other community services.

Conclusion

To minimize the disruption that a research study might have caused to normal clinical workflow, the primary author played the role that a medical social worker or other PACT member might play in the future. This project sheds light on how to improve outcomes for community referrals and an important future step in this research would be to develop and test a process that would integrate the PACT into the referral process.

More than one-third of veterans seen in the VASLCHCS PCC are caregivers. To the authors’ knowledge, this is the first estimate of prevalence of caregiving in veterans who receive primary care from the VHA. About 63% of caregiving veterans perceived some burden due to caregiving, and 66% accepted referral to community resources. However, only 12% who were asked to self-refer made contact with the AAA compared with 64% when a provider made the referral for them. Provider referral is more effective in connecting caregiving veterans with resources. Development of interagency partnerships should be fostered to help veterans decrease caregiving burden.

This project is one of the few studies looking at this special group of caregivers: veterans who serve as caregivers. It highlights the need for the VHA to establish policies and partnerships to improve caregiver support to this valuable group of veterans.

More than 20% of the U.S. population will be aged ≥ 65 years by 2030, an increase from 13% in 2012.¹ The likelihood of needing assistance with activities of daily living (ADLs) increases with age.² People who need such assistance often depend on informal and unpaid assistance from friends and family. In 2009, about 65.7 million Americans (28.5%) provided informal care for people with an illness or disability, and that number only is expected to rise.³ These informal caregivers provide up to 80% of the total care hours needed by community-dwelling older adults—an estimated economic value of $450 billion in unpaid contributions in 2009.^4,5

Caregiving can lead to significant physical, psychological, social, and financial burdens.⁶ The caregiving burden is associated with a host of adverse health behaviors and outcomes such as poor diet, lack of exercise and sleep, smoking, decreased participation in preventive health care, anxiety, depression, relationship difficulties, employment disruption, financial hardship, suicide, and higher mortality compared with that of noncaregivers.^6-10 Additionally, care recipients are at increased risk for abuse or neglect when the caregiver is experiencing a significant burden.¹¹ Therefore, efforts to improve caregiver support are important for both partners in the caregiver/care recipient dyad.

Caregiver support is beneficial to the health of caregivers and care recipients.^10,12 For example, the Resources for Enhancing Alzheimer’s Caregiver Health (REACH) program has been shown to reduce the stress of informal caregiving and the risk of depression in caregivers.^13,14 This program showed similar effects when implemented within the VHA.¹⁴ In the Partners in Dementia Care project, the VHA and Alzheimer’s Association coordinated care and support for veterans with dementia and their family and friends. This intervention resulted in lower caregiver strain and depression scores among participants.¹⁵

With a growing medical literature that shows the benefits of caregiver support interventions, the VHA developed a robust support program for informal caregivers of veterans. The VA caregiver support website (www.caregiver.va.gov) provides information and resources targeted to caregivers for veterans, including psychosocial and functional support for caregivers. The psychosocial support provided by the VA includes caregiver education, counseling, access to caregiver support coordinators, a caregiver support line, support groups, and referral to community support organizations.¹⁶ Functional support on the site includes financial assistance toward skilled home care, home hospice care, adult day care, home-based primary care, homemaker and home health aide services, telehealth, and respite care.¹⁶ Veterans who are caregiving for nonveterans have access to VHA psychosocial support but not to functional support services. For these veterans, functional caregiver support must come from family or referral to community organizations.

Background

In the U.S., about 11% of caregivers are veterans, but the availability of data about these caregivers is limited to veteran subgroups.³ For example, a 2011 study reported that 20% of veterans aged ≥ 60 years are caregivers.¹⁷ However, this estimate included child care for unimpaired children, which is not commonly included in other caregiving estimates. In another study, 30% of middle-aged active-duty officers reported helping their parents with instrumental ADLs (IADLs).¹⁸ These data suggest a significant proportion of veterans may be caregivers; however, the estimates do not identify prevalence of caregiving among a population of VHA enrolled veterans.

Likewise, few studies discuss the burden veterans experience from caregiving. A study of the 2009/2010 CDC Behavioral Risk Factor Surveillance System data found that female caregivers were more likely to report problems with sleep and mental health if they were veterans vs nonveterans.¹⁹ In a second study, caregiving veterans frequently reported physical (39%) and emotional (53%) strain, with emotional strain relating to depressive symptoms. The study of active-duty officers noted that worry was prevalent among military officers caregiving for parents from a distance.¹⁸ In contrast to the negative outcomes of caregiving, Monin and colleagues found that many veterans perceived caregiving as rewarding. Since caregiving may be a positive experience, veterans may benefit and be a potential resource for care to elderly and disabled citizens.¹⁷

Project Rationale and Goals

Social workers are the cornerstone of caregiver support at the George E. Wahlen VA Salt Lake City Health Care System (VASLCHCS) in Utah. They educate veterans and caregivers about VA resources to support caregivers of veterans. For those veterans who are caregiving for a nonveteran, the VASLCHCS social workers provide psychosocial support and help veterans connect to a local area agency on aging (AAA) for access to functional support. In practice, primary care clinic (PCC) providers have observed that directing a veteran to call the AAA does not usually result in a phone call. Therefore, an aim of this quality improvement (QI) project was to determine the most effective means of completing a successful AAA referral.

The VASLCHCS Geriatric Research Education and Clinical Center collaborates with the Utah Aging and Disability Resource Connection (ADRC) to improve awareness of available resources for veterans. Building on this collaborative project, the authors created a formal referral process for veterans needing local AAA services. This QI project had 3 aims: (1) estimate the prevalence of caregiving among veterans in the VASLCHCS primary care clinic; (2) identify perceived caregiving difficulties and resource use difficulty in caregiving tasks; and (3) test different strategies to connect veterans with a referral to community resources through the AAA.

The authors hypothesized that a veteran would be more likely to connect with the AAA if contact was initiated by the AAA rather than the standard practice of asking the veteran to make the call. However, the authors also hypothesized that a veteran who took the time to make the call would be more likely to use AAA resources compared with veterans who were called by the AAA.

Methods

The VASLCHCS Research and Development Office reviewed this project and determined that it met the definition of QI. Therefore, it did not require IRB approval.

The study drew from a convenience sample of veterans who were waiting for appointments in the PCC and who were referred by their health care provider (HCP). To identify caregivers, veterans were asked: “People may provide regular care or assistance to a friend or family member who has a health problem, long-term illness, or disability. During the past month, did you provide any such care or assistance to a friend or family member?” Referrals from HCPs were included in all calculations except the prevalence estimate.

The authors interviewed veterans over a 3-month period in 2015. As of November 2014, the clinic was serving about 11,000 veterans, of which 6,589 lived in Salt Lake County. The clinic also serves veterans who live in other counties in Utah, Nevada, Wyoming, Idaho, and Colorado. 

Intervention and Partnering With Community Resources

All willing caregivers were provided a referral to a local AAA (Figure). Salt Lake County veterans interested in referral to the AAA were randomized to 1 of 2 referral methods: veteran-initiated referral (VIR), in which the veteran was given a handout with the phone number of the Salt Lake County caregiver support program (CSP), or provider-initiated referral (PIR), in which the veteran’s phone number was given to the CSP. Caregiving veterans living outside Salt Lake County were provided the AAA phone number in their area and instructed to call for information.

The interview form was randomized using an even or odd number before the interview. Some veterans who were randomized to a PIR needed to be moved into the VIR intervention arm because of the following reasons: the veteran’s care recipient was aged < 18 years (3); the veteran lived outside of Salt Lake County (20); the veteran did not want his/her name given to an outside agency (5); or the interviewer mistakenly gave the veteran the AAA contact information (4).

The primary author called caregivers in the PIR and VIR groups 2 to 4 weeks after the referral to determine whether they had contacted or were contacted by the AAA. Ten call attempts were made before participants were considered lost to follow-up. Caregivers that had been in contact with the AAA reported in open-ended fashion the resources to which they had been referred and whether those resources had been helpful.

Analysis

In this evaluation, the primary outcome of interest was whether contact between the veteran and AAA occurred. For the VIR group, contact was defined as the veteran having called the AAA, regardless of whether he or she actually spoke to someone. For the PIR group, contact occurred if the veteran reported receiving a phone call from AAA regardless of whether he or she had actually spoken with someone (eg, if the veteran reported that the AAA had left a voice mail, this was considered contact). Veterans also were asked whether connecting with the AAA led to resource referrals and whether these referrals were useful.

To achieve a power of 80% with a 95% confidence interval, 20 people were needed in each intervention group to detect a 40% difference in the rate of contact between the 2 groups. STATA12 (College Station, TX) was used to calculate Fisher exact and chi-square values to evaluate differences between groups.

Results

For the study, 433 PCC veterans were interviewed, and 157 (36%) self-identified as a caregiver. An additional 22 referrals were included for a total of 179 caregivers. Caregiver and care recipient characteristics, caregiver burden, and resource utilization were calculated for all 179 caregivers; however, all caregivers did not answer every question. Ninety-eight percent (176) of caregivers were men; 64% (109/170) were from Salt Lake County, and 5% were from outside Utah (8). Twelve percent (21) of the 179 caregivers were providing care for > 1 person. Of 177 caregivers, 3% (5) were caring for both a veteran and a nonveteran, 69% (122) were caring for a nonveteran only, and 28% (49) were caring for another veteran only (Table 1).

The most common burden reported by caregivers was stress (63%); 70% endorsed family/friends as a resource (Table 2). Just 6% (10) of caregivers used the AAA, whereas 26% (45) received VHA support. Of the 54 veterans who were caring for a veteran, 40 reported using the VHA as a resource. Five people caring for nonveterans reported using the VHA as a resource; however, data about which resources those caregivers were accessing were not collected (Table 3).

AAA Referral and Randomization

Sixty-five percent of caregivers accepted AAA referrals. Of 109 Salt Lake County caregivers, 70% accepted referral to the AAA. There was no statistically significant difference in referral acceptance rates when comparing Salt Lake County residents with nonresidents (P = .09).The authors were unable to obtain the phone number for 1 caregiver who had accepted a referral, and 1 caregiver who accepted referral did not want a follow-up. This left 111 caregivers available for follow-up, 75 in Salt Lake County. Fifty Salt Lake County veterans were randomly assigned to the VIR group and 25 to the PIR group. The 36 caregivers who accepted referrals outside Salt Lake County also were placed in the VIR group, for a total of 86 caregivers.

Follow-up

Ninety-eight percent of caregivers were reached for follow-up. Both people lost to follow-up were in Salt Lake County (1 in each group).

In Salt Lake County, 12% (6) of the VIR group and 64% (16) of the PIR group had connected with the AAA (P < .01). Although 64% of those in the PIR group reported having been called by the AAA, the AAA representative reported all 25 had been called. The AAA records showed 9 of those called were reached by voice mail, 6 were provided information about caregiving resources, 2 formally joined the support program, 5 declined help, 1 was no longer caregiving, 1 was too busy to talk, and 1 was the wrong phone number (and was lost to follow-up as well).

Outside of Salt Lake County 19% (7) reported calling the local AAA. There was no difference in referral completion between the Salt Lake County/non-Salt Lake County VIR groups (P = .4).

Fifteen percent of all VIR caregivers reported calling the AAA. There were no statistical differences between Salt Lake County VIR and non-Salt Lake County VIR for reasons why the veteran had not called the AAA (Table 4).

Of 28 people who connected with the AAA, 16 (57%) said they had received access to a needed resource as a result of the phone call. Seven caregivers (25%) said they had not been referred to other resources as a result of the call. The VIR group was more likely to be referred to other resources after contacting the AAA than was the PIR group, although this difference did not reach significance (69% vs 47%, P = .28).

Discussion

More than one-third (36%) of veterans seen in the VASLCHCS PCC are caregivers. This prevalence is higher than that reported for the general U.S. population and higher than that reported in other veteran groups.^5,17,18 Most caregivers in this project were caring for nonveterans and only had access to VHA psychosocial caregiver support programs because VHA functional caregiver support (eg, respite, homemaker services) is not available to veterans who care for nonveterans. A majority (78%) of caregiving veterans reported some caregiver burden. Despite the burden, most are not using community resources. However when offered, more than half the caregivers were interested in an AAA referral.

Although the VHA does not provide functional caregiver support resources to veterans caring for nonveterans, there are other agencies that can assist veterans: AAAs for care recipients aged ≥ 60 years and the ADRCs for younger veterans. Through AAAs, caregivers can access a variety of support services, including transportation, adult day care, caregiver support, and health promotion programs. Partnership between agencies such as the VHA and the AAAs could benefit caregiving veterans. This QI project suggests ways to strengthen interagency cooperation.

This study also suggests that a provider or clinic-initiated referral is more likely to connect veterans with information and resources than the current practice of recommending that the veteran initiate the referral. Once in contact with the AAA, most caregivers were referred to needed resources. The next step will be to establish an efficient way for clinic staff to identify caregiving veterans and make referrals to community programs. Referrals could be made by any member of the patient aligned care team (PACT) to further standardize and streamline the process.

Thirty-one percent of veterans in this project were eligible for the VHA caregiver support program because they cared for a veteran. However, 25% of these caregiving veterans were not accessing this resource. Increasing awareness of the VHA caregiver support program among veterans caring for other veterans would improve caregiver support to both caregiving and care recipient veterans.

Limitations

One limitation of this project was the intentional exclusion of the women’s clinic from the sampling process. For consistency, the authors wanted to limit the intervention to 1 PCC and so they chose the clinic that serves the majority of the veterans who receive primary care at VASLCHCS. Additionally, the literature showed that male caregivers compared with women caregivers^20,21 have different characteristics in regards to caregiver burden, and a well-designed study of women caregivers already has been published.¹⁹

Also, this study did not obtain data on age, health problems, or socioeconomic status of the caregivers to avoid identifying information. Last, the authors did not ask about time spent caregiving or type of care provided. These questions may be important for future studies. Future investigations should evaluate health care use and health of caregivers vs noncaregivers in the veteran population. It also could be important to determine methods for building bridges between the VHA, AAAs, and other community services.

Conclusion

To minimize the disruption that a research study might have caused to normal clinical workflow, the primary author played the role that a medical social worker or other PACT member might play in the future. This project sheds light on how to improve outcomes for community referrals and an important future step in this research would be to develop and test a process that would integrate the PACT into the referral process.

More than one-third of veterans seen in the VASLCHCS PCC are caregivers. To the authors’ knowledge, this is the first estimate of prevalence of caregiving in veterans who receive primary care from the VHA. About 63% of caregiving veterans perceived some burden due to caregiving, and 66% accepted referral to community resources. However, only 12% who were asked to self-refer made contact with the AAA compared with 64% when a provider made the referral for them. Provider referral is more effective in connecting caregiving veterans with resources. Development of interagency partnerships should be fostered to help veterans decrease caregiving burden.

This project is one of the few studies looking at this special group of caregivers: veterans who serve as caregivers. It highlights the need for the VHA to establish policies and partnerships to improve caregiver support to this valuable group of veterans.

Image by Ian Johnston

Experiments in zebrafish embryos have suggested that trunk neural crest cells play a key role in the specification of hematopoietic stem cells (HSCs).

Researchers believe this finding could be used to aid the creation of HSCs in the lab and ultimately help improve access to HSC transplant.

“The research will likely open new avenues of investigation in stem cell biology and blood development and provide insight to aid efforts to make transplantable hematopoietic stem cells in the lab,” said Wilson Clements, PhD, of St. Jude Children’s Research Hospital in Memphis, Tennessee.

Dr Clements and Erich W. Damm, PhD, also of St. Jude, described this research in Nature Cell Biology.

The researchers noted that scientists have yet to achieve in vitro specification of normal HSCs with a high level of engraftment and normal multilineage potential. And this suggests key specification signals remain unknown.

The pair pointed out that, in all vertebrates, HSCs arise from hemogenic endothelium in the ventral floor of the dorsal aorta. And stromal cells residing in stem cell microenvironments often act as a niche to contribute cues that regulate behavior.

“Researchers have speculated that the endothelial cells that give rise to blood-forming stem cells are surrounded by a support niche of other cells whose identity and origins were unknown,” Dr Damm said. “Our results support the existence of a niche and identify trunk neural crest cells as an occupant.”

Trunk neural crest cells are made in the developing spinal cord and migrate throughout the embryo. The cells eventually give rise to a variety of adult cells, including neurons and glial cells in the sympathetic and parasympathetic nervous system.

Using time-lapse video, Drs Clements and Damm tracked the migration of neural crest cells in the transparent embryos of zebrafish. (Zebrafish and humans share nearly identical blood systems.)

After about 20 hours, the neural crest cells had reached the developing aorta. After hour 24, the migrating cells had cozied up to the endothelial cells in the aorta, which then turned on genes, such as runx1, indicating their conversion to HSCs.

Additional experiments revealed that migration of neural crest cells to the dorsal aorta is dependent on platelet-derived growth factor signaling, and this signaling is required for HSC specification.

Likewise, the physical association of neural crest cells with the pre-hematopoietic dorsal aorta is required for initiation of the hematopoietic program and HSC specification.

Drs Clements and Damm said these results suggest neural crest cells are key cellular components of the HSC specification niche that can be profiled to identify unknown HSC specification signals.

Image by Ian Johnston

Experiments in zebrafish embryos have suggested that trunk neural crest cells play a key role in the specification of hematopoietic stem cells (HSCs).

Researchers believe this finding could be used to aid the creation of HSCs in the lab and ultimately help improve access to HSC transplant.

“The research will likely open new avenues of investigation in stem cell biology and blood development and provide insight to aid efforts to make transplantable hematopoietic stem cells in the lab,” said Wilson Clements, PhD, of St. Jude Children’s Research Hospital in Memphis, Tennessee.

Dr Clements and Erich W. Damm, PhD, also of St. Jude, described this research in Nature Cell Biology.

The researchers noted that scientists have yet to achieve in vitro specification of normal HSCs with a high level of engraftment and normal multilineage potential. And this suggests key specification signals remain unknown.

The pair pointed out that, in all vertebrates, HSCs arise from hemogenic endothelium in the ventral floor of the dorsal aorta. And stromal cells residing in stem cell microenvironments often act as a niche to contribute cues that regulate behavior.

“Researchers have speculated that the endothelial cells that give rise to blood-forming stem cells are surrounded by a support niche of other cells whose identity and origins were unknown,” Dr Damm said. “Our results support the existence of a niche and identify trunk neural crest cells as an occupant.”

Trunk neural crest cells are made in the developing spinal cord and migrate throughout the embryo. The cells eventually give rise to a variety of adult cells, including neurons and glial cells in the sympathetic and parasympathetic nervous system.

Using time-lapse video, Drs Clements and Damm tracked the migration of neural crest cells in the transparent embryos of zebrafish. (Zebrafish and humans share nearly identical blood systems.)

After about 20 hours, the neural crest cells had reached the developing aorta. After hour 24, the migrating cells had cozied up to the endothelial cells in the aorta, which then turned on genes, such as runx1, indicating their conversion to HSCs.

Additional experiments revealed that migration of neural crest cells to the dorsal aorta is dependent on platelet-derived growth factor signaling, and this signaling is required for HSC specification.

Likewise, the physical association of neural crest cells with the pre-hematopoietic dorsal aorta is required for initiation of the hematopoietic program and HSC specification.

Drs Clements and Damm said these results suggest neural crest cells are key cellular components of the HSC specification niche that can be profiled to identify unknown HSC specification signals.

Image by Ian Johnston

Experiments in zebrafish embryos have suggested that trunk neural crest cells play a key role in the specification of hematopoietic stem cells (HSCs).

Researchers believe this finding could be used to aid the creation of HSCs in the lab and ultimately help improve access to HSC transplant.

“The research will likely open new avenues of investigation in stem cell biology and blood development and provide insight to aid efforts to make transplantable hematopoietic stem cells in the lab,” said Wilson Clements, PhD, of St. Jude Children’s Research Hospital in Memphis, Tennessee.

Dr Clements and Erich W. Damm, PhD, also of St. Jude, described this research in Nature Cell Biology.

The researchers noted that scientists have yet to achieve in vitro specification of normal HSCs with a high level of engraftment and normal multilineage potential. And this suggests key specification signals remain unknown.

The pair pointed out that, in all vertebrates, HSCs arise from hemogenic endothelium in the ventral floor of the dorsal aorta. And stromal cells residing in stem cell microenvironments often act as a niche to contribute cues that regulate behavior.

“Researchers have speculated that the endothelial cells that give rise to blood-forming stem cells are surrounded by a support niche of other cells whose identity and origins were unknown,” Dr Damm said. “Our results support the existence of a niche and identify trunk neural crest cells as an occupant.”

Trunk neural crest cells are made in the developing spinal cord and migrate throughout the embryo. The cells eventually give rise to a variety of adult cells, including neurons and glial cells in the sympathetic and parasympathetic nervous system.

Using time-lapse video, Drs Clements and Damm tracked the migration of neural crest cells in the transparent embryos of zebrafish. (Zebrafish and humans share nearly identical blood systems.)

After about 20 hours, the neural crest cells had reached the developing aorta. After hour 24, the migrating cells had cozied up to the endothelial cells in the aorta, which then turned on genes, such as runx1, indicating their conversion to HSCs.

Additional experiments revealed that migration of neural crest cells to the dorsal aorta is dependent on platelet-derived growth factor signaling, and this signaling is required for HSC specification.

Likewise, the physical association of neural crest cells with the pre-hematopoietic dorsal aorta is required for initiation of the hematopoietic program and HSC specification.

Drs Clements and Damm said these results suggest neural crest cells are key cellular components of the HSC specification niche that can be profiled to identify unknown HSC specification signals.

Photo by Rhoda Baer

WASHINGTON, DC—New research suggests HIV-positive adults in the US will see a shift in cancer risk and burden in the coming years.

The study indicates that, through 2030, people living with HIV will see a decrease in AIDS-defining cancers, such as non-Hodgkin lymphoma (NHL) and Kaposi sarcoma.

But this group will also see an increase in cancers not linked to AIDS, such as prostate and liver cancers.

Researchers made these projections in a presentation at the AACR Annual Meeting 2017 (abstract 5302).

“Declines in cancer incidence rates, particularly for AIDS-defining cancers, are likely driven by widespread treatment with modern antiretroviral therapies, which reduce immune suppression and decrease risk of some cancers,” said Jessica Y. Islam, a doctoral student at the University of North Carolina Gillings School of Global Public Health in Chapel Hill.

She and her collaborators estimated future cancer risk and burden for HIV-positive people using age-specific cancer incidence data from the National Cancer Institute HIV/AIDS Cancer Match (HACM) Study, and projected HIV prevalence data from the Centers for Disease Control and Prevention.

Cancer incidence

From 2000 to 2012, there were 23,907 cancers reported in 463,300 HIV-infected adults in the HACM Study. Based on trends in this study, the researchers made projections for cancer incidence through 2030.

They projected that HIV-positive adults of all ages will see a significant decrease over time in the incidence of NHL, Kaposi sarcoma, cervical cancer, anal cancer among men who have sex with men (MSM), lung cancer, and Hodgkin lymphoma.

Patients age 65 and older will see a significant decrease in colon cancer incidence over time. However, there will be no significant change for patients younger than 65.

HIV-positive adults of all ages will see no significant change over time in the incidence of liver cancer, oral cavity cancer, anal cancer among non-MSMs, and breast cancer.

The incidence of prostate cancer will increase significantly among patients ages 35 to 44 and among patients ages 45 to 64.

Cancer burden

The researchers said the number of adults living with HIV in the US is projected to increase from 1.06 million in 2006 to 1.17 million in 2018, but it is expected to decline to 1.09 million in 2030.

The team noted that, in 2006, there were an estimated 8241 cancers in patients with HIV—3522 AIDS-defining cancers and 4719 malignancies not associated with AIDS.

In 2030, the total number of cancers in the HIV-positive population is projected to be 6692, with decreases in AIDS-defining cancers (n=716) and increases in other cancers (n=5976) from the 2006 data.

In 2010, the most common cancers among HIV-positive patients were estimated to be NHL (n=1488), Kaposi sarcoma (n=1133), and lung cancer (n=815).

But in 2030, the most common cancers are projected to be prostate (n=1587), lung (n=1027), and liver cancers (n=483).

“It is critical to understand both incidence rates and burden over time, as rates capture changes in cancer risk, and burden quantifies the actual number of cancer cases expected to occur,” said study investigator Meredith S. Shiels, PhD, of the National Cancer Institute in Bethesda, Maryland.

“For example, lung cancer rates are expected to decrease in the future, but the burden is expected to increase due to the growing number of older people living with HIV.”

Photo by Rhoda Baer

WASHINGTON, DC—New research suggests HIV-positive adults in the US will see a shift in cancer risk and burden in the coming years.

The study indicates that, through 2030, people living with HIV will see a decrease in AIDS-defining cancers, such as non-Hodgkin lymphoma (NHL) and Kaposi sarcoma.

But this group will also see an increase in cancers not linked to AIDS, such as prostate and liver cancers.

Researchers made these projections in a presentation at the AACR Annual Meeting 2017 (abstract 5302).

“Declines in cancer incidence rates, particularly for AIDS-defining cancers, are likely driven by widespread treatment with modern antiretroviral therapies, which reduce immune suppression and decrease risk of some cancers,” said Jessica Y. Islam, a doctoral student at the University of North Carolina Gillings School of Global Public Health in Chapel Hill.

She and her collaborators estimated future cancer risk and burden for HIV-positive people using age-specific cancer incidence data from the National Cancer Institute HIV/AIDS Cancer Match (HACM) Study, and projected HIV prevalence data from the Centers for Disease Control and Prevention.

Cancer incidence

From 2000 to 2012, there were 23,907 cancers reported in 463,300 HIV-infected adults in the HACM Study. Based on trends in this study, the researchers made projections for cancer incidence through 2030.

They projected that HIV-positive adults of all ages will see a significant decrease over time in the incidence of NHL, Kaposi sarcoma, cervical cancer, anal cancer among men who have sex with men (MSM), lung cancer, and Hodgkin lymphoma.

Patients age 65 and older will see a significant decrease in colon cancer incidence over time. However, there will be no significant change for patients younger than 65.

HIV-positive adults of all ages will see no significant change over time in the incidence of liver cancer, oral cavity cancer, anal cancer among non-MSMs, and breast cancer.

The incidence of prostate cancer will increase significantly among patients ages 35 to 44 and among patients ages 45 to 64.

Cancer burden

The researchers said the number of adults living with HIV in the US is projected to increase from 1.06 million in 2006 to 1.17 million in 2018, but it is expected to decline to 1.09 million in 2030.

The team noted that, in 2006, there were an estimated 8241 cancers in patients with HIV—3522 AIDS-defining cancers and 4719 malignancies not associated with AIDS.

In 2030, the total number of cancers in the HIV-positive population is projected to be 6692, with decreases in AIDS-defining cancers (n=716) and increases in other cancers (n=5976) from the 2006 data.

In 2010, the most common cancers among HIV-positive patients were estimated to be NHL (n=1488), Kaposi sarcoma (n=1133), and lung cancer (n=815).

But in 2030, the most common cancers are projected to be prostate (n=1587), lung (n=1027), and liver cancers (n=483).

“It is critical to understand both incidence rates and burden over time, as rates capture changes in cancer risk, and burden quantifies the actual number of cancer cases expected to occur,” said study investigator Meredith S. Shiels, PhD, of the National Cancer Institute in Bethesda, Maryland.

“For example, lung cancer rates are expected to decrease in the future, but the burden is expected to increase due to the growing number of older people living with HIV.”

Photo by Rhoda Baer

WASHINGTON, DC—New research suggests HIV-positive adults in the US will see a shift in cancer risk and burden in the coming years.

The study indicates that, through 2030, people living with HIV will see a decrease in AIDS-defining cancers, such as non-Hodgkin lymphoma (NHL) and Kaposi sarcoma.

But this group will also see an increase in cancers not linked to AIDS, such as prostate and liver cancers.

Researchers made these projections in a presentation at the AACR Annual Meeting 2017 (abstract 5302).

“Declines in cancer incidence rates, particularly for AIDS-defining cancers, are likely driven by widespread treatment with modern antiretroviral therapies, which reduce immune suppression and decrease risk of some cancers,” said Jessica Y. Islam, a doctoral student at the University of North Carolina Gillings School of Global Public Health in Chapel Hill.

She and her collaborators estimated future cancer risk and burden for HIV-positive people using age-specific cancer incidence data from the National Cancer Institute HIV/AIDS Cancer Match (HACM) Study, and projected HIV prevalence data from the Centers for Disease Control and Prevention.

Cancer incidence

From 2000 to 2012, there were 23,907 cancers reported in 463,300 HIV-infected adults in the HACM Study. Based on trends in this study, the researchers made projections for cancer incidence through 2030.

They projected that HIV-positive adults of all ages will see a significant decrease over time in the incidence of NHL, Kaposi sarcoma, cervical cancer, anal cancer among men who have sex with men (MSM), lung cancer, and Hodgkin lymphoma.

Patients age 65 and older will see a significant decrease in colon cancer incidence over time. However, there will be no significant change for patients younger than 65.

HIV-positive adults of all ages will see no significant change over time in the incidence of liver cancer, oral cavity cancer, anal cancer among non-MSMs, and breast cancer.

The incidence of prostate cancer will increase significantly among patients ages 35 to 44 and among patients ages 45 to 64.

Cancer burden

The researchers said the number of adults living with HIV in the US is projected to increase from 1.06 million in 2006 to 1.17 million in 2018, but it is expected to decline to 1.09 million in 2030.

The team noted that, in 2006, there were an estimated 8241 cancers in patients with HIV—3522 AIDS-defining cancers and 4719 malignancies not associated with AIDS.

In 2030, the total number of cancers in the HIV-positive population is projected to be 6692, with decreases in AIDS-defining cancers (n=716) and increases in other cancers (n=5976) from the 2006 data.

In 2010, the most common cancers among HIV-positive patients were estimated to be NHL (n=1488), Kaposi sarcoma (n=1133), and lung cancer (n=815).

But in 2030, the most common cancers are projected to be prostate (n=1587), lung (n=1027), and liver cancers (n=483).

“It is critical to understand both incidence rates and burden over time, as rates capture changes in cancer risk, and burden quantifies the actual number of cancer cases expected to occur,” said study investigator Meredith S. Shiels, PhD, of the National Cancer Institute in Bethesda, Maryland.

“For example, lung cancer rates are expected to decrease in the future, but the burden is expected to increase due to the growing number of older people living with HIV.”

Antihemophilic factor

SCOTTSDALE, ARIZONA—The recombinant factor IX product trenonacog alfa appears safe and effective for previously treated patients with hemophilia B who are younger than 12 years of age, according to researchers.

The team conducted a pooled analysis of 2 studies, which included a total of 12 patients.

The median annualized bleeding rate (ABR) was low among patients who received trenonacog alfa as prophylaxis.

Among all patients, 72% of bleeding episodes were resolved with a single infusion of trenonacog alfa.

None of the patients developed factor IX inhibitors, and treatment-related adverse events consisted of fever and hyperhidrosis.

These results were presented in a poster at the Hemostasis and Thrombosis Research Society 2017 Scientific Symposium.

The research was conducted by employees of Aptevo Therapeutics, the company marketing trenonacog alfa as IXINITY®. The poster is available on the company’s website.

The researchers conducted a pooled analysis of 2 prospective, non-randomized studies of 12 children with hemophilia B under the age of 12.

The patients’ median age was 9.5 (range, 2-11). All patients were male. Half were Asian, 3 were white, 2 were Pacific Islanders, and 1 belonged to an “other” racial/ethnic group.

Eleven patients received trenonacog alfa as prophylaxis, and 1 patient received the treatment on demand.

Among the patients on prophylaxis, the median number of exposure days was 254 (range, 111-404), and the median dose per infusion was 75.3 IU/kg (range, 25.3-111.0).

For the patients on prophylaxis, the median number of bleeding episodes was 1.0 (range, 0-11), and the median ABR was 0.3 (range, 0-4.0).  Two patients had no bleeding episodes.

The patient who received trenonacog alfa on demand had 23 bleeding episodes and an ABR of 11.1.

There were a total of 61 bleeding episodes in this study. Most (72%, n=44) resolved after 1 infusion of trenonacog alfa, and 10% (n=6) resolved without any infusions.

Eight percent of the bleeding episodes (n=5) required 2 infusions of trenonacog alfa, and 10% (n=6) required 3, 4, or 5 infusions.

Adverse events thought to be related to trenonacog alfa were hyperhidrosis and fever in 1 patient, and hyperhidrosis in another patient.

Antihemophilic factor

SCOTTSDALE, ARIZONA—The recombinant factor IX product trenonacog alfa appears safe and effective for previously treated patients with hemophilia B who are younger than 12 years of age, according to researchers.

The team conducted a pooled analysis of 2 studies, which included a total of 12 patients.

The median annualized bleeding rate (ABR) was low among patients who received trenonacog alfa as prophylaxis.

Among all patients, 72% of bleeding episodes were resolved with a single infusion of trenonacog alfa.

None of the patients developed factor IX inhibitors, and treatment-related adverse events consisted of fever and hyperhidrosis.

These results were presented in a poster at the Hemostasis and Thrombosis Research Society 2017 Scientific Symposium.

The research was conducted by employees of Aptevo Therapeutics, the company marketing trenonacog alfa as IXINITY®. The poster is available on the company’s website.

The researchers conducted a pooled analysis of 2 prospective, non-randomized studies of 12 children with hemophilia B under the age of 12.

The patients’ median age was 9.5 (range, 2-11). All patients were male. Half were Asian, 3 were white, 2 were Pacific Islanders, and 1 belonged to an “other” racial/ethnic group.

Eleven patients received trenonacog alfa as prophylaxis, and 1 patient received the treatment on demand.

Among the patients on prophylaxis, the median number of exposure days was 254 (range, 111-404), and the median dose per infusion was 75.3 IU/kg (range, 25.3-111.0).

For the patients on prophylaxis, the median number of bleeding episodes was 1.0 (range, 0-11), and the median ABR was 0.3 (range, 0-4.0).  Two patients had no bleeding episodes.

The patient who received trenonacog alfa on demand had 23 bleeding episodes and an ABR of 11.1.

There were a total of 61 bleeding episodes in this study. Most (72%, n=44) resolved after 1 infusion of trenonacog alfa, and 10% (n=6) resolved without any infusions.

Eight percent of the bleeding episodes (n=5) required 2 infusions of trenonacog alfa, and 10% (n=6) required 3, 4, or 5 infusions.

Adverse events thought to be related to trenonacog alfa were hyperhidrosis and fever in 1 patient, and hyperhidrosis in another patient.

Antihemophilic factor

SCOTTSDALE, ARIZONA—The recombinant factor IX product trenonacog alfa appears safe and effective for previously treated patients with hemophilia B who are younger than 12 years of age, according to researchers.

The team conducted a pooled analysis of 2 studies, which included a total of 12 patients.

The median annualized bleeding rate (ABR) was low among patients who received trenonacog alfa as prophylaxis.

Among all patients, 72% of bleeding episodes were resolved with a single infusion of trenonacog alfa.

None of the patients developed factor IX inhibitors, and treatment-related adverse events consisted of fever and hyperhidrosis.

These results were presented in a poster at the Hemostasis and Thrombosis Research Society 2017 Scientific Symposium.

The research was conducted by employees of Aptevo Therapeutics, the company marketing trenonacog alfa as IXINITY®. The poster is available on the company’s website.

The researchers conducted a pooled analysis of 2 prospective, non-randomized studies of 12 children with hemophilia B under the age of 12.

The patients’ median age was 9.5 (range, 2-11). All patients were male. Half were Asian, 3 were white, 2 were Pacific Islanders, and 1 belonged to an “other” racial/ethnic group.

Eleven patients received trenonacog alfa as prophylaxis, and 1 patient received the treatment on demand.

Among the patients on prophylaxis, the median number of exposure days was 254 (range, 111-404), and the median dose per infusion was 75.3 IU/kg (range, 25.3-111.0).

For the patients on prophylaxis, the median number of bleeding episodes was 1.0 (range, 0-11), and the median ABR was 0.3 (range, 0-4.0).  Two patients had no bleeding episodes.

The patient who received trenonacog alfa on demand had 23 bleeding episodes and an ABR of 11.1.

There were a total of 61 bleeding episodes in this study. Most (72%, n=44) resolved after 1 infusion of trenonacog alfa, and 10% (n=6) resolved without any infusions.

Eight percent of the bleeding episodes (n=5) required 2 infusions of trenonacog alfa, and 10% (n=6) required 3, 4, or 5 infusions.

Adverse events thought to be related to trenonacog alfa were hyperhidrosis and fever in 1 patient, and hyperhidrosis in another patient.

Q)I have heard talk about the development of new drugs to treat hyperkalemia. What is the status of these?

Hyperkalemia is a commonly seen electrolyte imbalance in clinical practice. Risks associated with moderate-to-­severe hyperkalemia include potentially ­fatal cardiac conduction abnormalities/­arrhythmias, making identification and management critical. An in-depth discussion of hyper­kalemia diagnosis can be found in our March 2017 CE/CME activity (2017;27[3]:40-49).

Risk factors for hyperkalemia include excess intake or supplementation of potassium, type 2 diabetes, liver cirrhosis, congestive heart failure (CHF), and chronic kidney disease (CKD). The kidneys excrete 90% to 95% of ingested potassium, and the gut excretes the rest. Normal kidneys take six to 12 hours to excrete an acute potassium load. As kidney function decreases, risk for hyperkalemia increases.¹ Hyperkalemia rates as high as 26% have been observed in patients with CKD stages 3 to 5 (glomerular filtration rate [GFR], < 60 mL/min).²

Renin-angiotensin-aldosterone system (RAAS) inhibitors—including ACE inhibitors (ACEis), angiotensin-receptor blockers, and aldosterone agonists—are associated with hyperkalemia. While RAAS therapy can play an important role in the management of CKD and cardiovascular disease (CVD), the development of hyperkalemia can necessitate a dose reduction or discontinuation of these medications, limiting their therapeutic benefit. Other medications that elevate risk for hyperkalemia include NSAIDs, heparin, cyclosporine, amiloride, triamterene, and nonselective ­ß-blockers.¹

Therapeutic options for nonurgent treatment of hyperkalemia are limited. In addition to reducing or discontinuing associated medications, strategies include use of diuretics (as appropriate), treatment of metabolic acidosis, and dietary restrictions (ie, limiting high-potassium foods).¹ Pharmacologically, there has been one (less than ideal) option—until recently.

Sodium polystyrene sulfonate (SPS), an ion-exchange resin approved in 1958, can be used to treat hyperkalemia.³ It comes in an enema and an oral form; the former has a faster onset, but the latter is more effective, with an onset of action of one to two hours and a duration of four to six hours.¹ However, each gram of SPS contains 100 g of sodium, and the typical dose of SPS is 15 g to 60 g.⁴ The resulting increase in sodium load can be a concern for patients with CHF, severe hypertension, or severe edema.⁵

Data from randomized controlled trials (RCTs) are limited; however, one double-blind RCT investigated the effect of SPS on 33 patients with CKD and mild-to-moderate hyperkalemia (potassium level, 5 mEq/L to 5.9 mEq/L). The researchers found that patients who took 30 g/d of SPS for seven days experienced a 73% reduction in serum potassium, compared with a 38% reduction in patients who took a placebo. Of note, more gastrointestinal issues were observed in the SPS group.⁶

Additionally, a retrospective chart review of 14 patients with CKD and heart disease found low-dose SPS to be safe and effective when used as a secondary measure for hyperkalemia prevention in those taking RAAS therapy.⁷ However, a systematic review found that SPS use with and without concurrent sorbitol may be associated with serious and fatal gastrointestinal injuries.⁸ In 2011, the FDA issued a black box warning regarding increased risk for intestinal necrosis when SPS is used with sorbitol.⁹ In 2015, the FDA recommended separating SPS from other oral medications by at least six hours, due to its potential to bind with other medications.¹⁰

Patiromer, a new potassium binder, was approved by the FDA in 2015. This sodium-free, nonabsorbed, spherical polymer uses calcium as the exchange cation to bind potassium in the gastrointestinal tract. Its onset of action is seven hours, with a 24-hour duration of action. It is not approved for emergency use. There are no renal dosing adjustment considerations with patiromer.

In RCTs, patiromer has been associated with a significant reduction in serum potassium in patients with CKD (with or without diabetes) taking RAAS therapy. The starting dose is 8.4 g/d mixed with water, taken with food; this can be increased by 8.4 g each week as needed, to a maximum dosage of 25.2 g/d. Patiromer binds between 8.5 mEq to 8.8 mEq of potassium per gram of polymer.

The original approval included a black box warning to take patiromer six hours before and after other medications, due to concern for binding with certain medications. However, after an additional study in 2016, the FDA removed this warning and approved a change in administration to three hours before and after taking other medications.

Use of patiromer is not advised in those with severe constipation, bowel obstruction/impaction, or allergies to any of its components.¹¹ Adverse reactions associated with patiromer include constipation (which generally improves with time), hypomagnesemia, diarrhea, nausea, abdominal discomfort, and flatulence. A 52-week RCT of 304 patients with CKD on RAAS found the most common adverse event to be mild-to-moderate constipation (6.3% of patients), with two patients discontinuing therapy as a result.⁴ In clinical trials, 9% of patients developed hypomagnesemia (serum magnesium value, < 1.4 mg/dL). It is recommended that serum magnesium levels be monitored and supplementation offered, when appropriate.¹¹

Sodium zirconium cyclosilicate (ZS-9) is among the potassium-lowering medications on the horizon. In 2016, the FDA accepted a new drug application for this insoluble, unabsorbed cation exchanger that also works in the GI tract and uses sodium and hydrogen as exchange cations.¹²

For now, however, dietary education remains a mainstay of treatment for patients with elevated serum potassium levels. It is particularly important to inform your patients that many salt substitutes and low-sodium products contain potassium chloride. They should therefore exercise caution when incorporating sodium-reducing components into their diet. —CS

Cynthia Smith, DNP, CNN-NP, APRN, FNP-BC
Renal Consultants, PLLC, South Charleston, West Virginia

Q)I have heard talk about the development of new drugs to treat hyperkalemia. What is the status of these?

Hyperkalemia is a commonly seen electrolyte imbalance in clinical practice. Risks associated with moderate-to-­severe hyperkalemia include potentially ­fatal cardiac conduction abnormalities/­arrhythmias, making identification and management critical. An in-depth discussion of hyper­kalemia diagnosis can be found in our March 2017 CE/CME activity (2017;27[3]:40-49).

Risk factors for hyperkalemia include excess intake or supplementation of potassium, type 2 diabetes, liver cirrhosis, congestive heart failure (CHF), and chronic kidney disease (CKD). The kidneys excrete 90% to 95% of ingested potassium, and the gut excretes the rest. Normal kidneys take six to 12 hours to excrete an acute potassium load. As kidney function decreases, risk for hyperkalemia increases.¹ Hyperkalemia rates as high as 26% have been observed in patients with CKD stages 3 to 5 (glomerular filtration rate [GFR], < 60 mL/min).²

Renin-angiotensin-aldosterone system (RAAS) inhibitors—including ACE inhibitors (ACEis), angiotensin-receptor blockers, and aldosterone agonists—are associated with hyperkalemia. While RAAS therapy can play an important role in the management of CKD and cardiovascular disease (CVD), the development of hyperkalemia can necessitate a dose reduction or discontinuation of these medications, limiting their therapeutic benefit. Other medications that elevate risk for hyperkalemia include NSAIDs, heparin, cyclosporine, amiloride, triamterene, and nonselective ­ß-blockers.¹

Therapeutic options for nonurgent treatment of hyperkalemia are limited. In addition to reducing or discontinuing associated medications, strategies include use of diuretics (as appropriate), treatment of metabolic acidosis, and dietary restrictions (ie, limiting high-potassium foods).¹ Pharmacologically, there has been one (less than ideal) option—until recently.

Sodium polystyrene sulfonate (SPS), an ion-exchange resin approved in 1958, can be used to treat hyperkalemia.³ It comes in an enema and an oral form; the former has a faster onset, but the latter is more effective, with an onset of action of one to two hours and a duration of four to six hours.¹ However, each gram of SPS contains 100 g of sodium, and the typical dose of SPS is 15 g to 60 g.⁴ The resulting increase in sodium load can be a concern for patients with CHF, severe hypertension, or severe edema.⁵

Data from randomized controlled trials (RCTs) are limited; however, one double-blind RCT investigated the effect of SPS on 33 patients with CKD and mild-to-moderate hyperkalemia (potassium level, 5 mEq/L to 5.9 mEq/L). The researchers found that patients who took 30 g/d of SPS for seven days experienced a 73% reduction in serum potassium, compared with a 38% reduction in patients who took a placebo. Of note, more gastrointestinal issues were observed in the SPS group.⁶

Additionally, a retrospective chart review of 14 patients with CKD and heart disease found low-dose SPS to be safe and effective when used as a secondary measure for hyperkalemia prevention in those taking RAAS therapy.⁷ However, a systematic review found that SPS use with and without concurrent sorbitol may be associated with serious and fatal gastrointestinal injuries.⁸ In 2011, the FDA issued a black box warning regarding increased risk for intestinal necrosis when SPS is used with sorbitol.⁹ In 2015, the FDA recommended separating SPS from other oral medications by at least six hours, due to its potential to bind with other medications.¹⁰

Patiromer, a new potassium binder, was approved by the FDA in 2015. This sodium-free, nonabsorbed, spherical polymer uses calcium as the exchange cation to bind potassium in the gastrointestinal tract. Its onset of action is seven hours, with a 24-hour duration of action. It is not approved for emergency use. There are no renal dosing adjustment considerations with patiromer.

In RCTs, patiromer has been associated with a significant reduction in serum potassium in patients with CKD (with or without diabetes) taking RAAS therapy. The starting dose is 8.4 g/d mixed with water, taken with food; this can be increased by 8.4 g each week as needed, to a maximum dosage of 25.2 g/d. Patiromer binds between 8.5 mEq to 8.8 mEq of potassium per gram of polymer.

The original approval included a black box warning to take patiromer six hours before and after other medications, due to concern for binding with certain medications. However, after an additional study in 2016, the FDA removed this warning and approved a change in administration to three hours before and after taking other medications.

Use of patiromer is not advised in those with severe constipation, bowel obstruction/impaction, or allergies to any of its components.¹¹ Adverse reactions associated with patiromer include constipation (which generally improves with time), hypomagnesemia, diarrhea, nausea, abdominal discomfort, and flatulence. A 52-week RCT of 304 patients with CKD on RAAS found the most common adverse event to be mild-to-moderate constipation (6.3% of patients), with two patients discontinuing therapy as a result.⁴ In clinical trials, 9% of patients developed hypomagnesemia (serum magnesium value, < 1.4 mg/dL). It is recommended that serum magnesium levels be monitored and supplementation offered, when appropriate.¹¹

Sodium zirconium cyclosilicate (ZS-9) is among the potassium-lowering medications on the horizon. In 2016, the FDA accepted a new drug application for this insoluble, unabsorbed cation exchanger that also works in the GI tract and uses sodium and hydrogen as exchange cations.¹²

For now, however, dietary education remains a mainstay of treatment for patients with elevated serum potassium levels. It is particularly important to inform your patients that many salt substitutes and low-sodium products contain potassium chloride. They should therefore exercise caution when incorporating sodium-reducing components into their diet. —CS

Cynthia Smith, DNP, CNN-NP, APRN, FNP-BC
Renal Consultants, PLLC, South Charleston, West Virginia

Q)I have heard talk about the development of new drugs to treat hyperkalemia. What is the status of these?

Hyperkalemia is a commonly seen electrolyte imbalance in clinical practice. Risks associated with moderate-to-­severe hyperkalemia include potentially ­fatal cardiac conduction abnormalities/­arrhythmias, making identification and management critical. An in-depth discussion of hyper­kalemia diagnosis can be found in our March 2017 CE/CME activity (2017;27[3]:40-49).

Risk factors for hyperkalemia include excess intake or supplementation of potassium, type 2 diabetes, liver cirrhosis, congestive heart failure (CHF), and chronic kidney disease (CKD). The kidneys excrete 90% to 95% of ingested potassium, and the gut excretes the rest. Normal kidneys take six to 12 hours to excrete an acute potassium load. As kidney function decreases, risk for hyperkalemia increases.¹ Hyperkalemia rates as high as 26% have been observed in patients with CKD stages 3 to 5 (glomerular filtration rate [GFR], < 60 mL/min).²

Renin-angiotensin-aldosterone system (RAAS) inhibitors—including ACE inhibitors (ACEis), angiotensin-receptor blockers, and aldosterone agonists—are associated with hyperkalemia. While RAAS therapy can play an important role in the management of CKD and cardiovascular disease (CVD), the development of hyperkalemia can necessitate a dose reduction or discontinuation of these medications, limiting their therapeutic benefit. Other medications that elevate risk for hyperkalemia include NSAIDs, heparin, cyclosporine, amiloride, triamterene, and nonselective ­ß-blockers.¹

Therapeutic options for nonurgent treatment of hyperkalemia are limited. In addition to reducing or discontinuing associated medications, strategies include use of diuretics (as appropriate), treatment of metabolic acidosis, and dietary restrictions (ie, limiting high-potassium foods).¹ Pharmacologically, there has been one (less than ideal) option—until recently.

Sodium polystyrene sulfonate (SPS), an ion-exchange resin approved in 1958, can be used to treat hyperkalemia.³ It comes in an enema and an oral form; the former has a faster onset, but the latter is more effective, with an onset of action of one to two hours and a duration of four to six hours.¹ However, each gram of SPS contains 100 g of sodium, and the typical dose of SPS is 15 g to 60 g.⁴ The resulting increase in sodium load can be a concern for patients with CHF, severe hypertension, or severe edema.⁵

Data from randomized controlled trials (RCTs) are limited; however, one double-blind RCT investigated the effect of SPS on 33 patients with CKD and mild-to-moderate hyperkalemia (potassium level, 5 mEq/L to 5.9 mEq/L). The researchers found that patients who took 30 g/d of SPS for seven days experienced a 73% reduction in serum potassium, compared with a 38% reduction in patients who took a placebo. Of note, more gastrointestinal issues were observed in the SPS group.⁶

Additionally, a retrospective chart review of 14 patients with CKD and heart disease found low-dose SPS to be safe and effective when used as a secondary measure for hyperkalemia prevention in those taking RAAS therapy.⁷ However, a systematic review found that SPS use with and without concurrent sorbitol may be associated with serious and fatal gastrointestinal injuries.⁸ In 2011, the FDA issued a black box warning regarding increased risk for intestinal necrosis when SPS is used with sorbitol.⁹ In 2015, the FDA recommended separating SPS from other oral medications by at least six hours, due to its potential to bind with other medications.¹⁰

Patiromer, a new potassium binder, was approved by the FDA in 2015. This sodium-free, nonabsorbed, spherical polymer uses calcium as the exchange cation to bind potassium in the gastrointestinal tract. Its onset of action is seven hours, with a 24-hour duration of action. It is not approved for emergency use. There are no renal dosing adjustment considerations with patiromer.

In RCTs, patiromer has been associated with a significant reduction in serum potassium in patients with CKD (with or without diabetes) taking RAAS therapy. The starting dose is 8.4 g/d mixed with water, taken with food; this can be increased by 8.4 g each week as needed, to a maximum dosage of 25.2 g/d. Patiromer binds between 8.5 mEq to 8.8 mEq of potassium per gram of polymer.

The original approval included a black box warning to take patiromer six hours before and after other medications, due to concern for binding with certain medications. However, after an additional study in 2016, the FDA removed this warning and approved a change in administration to three hours before and after taking other medications.

Use of patiromer is not advised in those with severe constipation, bowel obstruction/impaction, or allergies to any of its components.¹¹ Adverse reactions associated with patiromer include constipation (which generally improves with time), hypomagnesemia, diarrhea, nausea, abdominal discomfort, and flatulence. A 52-week RCT of 304 patients with CKD on RAAS found the most common adverse event to be mild-to-moderate constipation (6.3% of patients), with two patients discontinuing therapy as a result.⁴ In clinical trials, 9% of patients developed hypomagnesemia (serum magnesium value, < 1.4 mg/dL). It is recommended that serum magnesium levels be monitored and supplementation offered, when appropriate.¹¹

Sodium zirconium cyclosilicate (ZS-9) is among the potassium-lowering medications on the horizon. In 2016, the FDA accepted a new drug application for this insoluble, unabsorbed cation exchanger that also works in the GI tract and uses sodium and hydrogen as exchange cations.¹²

For now, however, dietary education remains a mainstay of treatment for patients with elevated serum potassium levels. It is particularly important to inform your patients that many salt substitutes and low-sodium products contain potassium chloride. They should therefore exercise caution when incorporating sodium-reducing components into their diet. —CS

Cynthia Smith, DNP, CNN-NP, APRN, FNP-BC
Renal Consultants, PLLC, South Charleston, West Virginia

Outpatient visits for influenza were down again in the United States during the week ending April 1, and the number of states at the highest level of flu activity dropped from seven to four, according to the Centers for Disease Control and Prevention.

The national proportion of outpatient visits for influenza-like illness (ILI) was 2.9% for the week ending April 1, compared with 3.2% the week before, the CDC’s Outpatient Influenza-like Illness Surveillance Network reported. The national baseline level is 2.2%.

rfranki@frontlinemedcom.com

Outpatient visits for influenza were down again in the United States during the week ending April 1, and the number of states at the highest level of flu activity dropped from seven to four, according to the Centers for Disease Control and Prevention.

The national proportion of outpatient visits for influenza-like illness (ILI) was 2.9% for the week ending April 1, compared with 3.2% the week before, the CDC’s Outpatient Influenza-like Illness Surveillance Network reported. The national baseline level is 2.2%.

rfranki@frontlinemedcom.com

Outpatient visits for influenza were down again in the United States during the week ending April 1, and the number of states at the highest level of flu activity dropped from seven to four, according to the Centers for Disease Control and Prevention.

The national proportion of outpatient visits for influenza-like illness (ILI) was 2.9% for the week ending April 1, compared with 3.2% the week before, the CDC’s Outpatient Influenza-like Illness Surveillance Network reported. The national baseline level is 2.2%.

rfranki@frontlinemedcom.com

WASHINGTON – Is it finally time to give up on HDL cholesterol–based interventions to treat atherosclerotic disease?

The approach “is on life support,” admitted Stephen J. Nicholls, MD, a long-time leader in the field who has reported results from a series of studies during the past 10 or so years that tested various approaches to juicing HDL cholesterol activity in patients, only to see each and every candidate intervention result in an inability to budge clinical outcomes.

Mitchel L. Zoler/Frontline Medical News

Mitchel L. Zoler/Frontline Medical News

mzoler@frontlinemedcom.com

On Twitter @mitchelzoler

WASHINGTON – Is it finally time to give up on HDL cholesterol–based interventions to treat atherosclerotic disease?

The approach “is on life support,” admitted Stephen J. Nicholls, MD, a long-time leader in the field who has reported results from a series of studies during the past 10 or so years that tested various approaches to juicing HDL cholesterol activity in patients, only to see each and every candidate intervention result in an inability to budge clinical outcomes.

Mitchel L. Zoler/Frontline Medical News

Mitchel L. Zoler/Frontline Medical News

mzoler@frontlinemedcom.com

On Twitter @mitchelzoler

WASHINGTON – Is it finally time to give up on HDL cholesterol–based interventions to treat atherosclerotic disease?

The approach “is on life support,” admitted Stephen J. Nicholls, MD, a long-time leader in the field who has reported results from a series of studies during the past 10 or so years that tested various approaches to juicing HDL cholesterol activity in patients, only to see each and every candidate intervention result in an inability to budge clinical outcomes.

Mitchel L. Zoler/Frontline Medical News

Mitchel L. Zoler/Frontline Medical News

mzoler@frontlinemedcom.com

On Twitter @mitchelzoler

MELBOURNE – Researchers have identified six microRNAs that may indicate a better likelihood of response to cyclophosphamide in patients with lupus nephritis, according to a study presented at an international conference on systemic lupus erythematosus.

“MicroRNA has been shown to be important in systemic lupus in several studies, and they’ve identified several microRNA that have been shown to affect the outcome measures in patients,” said Sarfaraz Hasni, MD, director of the Lupus Clinical Research Program at the National Institute of Arthritis and Musculoskeletal and Skin Diseases in Bethesda, Md., who presented a poster on the study at the meeting.

Bianca Nogrady/Frontline Medical News

MELBOURNE – Researchers have identified six microRNAs that may indicate a better likelihood of response to cyclophosphamide in patients with lupus nephritis, according to a study presented at an international conference on systemic lupus erythematosus.

“MicroRNA has been shown to be important in systemic lupus in several studies, and they’ve identified several microRNA that have been shown to affect the outcome measures in patients,” said Sarfaraz Hasni, MD, director of the Lupus Clinical Research Program at the National Institute of Arthritis and Musculoskeletal and Skin Diseases in Bethesda, Md., who presented a poster on the study at the meeting.

Bianca Nogrady/Frontline Medical News

MELBOURNE – Researchers have identified six microRNAs that may indicate a better likelihood of response to cyclophosphamide in patients with lupus nephritis, according to a study presented at an international conference on systemic lupus erythematosus.

“MicroRNA has been shown to be important in systemic lupus in several studies, and they’ve identified several microRNA that have been shown to affect the outcome measures in patients,” said Sarfaraz Hasni, MD, director of the Lupus Clinical Research Program at the National Institute of Arthritis and Musculoskeletal and Skin Diseases in Bethesda, Md., who presented a poster on the study at the meeting.

Bianca Nogrady/Frontline Medical News

Metformin use was associated with better survival for patients with renal cell carcinoma and diabetes in a meta-analysis, investigators report.

Yang Li, MD, and associates at Chongqing (China) Medical University, performed a pooled analysis of data from 254,329 patients with both localized and metastatic renal cell carcinoma, and found the risk of mortality was reduced in patients exposed to metformin (hazard ratio, 0.41; P less than .001).

However, there was significant heterogeneity among the eight eligible studies included in the meta-analysis, Dr. Li and associates reported (Int Urol Nephrol. 2017 Mar 7. doi: 10.1007/s11255-017-1548-4).

In a subgroup analysis, the association held in patients with localized disease, but was not significant in those with metastatic disease.

The current meta-analysis suggests that the use of metformin could improve the survival of kidney cancer patients, particularly those with localized disease; however, further studies are needed, the investigators conclude.

The authors declared that they had no conflicts of interest.

Metformin use was associated with better survival for patients with renal cell carcinoma and diabetes in a meta-analysis, investigators report.

Yang Li, MD, and associates at Chongqing (China) Medical University, performed a pooled analysis of data from 254,329 patients with both localized and metastatic renal cell carcinoma, and found the risk of mortality was reduced in patients exposed to metformin (hazard ratio, 0.41; P less than .001).

However, there was significant heterogeneity among the eight eligible studies included in the meta-analysis, Dr. Li and associates reported (Int Urol Nephrol. 2017 Mar 7. doi: 10.1007/s11255-017-1548-4).

In a subgroup analysis, the association held in patients with localized disease, but was not significant in those with metastatic disease.

The current meta-analysis suggests that the use of metformin could improve the survival of kidney cancer patients, particularly those with localized disease; however, further studies are needed, the investigators conclude.

The authors declared that they had no conflicts of interest.

Metformin use was associated with better survival for patients with renal cell carcinoma and diabetes in a meta-analysis, investigators report.

Yang Li, MD, and associates at Chongqing (China) Medical University, performed a pooled analysis of data from 254,329 patients with both localized and metastatic renal cell carcinoma, and found the risk of mortality was reduced in patients exposed to metformin (hazard ratio, 0.41; P less than .001).

However, there was significant heterogeneity among the eight eligible studies included in the meta-analysis, Dr. Li and associates reported (Int Urol Nephrol. 2017 Mar 7. doi: 10.1007/s11255-017-1548-4).

In a subgroup analysis, the association held in patients with localized disease, but was not significant in those with metastatic disease.

The current meta-analysis suggests that the use of metformin could improve the survival of kidney cancer patients, particularly those with localized disease; however, further studies are needed, the investigators conclude.

The authors declared that they had no conflicts of interest.

A rectovaginal endometriosis (RVE) is the most severe form of endometriosis. The gold standard for diagnosis is laparoscopy with histologic confirmation. A review of the literature suggests that surgery improves up to 70% of symptoms with generally favorable outcomes.

In this video, we provide a general introduction to endometriosis and a discussion of disease treatment options, ranging from hormonal suppression to radical bowel resections. We also illustrate the steps in robot-assisted laparoscopic excision of an RVE nodule:

1. identify the borders of the rectosigmoid
2. dissect the pararectal spaces  
3. release the rectosigmoid from its attachment to the RVE nodule
4. identify and isolate the ureter(s)
5. determine the margins of the nodule  
6. ensure complete resection.

Excision of an RVE nodule is a technically challenging surgical procedure. Use of the robot for resection is safe and feasible when performed by a trained and experienced surgeon.

I am pleased to bring you this video, and I hope that it is helpful to your practice. 

>> Arnold P. Advincula, MD

Vidyard Video

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

A rectovaginal endometriosis (RVE) is the most severe form of endometriosis. The gold standard for diagnosis is laparoscopy with histologic confirmation. A review of the literature suggests that surgery improves up to 70% of symptoms with generally favorable outcomes.

In this video, we provide a general introduction to endometriosis and a discussion of disease treatment options, ranging from hormonal suppression to radical bowel resections. We also illustrate the steps in robot-assisted laparoscopic excision of an RVE nodule:

1. identify the borders of the rectosigmoid
2. dissect the pararectal spaces  
3. release the rectosigmoid from its attachment to the RVE nodule
4. identify and isolate the ureter(s)
5. determine the margins of the nodule  
6. ensure complete resection.

Excision of an RVE nodule is a technically challenging surgical procedure. Use of the robot for resection is safe and feasible when performed by a trained and experienced surgeon.

I am pleased to bring you this video, and I hope that it is helpful to your practice. 

>> Arnold P. Advincula, MD

Vidyard Video

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

A rectovaginal endometriosis (RVE) is the most severe form of endometriosis. The gold standard for diagnosis is laparoscopy with histologic confirmation. A review of the literature suggests that surgery improves up to 70% of symptoms with generally favorable outcomes.

In this video, we provide a general introduction to endometriosis and a discussion of disease treatment options, ranging from hormonal suppression to radical bowel resections. We also illustrate the steps in robot-assisted laparoscopic excision of an RVE nodule:

1. identify the borders of the rectosigmoid
2. dissect the pararectal spaces  
3. release the rectosigmoid from its attachment to the RVE nodule
4. identify and isolate the ureter(s)
5. determine the margins of the nodule  
6. ensure complete resection.

Excision of an RVE nodule is a technically challenging surgical procedure. Use of the robot for resection is safe and feasible when performed by a trained and experienced surgeon.

I am pleased to bring you this video, and I hope that it is helpful to your practice. 

>> Arnold P. Advincula, MD

Vidyard Video

Share your thoughts! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.