A model of quality assessment in patients on long-term oxygen therapy

Development and pilot-testing of an evidence-based quality indicator set for home mechanical ventilation care: the OVER-BEAS project

BACKGROUND

The number of patients depending on home mechanical ventilation (HMV) has increased substantially in Germany in recent years. These patients receive long-term care in different nursing facilities (nursing home, shared living community, private home). However, there are limited data available on the quality of care of HMV patients. The aim of the OVER-BEAS project was to identify quality indicators (QIs) of HMV care using an evidence-based approach.

METHODS

A multidisciplinary board consisting of professionals and experts of HMV provision compiled a set of QIs between March and September 2019. In a structured, transparent process a set of QIs covering structures, processes and outcome of HMV patient's care were proposed and evaluated based on the best available evidence. QIs were defined as relevant, reliable and valid measurements of the quality of HMV care and furthermore to be comprehensive and applicable in practice.

RESULTS

The experts proposed 40 QIs and consented a final set of 26 QIs. Based on the final set, questionnaires to document the QIs were developed: (1) to assess the quality and describe the structure of the nursing facility; and (2) to gather information on patient-related processes and outcomes. The feasibility of the questionnaires was tested in 5 nursing facilities treating HMV patients. The remarks from the nursing specialists were categorised in three groups: (1) term missing accuracy, (2) problem of understanding, and (3) not documented or documented elsewhere. Mean documentation time by the nursing specialists for one patient was 15 min. Based on this feedback, the questionnaires were finalised.

CONCLUSIONS

We proposed a set of QIs relating to long-term HMV care and developed two questionnaires to collect this information. In a pilot study, we found the set of questionnaires to be feasible in assessing the quality of HMV care according to current evidence. The development of standardised evidence-based QIs to evaluate HMV care is a step towards implementing a standardised quality assurance program to document the quality of care of HMV patients.

New Perspectives in Oxygen Therapy Titration: Is Automatic Titration the Future?

Oxygen therapy, like all technology-based treatments, is continuously evolving. There are no doubts as to its effectiveness in the treatment of acute and respiratory failure in different clinical scenarios. However, the dosing guidelines for oxygen therapy are not as strict as for other treatments. The use of higher than necessary flows over excessively long periods, derived from the clinician's perception of it as a 'life-saving treatment with few side effects', has led to a rather liberal use of this intervention, despite evidence that overuse and suboptimal adjustment can be harmful. The titration of oxygen therapy, which is traditionally performed manually, has been shown to be beneficial. Recently, new devices have been developed that automatically adjust oxygen flow rates to the needs of each patient, in order to maintain stable oxygen saturation levels. These closed-loop oxygen supply systems can potentially reduce medical error, improve morbidity and mortality, and reduce care costs. Familiarizing the medical community with these technological advances will improve awareness of the risks of the inappropriate use of oxygen therapy. The aim of this paper is to provide an update of recent developments in oxygen therapy titration.

Lung transplantation and survival outcomes in patients with oxygen-dependent COPD with regard to their alpha-1 antitrypsin deficiency status

Background

Individuals with severe alpha-1 antitrypsin deficiency (AATD) have an increased risk of developing COPD. However, outcomes during long-term oxygen therapy (LTOT) in patients with severe AATD and hypoxemia are unknown.

Patients and methods

This was a prospective, population-based, consecutive cohort study of patients on LTOT due to COPD in the period from January 1, 1987, to June 30, 2015, in the Swedish National Registry for Respiratory Failure (Swedevox). Severe AATD was identified using the Swedish AATD registry and confirmed by isoelectric focusing. Data on lung transplantation (LTx) were obtained from the two lung transplantation centers in Sweden. Mortality and causes of death were assessed based on the National Causes of Death Registry and analyzed using multivariable Cox regression.

Results

A total of 14,644 patients who started LTOT due to COPD were included in this study. No patient was lost to follow up. Patients with AATD were younger, included more males and more never smokers, and had fewer comorbidities. During a median follow-up of 1.6 years (interquartile range [IQR], 2.7) on LTOT, patients without severe AATD had a higher mortality, hazard ratio [HR] 1.53 (95% CI, 1.24–1.88), adjusting for age, sex, smoking status, body mass index, performance status, level of hypoxemia, and comorbidities. Cardiovascular deaths were increased. A higher proportion of AATD patients underwent LTx, 53 (19%) vs 118 (1%). Survival after LTx was similar for AATD and non-AATD patients and was predicted by age.

Conclusion

In oxygen-dependent COPD, patients with severe AATD have a longer survival time on LTOT, but they have a similar prognosis after lung transplantation compared with patients without AATD.

A nationwide structure for valid long-term oxygen therapy: 29-year prospective data in Sweden

Background

Long-term oxygen therapy (LTOT) improves prognosis in COPD with severe hypoxemia. However, adherence to criteria for eligibility and quality of LTOT is often insufficient and varies between countries. The aim of this study was to evaluate a national structure for prescription and management of LTOT over three decades in Sweden.

Methods

The study was a prospective, population-based study of 23,909 patients on LTOT from 1987 to 2015 in the Swedish National Register of Respiratory Failure (Swedevox). We assessed the prevalence, incidence, and structure of LTOT; completeness of registration in Swedevox; and validity of prescription and management of LTOT in Sweden according to seven published quality indicators.

Results

LTOT was prescribed by 48 respiratory or medicine units and managed mainly by specialized oxygen nurses. Swedevox had a stable completeness of 85% of patients starting LTOT since 1987. The national incidence of LTOT increased from 3.9 to 14.7/100,000 inhabitants over the time period. In 2015, 2,596 patients had ongoing therapeutic LTOT in the registry, a national prevalence of 31.6/100,000. Adherence to prescription recommendations and fulfillment of quality criteria was stable or improved over time. Of patients starting LTOT in 2015, 88% had severe hypoxemia (partial pressure of arterial oxygen [PaO₂] <7.4 kPa) and 97% had any degree of hypoxemia (PaO₂ <8.0 kPa); 98% were prescribed oxygen ≥15 hours/day or more; 76% had both stationary and mobile oxygen equipment; 75% had a mean PaO₂ >8.0 kPa breathing oxygen; and 98% were non-smokers.

Conclusion

We present a structure for prescription, management, and follow-up of LTOT. The national registry effectively monitored adherence to prescription recommendations and most likely contributed to improved quality of care.

Home oxygen therapy: evidence versus reality

INTRODUCTION

LTOT is a well-established treatment option for hypoxemic patients. Scientific evidence for its benefits of LTOT dates back to the 1980s, when two randomized controlled trials showed prolonged survival in COPD-patients undergoing LTOT for at least 15 hours/day. In contrast, the potential benefits of LTOT in non-COPD-patients has not been well researched and the recommendations for its application are primarily extrapolated from trials on COPD-patients. Recently, a large trial confirmed that COPD-patients who don't meet classic indication criteria, and have moderate desaturation at rest or during exercise, do not benefit from oxygen therapy. Also the significant technical evolution of LTOT devices has improved its application. Areas covered: A literature research was performed in pubmed regarding home oxygen therapy (terms: LTOT, ambulatory oxygen therapy, short burst oxygen therapy, nocturnal oxygen therapy). Expert commentary: LTOT proved a survival benefit for COPD patients about 30 years ago. Whether the results of these trials are still valid for patients under modern treatment guidelines remains unknown. Nevertheless, the classic indication criteria for LTOT still persist in guidelines, since there is a lack of updated evidence for the effects of LTOT in more severe hypoxemic patients.

The risk of burn injury during long-term oxygen therapy: a 17-year longitudinal national study in Sweden

BACKGROUND

Long-term oxygen therapy (LTOT) improves the survival time in hypoxemic chronic obstructive pulmonary disease. Despite warnings about potential dangers, a considerable number of patients continue to smoke while on LTOT. The incidence of burn injuries related to LTOT is unknown. The aim of this study was to estimate the rate of burn injury requiring health care contact during LTOT.

METHODS

Prospective, population-based, consecutive cohort study of people starting LTOT from any cause between January 1, 1992 and December 31, 2009 in the Swedish National Register of Respiratory Failure (Swedevox).

RESULTS

In total, 12,497 patients (53% women) were included. The mean (standard deviation) age was 72±9 years. The main reasons for starting LTOT were chronic obstructive pulmonary disease (75%) and pulmonary fibrosis (15%). Only 269 (2%) were active smokers when LTOT was initiated. The median follow-up time to event was 1.5 years (interquartile range, 0.55-3.1). In total, 17 patients had a diagnosed burn injury during 27,890 person-years of LTOT. The rate of burn injury was 61 (95% confidence interval, 36-98) per 100,000 person-years. There was no statistically significant difference in the rate of burn injury between ever-smokers and never-smokers, or between men and women.

CONCLUSION

The rate of burn injuries in patients on LTOT seems to be low in Sweden. The strict requirements in Sweden for smoking cessation before LTOT initiation may contribute to this finding.

Assessment of health status and program performance in patients on long-term oxygen therapy

BACKGROUND

Despite well established clinical guidelines, performance of long-term oxygen therapy (LTOT) programs shows marked variability among territories. The current study assessed the LTOT program and the health status of patients on LTOT prior to the deployment of community-based integrated care in an urban health district of Barcelona (Spain).

AIMS

To assess: i) the LTOT program and health status of the patients on LTOT in the health district; ii) their frailty profile; and, iii) the requirements for effective deployment of integrated care services for these patients.

METHODS

Cross-sectional observational study design including all patients (n = 406) on LTOT living in the health district. Health status, frailty, arterial blood gases, forced spirometry and hand-grip muscle strength were measured. Network analysis of frailty was carried out.

RESULTS

Adequacy of LTOT prescription (n = 362): 47% and 31% of the patients had PaO2 ≤ 60 mmHg and ≤55 mmHg, respectively. Adherence to LTOT: 31% of all patients used LTOT ≥15 h/d; this figure increased to 67% in those with PaO2≤60 mmHg. Assessment of frailty: Overall, LTOT patients presented moderate to severe frailty. Care complexity was observed in 42% of the patients.

CONCLUSIONS

Adequacy and adherence to LTOT was poor and many patients were frail and complex. The outcomes of the network analysis may contribute to enhance assessment of frailty in LTOT patients. These observations suggest that an integrated care strategy has the potential to improve the health outcomes of these patients.

Trends in long-term oxygen therapy for COPD in Denmark from 2001 to 2010

OBJECTIVES

To evaluate changes in demographics, incidence, prevalence, treatment modalities, and survival of COPD patients on long-term oxygen therapy (LTOT) from year 2001-2010 in Denmark.

METHODS

All 14,965 COPD patients with COPD treated LTOT in Denmark in the period 2001-2010.

RESULTS

During the study period, the incidence and prevalence of COPD patients on LTOT increased from 30.5 to 32.2 per 100.000, and from 42.0 to 48.1 per 100.000, respectively. Mean age of patients increased from 73.4 to 74.8 years, P < 0.001. An increasing number of patients were prescribed LTOT in connection with discharge after hospitalisation for an exacerbation (2001 vs. 2010: 76.5% vs. 91.7%, P < 0.001); were prescribed oxygen 15-24 h/day (85.8% vs. 89.5%, P < 0.001); had mobile oxygen (56.4% vs. 94.2%, P < 0.001), and stopped LTOT alive within 6 months (20.6% vs. 30.8%, P < 0.001). Ninety-nine percent of the patients received oxygen concentrator or liquid oxygen with no change in the study period (P = 0.66). The median survival on LTOT increased insignificantly from 16.5 to 17.8 months (P = 0.12). Women had a lower risk of dying compared with men, with an adjusted hazard ratio of 0.81 (95% confidence interval (CI) 0.78-0.84), P < 0.001). During the study period, the risk of death for women, compared to men, decreased significantly with a hazard ratio of 0.978 (95% CI: 0.964-0.992) per calendar year.

CONCLUSIONS

The incidence of COPD patients on LTOT in Denmark has levelled of during recent years, and the quality of prescribing LTOT and follow up has improved. Women had better survival than men, and this difference has increased during the study period.

A nationwide cohort study of the risk of chronic obstructive pulmonary disease in coeliac disease

OBJECTIVE

Chronic obstructive pulmonary disease (COPD) continues to be an important cause of morbidity, mortality and healthcare costs in the western world. Although smoking is an important trigger of COPD, other factors such as chronic inflammation and malnutrition are known to influence its development. Because coeliac disease (CD) is characterized both by dysregulated inflammation and malnutrition, the possibility of an association between CD and COPD was investigated.

METHODS

Through biopsy data from all Swedish pathology departments, we identified 10 990 individuals with CD who were biopsied between 1987 and 2008 (Marsh 3: villous atrophy). As controls, 54 129 reference individuals matched for age, sex, county and calendar year of first biopsy were selected. Cox regression analysis was then performed to estimate hazard ratios (HRs) for having a diagnosis of COPD according to the Swedish Patient Register.

RESULTS

During follow-up, 380 individuals with CD (3.5%) and 1391 (2.6%) controls had an incident diagnosis of COPD, which corresponds to an HR of 1.24 (95% CI: 1.10-1.38) and an excess risk of COPD of 79/100 000 person-years in CD. The risk increase remained 5 years after biopsy (HR = 1.17; 95% CI: 1.00-1.37). Risk estimates did not change with adjustment for type 1 diabetes, thyroid disease, rheumatoid arthritis, country of birth or level of education. Men with CD were at a higher risk of COPD (HR = 1.39; 95% CI: 1.18-1.62) than women with CD (HR = 1.11; 95% CI: 0.94-1.30). Of note, CD was also associated with COPD before CD diagnosis (odds ratio = 1.22; 95% CI: 1.02-1.46). Conclusion.  Patients with CD seem to be at a moderately increased risk of COPD both before and after CD diagnosis.