Eligibility for home oxygen programs and funding across Canada

The benefits and drawbacks of home oxygen therapy for COPD: what's next?

INTRODUCTION

Home oxygen therapy is one of the few interventions that can improve survival in patients with chronic obstructive pulmonary disease (COPD) when administered appropriately, although it may cause side effects and be an unnecessary burden for some patients.

AREAS COVERED

This narrative review summarizes the current literature on the assessment of hypoxemia, different types of home oxygen therapy, potential beneficial and adverse effects, and emerging research on home oxygen therapy in COPD. A literature search was performed using MEDLINE and EMBASE up to January 2024, with additional articles being identified through clinical guidelines.

EXPERT OPINION

Hypoxemia is common in patients with more severe COPD. Long-term oxygen therapy is established to prolong survival in patients with chronic severe resting hypoxemia. Conversely, in the absence of chronic severe resting hypoxemia, home oxygen therapy has an unclear or conflicting evidence base, including for palliation of breathlessness, and is generally not recommended. However, beneficial effects in some patients cannot be precluded. Evidence is emerging on the optimal daily duration of oxygen use, the role of high-flow and auto-titrated oxygen therapy, improved informed decision-making, and telemonitoring. Further research is needed to validate novel oxygen delivery systems and monitoring tools and establish long-term effects of ambulatory oxygen therapy in COPD.

Use of Palliative Oxygen in Cancer Patients

Background: Despite the lack of evidence to support the use of palliative oxygen to relieve dyspnea at the end of life, its prescription is widespread and often supported by local and national practice guidelines. Objectives: The objectives of this study were (1) to determine to what extent oxygen prescriptions meet the proposed prescription criteria in our institution, (2) to examine the indication of individual prescriptions in relation to the severity of dyspnea and (3) to review the utilization of opioids in patients receiving palliative oxygen. Methods: Retrospective chart review of cancer patients who were prescribed palliative oxygen between April 2015 and January 2020 through a respiratory home care program in Quebec City, Canada. According to provincial prescription guidelines, palliative oxygen was provided and reimbursed in case of severe hypoxemia (pulse oximetry saturation at rest < 88%) in cancer patients with an estimated prognosis of less than 3 months. Results: 134 patients receiving palliative oxygen were included; 25 (19%) did not fulfill reimbursement criteria. Median survival was 44 days. At initiation of palliative oxygen, 48 patients (36%) had only mild or moderate dyspnea (Medical Research Council dyspnea score 1-3), 26 (19%) did not receive opioids, and 9 (7%) were prescribed palliative oxygen without being dyspneic or receiving opioids. Conclusion: Most prescriptions of palliative oxygen met the proposed prescription criteria in our institution. Half of those who received palliative oxygen were only mildly dyspneic and/or were not receiving opioids at the time of the prescription.

2022 Brazilian Thoracic Association recommendations for long-term home oxygen therapy

Some chronic respiratory diseases can cause hypoxemia and, in such cases, long-term home oxygen therapy (LTOT) is indicated as a treatment option primarily to improve patient quality of life and life expectancy. Home oxygen has been used for more than 70 years, and support for LTOT is based on two studies from the 1980s that demonstrated that oxygen use improves survival in patients with COPD. There is evidence that LTOT has other beneficial effects such as improved cognitive function, improved exercise capacity, and reduced hospitalizations. LTOT is indicated in other respiratory diseases that cause hypoxemia, on the basis of the same criteria as those used for COPD. There has been an increase in the use of LTOT, probably because of increased life expectancy and a higher prevalence of chronic respiratory diseases, as well as greater availability of LTOT in the health care system. The first Brazilian Thoracic Association consensus statement on LTOT was published in 2000. Twenty-two years la-ter, we present this updated version. This document is a nonsystematic review of the literature, conducted by pulmonologists who evaluated scientific evidence and international guidelines on LTOT in the various diseases that cause hypoxemia and in specific situations (i.e., exercise, sleep, and air travel). These recommendations, produced with a view to clinical practice, contain several charts with information on indications for LTOT, oxygen sources, accessories, strategies for improved efficiency and effectiveness, and recommendations for the safe use of LTOT, as well as a LTOT prescribing model.

Cost-Effectiveness of an Extended Home Visit Program for Oxygen-Dependent COPD Patients

BACKGROUND

Long-term oxygen therapy in COPD is usually supervised through home-care respiratory programs. Such programs often involve an intensive education intervention at the initiation of long-term oxygen therapy, followed by an extended follow-up period that aims toward home oxygen adherence. The objective of this study was to estimate the cost-effectiveness ratio of such a maintenance program.

METHODS

A simulation model was developed that compared 2 strategies after the intensive education intervention: (1) enrollment and (2) no enrollment in a maintenance program. The study population consisted of a hypothetical cohort of 200 patients (100 patients per group; mean age, 74 years; 45% men; mean FEV₁ of 43% predicted value; and mean resting P_aO2 while breathing air, 50 mm Hg). Effectiveness assumptions of the program were derived from a current literature review. The primary outcome was the ratio of the incremental cost of the program per quality-adjusted life-years gained. Only direct costs were considered; a health-care system perspective was adopted. Costs are reported in 2020 Canadian dollars (Can $).

RESULTS

Over a 5-year period, an extended home-visit program may prevent 9 deaths and provide an additional 39 years of life and 24 quality-adjusted life-years. Compared with usual care (ie, no enrollment in the maintenance program), the incremental cost-effectiveness ratio was Can $17,197 per quality-adjusted life-years gained. Sensitivity analyses demonstrated the robustness of the model. Only a reduction in adherence of 25% per year would increase the incremental cost-effectiveness ratio per quality-adjusted life-years beyond the threshold of Can $50,000 that is usually considered as acceptable from a health-care system perspective.

CONCLUSIONS

An extended home-visit program to maintain or improve adherence to long-term oxygen therapy in patients with COPD would most likely be cost-effective.

Rapid Growth Of Remote Patient Monitoring Is Driven By A Small Number Of Primary Care Providers

Growing enthusiasm for remote patient monitoring has been motivated by the hope that it can improve care for patients with poorly controlled chronic illness. In a national commercially insured population in the US, we found that billing for remote patient monitoring increased more than fourfold during the first year of the COVID-19 pandemic. Most of this growth was driven by a small number of primary care providers. Among the patients of these providers with a high volume of remote patient monitoring, we did not observe substantial targeting of remote patient monitoring to people with greater disease burden or worse disease control. Further research is needed to identify which patients benefit from remote patient monitoring, to inform evidence-based use and coverage decisions. In the meantime, payers and policy makers should closely monitor remote patient monitoring use and spending.

Oximetry neither to prescribe long-term oxygen therapy nor to screen for severe hypoxaemia

Background and objective

Transcutaneous pulse oximetry saturation (S_pO2) is widely used to diagnose severe hypoxaemia and to prescribe long-term oxygen therapy (LTOT) in COPD. This practice is not based on evidence. The primary objective of this study was to determine the accuracy (false positive and false negative rates) of oximetry for prescribing LTOT or for screening for severe hypoxaemia in patients with COPD.

Methods

In a cross-sectional study, we correlated arterial oxygen saturation (S_aO2) and S_pO2 in patients with COPD and moderate hypoxaemia (n=240) and calculated the false positive and false negative rates of S_aO2 at the threshold of ≤88% to identify severe hypoxaemia (arterial oxygen tension (P_aO2) ≤55 mmHg or P_aO2 <60 mmHg) in 452 patients with COPD with moderate or severe hypoxaemia.

Results

The correlation between S_aO2 and S_pO2 was only moderate (intra-class coefficient of correlation: 0.43; 95% confidence interval: 0.32–0.53). LTOT would be denied in 40% of truly hypoxaemic patients on the basis of a S_aO2 >88% (i.e., false negative result). Conversely, LTOT would be prescribed on the basis of a S_aO2 ≤88% in 2% of patients who would not qualify for LTOT (i.e., false positive result). Using a screening threshold of ≤92%, 5% of severely hypoxaemic patients would not be referred for further evaluation.

Conclusions

Several patients who qualify for LTOT would be denied treatment using a prescription threshold of saturation ≤88% or a screening threshold of ≤92%. Prescription of LTOT should be based on P_aO2 measurement.

Although transcutaneous pulse oximetry is widely used to diagnose severe hypoxaemia and prescribe long-term oxygen therapy in COPD, up to 40% of patients who qualify for this therapy would be denied treatment using the saturation threshold of ≤88%https://bit.ly/3jolWU5

Patient-centered Outcomes Research in Interstitial Lung Disease: An Official American Thoracic Society Research Statement

Background: In the past two decades, many advances have been made to our understanding of interstitial lung disease (ILD) and the way we approach its treatment. Despite this, many questions remain unanswered, particularly those related to how the disease and its therapies impact outcomes that are most important to patients. There is currently a lack of guidance on how to best define and incorporate these patient-centered outcomes in ILD research. Objectives: To summarize the current state of patient-centered outcomes research in ILD, identify gaps in knowledge and research, and highlight opportunities and methods for future patient-centered research agendas in ILD. Methods: An international interdisciplinary group of experts was assembled. The group identified top patient-centered outcomes in ILD, reviewed available literature for each outcome, highlighted important discoveries and knowledge gaps, and formulated research recommendations. Results: The committee identified seven themes around patient-centered outcomes as the focus of the statement. After a review of the literature and expert committee discussion, we developed 28 research recommendations. Conclusions: Patient-centered outcomes are key to ascertaining whether and how ILD and interventions used to treat it affect the way patients feel and function in their daily lives. Ample opportunities exist to conduct additional work dedicated to elevating and incorporating patient-centered outcomes in ILD research.

Ambulatory oxygen for treatment of exertional hypoxaemia in pulmonary fibrosis (PFOX trial): a randomised controlled trial

INTRODUCTION

Interstitial lung diseases are characterised by scarring of lung tissue that leads to reduced transfer of oxygen into the blood, decreased exercise capacity and premature death. Ambulatory oxygen therapy may be used to treat exertional oxyhaemoglobin desaturation, but there is little evidence to support its efficacy and there is wide variation in clinical practice. This study aims to compare the clinical efficacy and cost-effectiveness of ambulatory oxygen versus ambulatory air in people with fibrotic interstitial lung disease and exertional desaturation.

METHODS AND ANALYSIS

A randomised, controlled trial with blinding of participants, clinicians and researchers will be conducted at trial sites in Australia and Sweden. Eligible participants will be randomised 1:1 into two groups. Intervention participants will receive ambulatory oxygen therapy using a portable oxygen concentrator (POC) during daily activities and control participants will use an identical POC modified to deliver air. Outcomes will be assessed at baseline, 3 months and 6 months. The primary outcome is change in physical activity measured by number of steps per day using a physical activity monitor (StepWatch). Secondary outcomes are functional capacity (6-minute walk distance), health-related quality of life (St George Respiratory Questionnaire, EQ-5D-5L and King's Brief Interstitial Lung Disease Questionnaire), breathlessness (Dyspnoea-12), fatigue (Fatigue Severity Scale), anxiety and depression (Hospital Anxiety and Depression Scale), physical activity level (GENEActive), oxygen saturation in daily life, POC usage, and plasma markers of skeletal muscle metabolism, systematic inflammation and oxidative stress. A cost-effectiveness evaluation will also be undertaken.

ETHICS AND DISSEMINATION

Ethical approval has been granted in Australia by Alfred Hospital Human Research Ethics Committee (HREC/18/Alfred/42) with governance approval at all Australian sites, and in Sweden (Lund Dnr: 2019-02963). The results will be published in peer-reviewed scientific journals, presented at conferences and disseminated to consumers in publications for lay audiences.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03737409).

Home Oxygen Therapy for Adults with Chronic Lung Disease. An Official American Thoracic Society Clinical Practice Guideline

Background: Evidence-based guidelines are needed for effective delivery of home oxygen therapy to appropriate patients with chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD).Methods: The multidisciplinary panel created six research questions using a modified Delphi approach. A systematic review of the literature was completed, and the Grading of Recommendations Assessment, Development and Evaluation approach was used to formulate clinical recommendations.Recommendations: The panel found varying quality and availability of evidence and made the following judgments: 1) strong recommendations for long-term oxygen use in patients with COPD (moderate-quality evidence) or ILD (low-quality evidence) with severe chronic resting hypoxemia, 2) a conditional recommendation against long-term oxygen use in patients with COPD with moderate chronic resting hypoxemia, 3) conditional recommendations for ambulatory oxygen use in patients with COPD (moderate-quality evidence) or ILD (low-quality evidence) with severe exertional hypoxemia, 4) a conditional recommendation for ambulatory liquid-oxygen use in patients who are mobile outside the home and require >3 L/min of continuous-flow oxygen during exertion (very-low-quality evidence), and 5) a recommendation that patients and their caregivers receive education on oxygen equipment and safety (best-practice statement).Conclusions: These guidelines provide the basis for evidence-based use of home oxygen therapy in adults with COPD or ILD but also highlight the need for additional research to guide clinical practice.

Home Oxygen in Chronic Obstructive Pulmonary Disease

Two landmark trials conducted more than 35 years ago provided scientific evidence that, under very specific circumstances, long-term oxygen therapy (LTOT) may prolong life. These two trials enrolled 290 patients with chronic obstructive pulmonary disease and severe daytime hypoxemia documented by direct arterial blood gas measurement. From that time, LTOT became a standard of care, and the indications for oxygen therapy expanded to include nocturnal oxygen therapy for isolated nocturnal oxygen desaturation, ambulatory oxygen to correct exercise-induced desaturation, and short-burst oxygen to relieve dyspnea. In most cases, the rationale for broadening the indications for oxygen therapy is that, if hypoxemia exists, correcting it by increasing the Fi_O2 should help. However, with the exception of LTOT in severely hypoxemic patients with chronic obstructive pulmonary disease, randomized controlled trials of oxygen therapy have failed to demonstrate clinically significant benefits. Also, adherence to LTOT is usually suboptimal. Important areas for future research include improving understanding of the mechanisms of action of supplemental oxygen, the clinical and biochemical predictors of responsiveness to LTOT, the methods for measuring and enhancing adherence to LTOT, and the cost-effectiveness of oxygen therapy. A standardization of terminology to describe the use of supplemental oxygen at home is provided.

Patient registries for home oxygen research and evaluation

Randomized clinical trials are the preferred study design to address key research questions about the benefits or harms of interventions. However, randomized trials of oxygen therapy are difficult to conduct and have limitations. The purpose of this article is to offer our view on the potential use of patient registries in the field of home oxygen in COPD as an alternative to randomized trials by referring to the Swedish experience with a national registry for respiratory failure. Patient registries use observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure. As opposed to administrative databases, patient registries serve one or more predetermined scientific, clinical, or policy purposes. By systematically and prospectively compiling relevant data, patient registries may describe the natural history of a disease, determine effectiveness and cost-effectiveness, assess safety or harm, and measure quality of care. Registry-based randomized trials (ie, randomized trials within a clinical registry) combine the advantages of a prospective randomized trial with the strengths of a large-scale all-comers clinical registry. Challenges and issues in the design and implementation of patient registries include the representativeness of participants, data collection, quality assurance, ownership, and governance. Notwithstanding their limitations, patient registries represent valuable tools in the conduct of research in the area of home oxygen therapy.