Reassessment of Home Oxygen Prescription after Hospitalization for Chronic Obstructive Pulmonary Disease. A Potential Target for Deimplementation

Abstract

Rationale: Hypoxemia associated with acute exacerbations of chronic obstructive pulmonary disease (COPD) often resolves with time. Current guidelines recommend that patients recently discharged with supplemental home oxygen after hospitalization should not have renewal of the prescription without assessment for hypoxemia. Understanding patterns of home oxygen reassessment is an opportunity to improve quality and value in home oxygen prescribing and may provide future targets for deimplementation.Objectives: We sought to measure the frequency of home oxygen reassessment within 90 days of hospitalization for COPD and determine the potential population eligible for deimplementation.Methods: We performed a cohort study of patients ≥40 years hospitalized for COPD at five Veterans Affairs facilities who were prescribed home oxygen at discharge. Our primary outcome was the frequency of reassessment within 90 days by oxygen saturation (Sp_O2) measurement. Secondary outcomes included the proportion of patients potentially eligible for discontinuation (Sp_O2 > 88%) and patients in whom oxygen was discontinued. Our primary exposures were treatment with long-acting bronchodilators, prior history of COPD exacerbation, smoking status, and pulmonary hypertension. We used a mixed-effects Poisson model to measure the association between patient-level variables and our outcome, clustered by site. We also performed a positive deviant analysis using chart review to uncover system processes associated with high-quality oxygen prescribing.Results: A total of 287 of 659 (43.6%; range 24.8-78.5% by site) patients had complete reassessment within 90 days. None of our patient-level exposures were associated with oxygen reassessment. Nearly half of those with complete reassessment were eligible for discontinuation on the basis of Medicare guidelines (43.2%; n = 124/287). When using the newest evidence available by the Long-Term Oxygen Treatment Trial, most of the cohort did not have resting hypoxemia (84.3%; 393/466) and would be eligible for discontinuation. The highest-performing Veterans Affairs facility had four care processes to support oxygen reassessment and discontinuation, versus zero to one at all other sites.Conclusions: Fewer than half of patients prescribed home oxygen after a COPD exacerbation are reassessed within 90 days. New system processes supporting timely reassessment and discontinuation of unnecessary home oxygen therapy could improve the quality and value of care.

Keywords: COPD; care quality; oxygen.

Figure 1.

Flow diagram of cohort depicting oxygen discontinuation within 90 days of discharge. Values are given as n (%) with denominators. The flow tracts in blue depict the proportion of the cohort who had oxygen continued or discontinued in alignment with recommended practice. The flow tract in green represents the proportion of the cohort with oxygen continued for ambulatory hypoxemia, which is no longer recommended practice after the Long-Term Oxygen Treatment Trial (LOTT), and these patients would now be eligible for discontinuation. The flow tract in yellow represents a group that was inappropriately continued at the time of the cohort and is eligible for discontinuation. The flow tract in orange was incompletely reassessed based on recommendations at the time of the cohort but would be eligible for discontinuation based on LOTT. The flow tracts in red demonstrate the proportion of the cohort who did not have reassessment at rest or with ambulation. Five patients requested to discontinue home oxygen despite demonstrated hypoxemia and were not included in the flow diagram. *Eligible populations for oxygen discontinuation based on the new evidence provided by LOTT. ^†This flow tract includes 80 patients who underwent testing with ambulation and 23 without testing with ambulation. appt = appointment; PCP = primary care provider; Sp_O2 = peripheral oxygen saturation.