Home oxygen therapy in Medicare beneficiaries, 1991 and 1992

Clinical features of patients on home oxygen therapy due to chronic respiratory failure at one university hospital

BACKGROUND/AIMS

Home oxygen therapy (HOT) costs a great deal every year and demand for the service is growing. In Korea, health insurance has covered HOT since November 1, 2006. The objective of this study was to evaluate clinical features of patients who used long-term HOT due to chronic respiratory failure and to determine the appropriateness of oxygen prescriptions.

METHODS

Between November 2006 and April 2010, patients prescribed long-term HOT were enrolled in the study at a tertiary university referral hospital and their medical records and telephone survey information were evaluated. In total, 340 patients were evaluated retrospectively.

RESULTS

Regarding the initial indications for HOT, their mean PaO(2) was 49.8 mmHg and mean SpO(2) was 82.2%. Underlying diseases included chronic obstructive pulmonary disease (COPD, 19.8%), lung cancer (12.6%), and interstitial lung disease (11.2%). The admission rate within 1 year was 53.4% and the average number of admissions was 1.64/patient. Other underlying diseases for which oxygen was prescribed, despite not meeting the insurance coverage criteria, were lung cancer (36.6%) and interstitial pneumonia (16.6%).

CONCLUSIONS

Home oxygen prescriptions have increased since health insurance coverage was extended. However, cases of oxygen prescriptions frequently do not meet the coverage criteria. It is important to discuss extending the coverage criteria to other disease groups, such as interstitial lung disease and lung cancer, in terms of cost-effectiveness. Further, physicians prescribing oxygen therapy should be educated regarding the criteria.

Racial and sex differences in chronic obstructive pulmonary disease susceptibility, diagnosis, and treatment

PURPOSE OF REVIEW

Chronic obstructive pulmonary disease (COPD) is an increasing cause of morbidity and mortality worldwide. Although COPD has historically been considered a disease of white male smokers, it now clearly impacts both sexes and all races, with mortality rising fastest in women and African-Americans. Given the scarcity of data about non-African-American minorities, this review will focus on the disparities in COPD susceptibility, diagnosis, and treatment between men and women and between African-Americans and whites.

RECENT FINDINGS

Although the changing epidemiology of COPD in part reflects the changing epidemiology of cigarette smoking, there are data suggesting that women and African-Americans may be particularly susceptible to tobacco smoke and that the diagnosis, treatment, and natural history of the disease are influenced by race and sex.

SUMMARY

The possibility that sex or race or both, may influence COPD susceptibility and progression is of critical importance, and may mean that the potential future impact of the disease has been underestimated. Unfortunately, our understanding of these differences and the efficacy of standard COPD treatments in women and minorities remains limited by the low enrollment in clinical trials.

Responses to tiotropium in African-American and Caucasian patients with chronic obstructive pulmonary disease

Sparse information exists about chronic obstructive pulmonary disease (COPD) outcomes among different ethnic groups. To determine whether the effect of tiotropium on COPD exacerbation differs between African Americans and Caucasians, we performed a post hoc analysis of African-American (n = 150) and Caucasian (n = 1670) subgroups from a previously reported 6-month trial of tiotropium in patients with moderate-to-very-severe COPD. Compared with placebo, tiotropium reduced the likelihood of having at least 1 exacerbation in the entire group (RR, 0.81; 95% CI, 0.66-0.99, P = 0.037) with no statistically significant difference between African-American and Caucasian subgroups (P = 0.34). For African Americans, tiotropium significantly reduced the number of antibiotic days for COPD, hospitalizations for exacerbations, and hospitalization days for COPD. For Caucasians, tiotropium significantly reduced the number of exacerbations, exacerbation days, unscheduled clinic visits for COPD, and hospitalizations for exacerbations. Tiotropium reduced the frequencies of antibiotic days and of COPD hospital days to a significantly greater extent in African Americans compared with Caucasians (P = 0.027 and P = 0.025, respectively). No statistically significant ethnic-related differences were observed in the effect of tiotropium on the frequencies of exacerbations, exacerbation days, systemic corticosteroid days, unscheduled clinic visits, or COPD hospitalizations. Spirometry improved to a similar extent in both subgroups for the entire duration of the 6-month trial. African Americans used fewer respiratory medications than Caucasians in this study. We conclude that tiotropium reduces COPD exacerbations and associated health-care use to a similar extent in African Americans compared with Caucasians.

COPD: racial disparities in susceptibility, treatment, and outcomes

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States and mortality continues to increase particularly among African Americans. Although this increase may be caused by changing smoking habits, some studies suggest that African Americans may be more susceptible to tobacco smoke than whites. Unlike other respiratory diseases for which there are significant published data on racial and ethnic disparities in disease outcomes, such information is notably lacking in the COPD literature. This article examines the available data concerning racial disparities in COPD susceptibility and care.

The impact of the Danish Oxygen Register on adherence to guidelines for long-term oxygen therapy in COPD patients

OBJECTIVES

To evaluate the impact of The Danish Oxygen Register on COPD patients' treatment modalities, survival, and adherence to guidelines for long-term oxygen therapy (LTOT).

DESIGN

The Danish Oxygen Register.

SUBJECTS

8487 COPD patients who received LTOT in the study period from November 1, 1994, to December 31, 2000.

MAIN OUTCOME MEASURES

Follow-up, smoking status, correct prescription of LTOT (15-24h/day), and survival.

RESULTS

During the study period an increasing number of patients were prescribed LTOT in connection with discharge after hospitalisation for an exacerbation (1995 vs. 2000: 74.4% vs. 82.2%, P<0.001), were prescribed oxygen 15-24h/day (66.2% vs. 85.5%, P<0.001), had delivered oxygen concentrator or liquid oxygen (77.8% vs. 96.9%, P<0.001), and had mobile oxygen (29.9% vs. 42.8%, P<0.001). Only 65.8% of the patients were followed-up in an outpatient clinic with the possibility of re-evaluation of the criteria for LTOT and adjustment for oxygen flow, with no change during the study period (P=0.43). In a representative subsample, 77.1% had smoking habits or measurement of CO-level registered in 1995 compared to 79.6% in year 2000 (P=0.65), and 25.1% vs. 21.2% (P=0.34) were considered current smokers. The median survival increased from 1.07 to 1.40 years (P=0.032).

CONCLUSIONS

Adherence to guidelines for LTOT has improved concerning administration of oxygen, but has remained poor concerning follow-up of the patients and smoking cessation. Survival of COPD patients on LTOT has improved during the observation period.

Continuous Oxygen Therapy for Hypoxic Pulmonary Disease

Continuous oxygen therapy (COT) has become widely accepted in the last 20 years in patients with continuous hypoxemia. This review focuses on guidelines for COT, adherence to these guidelines, and the effect of COT on survival, hospitalization, and quality of life. Guidelines for COT are mainly based on three randomized studies where documentation of hypoxemia (P(a)O2 <60mm Hg) and administration of oxygen at least 15 hours/day, are essential. There is less certainty concerning the required correction for hypoxemia, the attitude against current smokers with hypoxemia, the frequency and methods of follow up, and the effect of prescribing domiciliary oxygen to patients with temporary hypoxemia due to a clinically unstable condition (i.e. short-term oxygen therapy [STOT]). The administration of COT to patients with hypoxemic conditions other than COPD rests on extrapolation of data from COPD patients in the NOTT (Nocturnal Oxygen Therapy Trial) and MRC (British Medical Research Council) studies. Adherence to these guidelines is low in general, and very low in some cases. In some countries, STOT accounts for the majority of all prescriptions of domiciliary oxygen, and because nearly half of these patients do not meet the hypoxemia criteria at 3-month follow-up, re-evaluation is mandatory. Only 35%, approximately, of the patients are followed up, and this is one of the main reasons for poor adherence to the hypoxemia criteria. In order to improve the quality of surveillance of COT, more effort has to be put into education of the patients and staff responsible for COT, centralization of the domiciliary organizations, better equipment for ambulation and traveling, and regular follow-up preferably with home visits. The role of an oxygen register on the quality of surveillance of COT has to be determined. The beneficial effect of COT on survival is well established, and some evidence suggests that COT reduces hospitalization. It appears that ambulatory oxygen from liquid source or lightweight cylinders improves disease-specific quality of life modestly in selected patients who partake in regular outdoor activity. Whether COT from oxygen concentrators improves quality of life significantly is, at present, less clear.

Data sources: use in the epidemiologic study of medical devices

Medical device epidemiology is the study of the prevalence and incidence of use, effectiveness, and adverse events associated with medical devices in a population. The identification of large data sources with medical device data provides a large population for epidemiologic studies. Two challenges in medical device epidemiology are the ability to find data on the specific device and the exposure of a patient to that device. This paper identifies data sources both from the govenment and from the private sector that can be used for epidemiologic studies of medical devices and, to a limited degree, studies of medical devices in women. Each source provides data for different types of devices and in differing specificity. The paper also discusses briefly the strengths and weaknesses of each data source. More data sources are needed to enhance the study of medical device epidemiology. Additional efforts and focus are needed to enhance the ability to study medical devices in women.

Are patients on long-term oxygen therapy followed up properly? Data from the Danish Oxygen Register

OBJECTIVES

The aim of the study was to assess the extent and quality of follow-up of patients on LTOT.

SETTING

The Danish Oxygen Register.

SUBJECTS

A total of 890 chronic obstructive pulmonary disease (COPD) patients who were on long-term oxygen therapy (LTOT) during the period from 1 November 1994 to 31 August 1995.

MAIN OUTCOME MEASURES

The extent and quality of follow-up.

RESULTS

Only 38.5% of the patients were followed up in the study period, and only 17.5% had a 'sufficient follow-up' defined as at least one follow-up visit within 10 months which included measurement of arterial blood gases or pulsoximetry with oxygen supply, verification that the patient used oxygen > or =15 h day-1 and was nonsmoker. Female gender, LTOT initiated 3-12 months ago, LTOT started by a chest physician at pulmonary department and LTOT prescribed > or =15 h day-1 were found to be significant predictors of 'sufficient follow-up' (odds ratio (OR): 1.7, 2.0, 3.7 and 1.9, respectively).

CONCLUSIONS

The extent and the quality of follow-up of patients on LTOT were poor, especially if a nonpulmonary physician initiated LTOT. We recommend that more attention should be paid on proper monitoring of LTOT, and that only chest physicians should be able to prescribe and re-evaluate LTOT.