Literature Review on Challenges of Home Oxygen Therapy
More than 1 million Americans utilise home supplemental oxygen for a variety of lung conditions (1). National (1–half dozen) and international (7) oxygen consensus conferences have proposed recommendations for prescribing and supplying oxygen, technology development, and patient education and support. However, express information are bachelor to quantify how well goals are being met from a patient perspective. Patient advocacy groups, health care professionals and patients report problems with equipment, services, reimbursement, and portable systems. Although supplemental oxygen is purported to assist patients "proceed with their social and professional lives" (8), patients report that electric current portable oxygen options relegate them to a "stay-at-home" lifestyle (9–12).
The socioeconomic and educational factors influencing supplemental oxygen services are complex. Increasing numbers of patients meet criteria for supplemental oxygen, a consequence of the large number of those diagnosed with chronic obstructive pulmonary disease (COPD) and other lung disorders (1, 13).
Oxygen is commonly provided equally a benefit of the Eye for Medicare and Medicaid Services (CMS), owing to the historic period and disability of recipients (14, 15). Consequently, CMS beneficiaries are affected past economic decisions from the federal Competitive Bidding Plan (CBP) that determines reimbursement for their durable medical equipment (DME). CMS is required to solicit bids from licensed DME companies to provide equipment and supplies, including oxygen (16). The intent of the CPB is to reduce costs, ensure beneficiary access to quality services, and reduce beneficiary out-of-pocket expenses. CMS reviews submitted bids from DME companies, based on a circuitous formula, and awards contracts to those that run across quality and financial standards and offering the all-time price. Contracted suppliers must agree to have consignment on claims and accept a single payment amount. The median of all winning bids for an item determines the amount (16). Results of this bidding process determine what services and equipment are available at each DME and are not uniform beyond providers. Well-nigh DMEs are moving to a price-saving "nondelivery" model for domicile oxygen services, which excludes providing liquid oxygen.
In 2015, the American Thoracic Society (ATS) Nursing Assembly Planning Commission addressed supplemental oxygen concerns. In 2016, the Nursing Assembly Oxygen Working Group (OWG) convened a multidisciplinary forum (meet Figure E1 in the online supplement) to place future initiatives. Five areas of concern emerged: 1) lack of data documenting oxygen users' precise problems; 2) increased clinician time to consummate CMS- and other payer-required documentation; 3) negative impact on supplemental oxygen users from decreased DME reimbursement; 4) gaps in oxygen education and grooming; and 5) absence of DME provider care standard metrics and quality measures.
This newspaper presents patient-reported data collected from supplemental oxygen users that identify the frequency and type of issues that they experience. Our goal was to seek perspectives of oxygen users equally an initial step in improving commitment of this vital service.
Methods
Section:
The web-based Checklist for Reporting Results of Internet E-Surveys (CHERRIES) (17) and E-Survey guidelines (xviii) directed the methodology for this assay.
Design
This is a descriptive study of responses obtained using the "Patient Supplemental Oxygen Survey" (Figure E2), a voluntary cocky-report instrument. Respondents were a convenience sample of adults in the U.s. prescribed oxygen as a consequence of lung disease.
Survey Development
Content areas identified at the May 2016 ATS multidisciplinary meeting guided detail development. Participants provided input from the perspective of multiple patient, advocacy, professional person, and payer organizations. Three oxygen users participated throughout the process. ATS participants represented Nursing, Pulmonary Rehabilitation, Health Policy, Authorities Relations, and the Public Advisory Roundtable (PAR).
After this initial meeting, a draft paper survey was developed by the OWG chair (S.S.J.) and reviewed for content and item inclusion by five skillful clinicians, each with more than 20 years of experience with oxygen-dependent patients. Later on revision, the survey underwent a second review by the remaining OWG participants, and representatives from the U.S. COPD Coalition and American Lung Association (ALA). A consultant in psychometrics provided advice regarding format and structure.
The revised survey was piloted on paper in a third review by nine oxygen-dependent patients to appraise question clarity and completion time. ATS staff then converted items into a SurveyMonkey electronic format. Five oxygen-dependent patients piloted online survey versions at ii centers to confirm its usability and technical function, and minor changes were made.
The final online survey included sixty items, with a combination of multiple choice, Likert calibration, and open-ended responses. Respondents were unable to "salve" the survey to complete at another fourth dimension, only could use a "back" button to review or change answers. The Stanford Academy Institutional Review Board canonical the project with a waiver for informed consent. The first folio included the purpose of the report, the length of the survey, the voluntary nature of completing items, and the investigator's contact information. No health information was collected to identify respondents and no incentives were offered to respondents.
Survey Administration
The ATS Public Advisory Roundtable website posted the survey link from September 1, 2016 through October 24, 2016. Multiple pulmonary organizations placed the link on their websites, including the OWG, ALA, American Association of Cardiovascular and Pulmonary Rehabilitation, U.S. COPD Coalition, country societies, and the ATS web-based "Washington Message." Numerous clinicians provided flyers nearly the survey in their chest clinics, pulmonary rehabilitation (PR) programs, and support groups. Survey responses captured through SurveyMonkey were exported to SPSS. Response rate was determined by counting unique Internet provider addresses, with duplicates removed before analysis with the almost recent entry used.
Statistical Assay
Statistical analysis included descriptive summaries of categorical variables equally frequencies and percentages, with χ2 used to test for significant differences. Standardized residuals of the associations tested by χii analysis were used to assess the contribution of individual comparisons to the overall result. If multiple comparisons had residuals greater than the absolute value of 2, partitioned contingency tables were used to place the comparisons with the greatest influence (19, 20). Continuous variables are reported as means and SD, with t test and ANOVA used to test for significant differences with Scheffé post hoc analysis used to identify where these differences occurred.
Results
Department:
Demographics
The final survey respondents (n = 1,926; Figure E3) were 64 ± xi years of age, primarily female, from suburban areas, and represented every country (Figure E4). Most 1-half (44%) reported living in a CBP area, 45% were unsure, and 11% lived in non-CPB areas. COPD (39%) and interstitial lung affliction (ILD) (27%) were the nearly mutual diagnoses (Tabular array 1). The majority were retired (47%) or disabled (41%), with only 23% working outside the home.
| Feature | Total Sample (%) | Reported Problems (%) | ||
|---|---|---|---|---|
| Yep | No | P Value | ||
| Age, mean (SD), twelvemonth | 64 (11) | 63 (11) | 65 (11) | <0.001 |
| Female, % | 72 | 54 | 46 | 0.001 |
| Diagnosis, % | <0.001 | |||
| COPD | 39 | 44 | 56 | |
| Interstitial lung disease | 27 | 51 | 49 | |
| Pulmonary hypertension | eighteen | 61 | 39 | |
| Blastoff-one antitrypsin deficiency | viii | 60 | 40 | |
| Lymphangioleiomyomatosis | four | seventy | 30 | |
| Other | five | 55 | 45 | |
| Employment, % | 0.006 | |||
| Retired | 47 | 47 | 53 | |
| Disabled | 41 | 57 | 43 | |
| Working full time | 8 | 51 | 49 | |
| Working part fourth dimension | 4 | 45 | 55 | |
| Residence, % | 0.04 | |||
| Suburban | 51 | 54 | 46 | |
| Rural | 28 | 46 | 54 | |
| Urban | 21 | 51 | 49 | |
| Live in Competitive Bidding Area, % | 0.02 | |||
| Yes | 44 | 55 | 45 | |
| No | xi | 49 | 51 | |
| Unsure | 45 | 48 | 52 | |
| Duration of oxygen use, % | <0.001 | |||
| <1 year | 17 | 41 | 59 | |
| 1–five twelvemonth | 51 | 51 | 49 | |
| >5 yr | 32 | 57 | 43 | |
| Oxygen requirement, % | ||||
| Continuous (24 h/d) | 60 | 54 | 46 | 0.006 |
| ≥v L/min exertion (pulse or cont) | 31 | 56 | 44 | 0.004 |
| Wellness intendance utilization, % | ||||
| Hospital admission in by 12 mo | 29 | 57 | 43 | 0.005 |
| Emergency room visit in past 12 mo | 34 | 56 | 44 | 0.006 |
| Educational activity, % | ||||
| Attended pulmonary rehab | 63 | 53 | 47 | 0.17 |
| Education on dwelling oxygen | 0.000 | |||
| Oxygen delivery personnel | 64 | 51 | 49 | |
| Health care personnel | 8 | 43 | 57 | |
| None | ten | 64 | 36 | |
| mMRC dyspnea score, hateful (SD) | ||||
| Using oxygen | 1.5 (1.ii) | 1.6 (ane.2) | 1.five (1.2) | 0.28 |
| Non using oxygen | two.6 (one.2) | 2.seven (1.2) | two.5 (i.2) | <0.001 |
Respondents varied in time on oxygen, with most reporting usage from 1 twelvemonth to more than than 5 years and using oxygen 24 h/d. One-tertiary of respondents used pulse or continuous menstruum rates equal to or exceeding 5 L/min during exertion. Dyspnea scores (modified Medical Research Council [mMRC]) were higher off than on oxygen (mean difference, i.12; 95% confidence interval, 1.06–1.16). During the 12 months preceding the survey, 29% of respondents reported a infirmary access and 34% an emergency room visit.
Education
Well-nigh respondents (63%) had attended a PR program (Table 1) and 93% used pulse oximeters. Liter flow adjustment varied, with 35% using the prescribed flow, 22% adjusting menses based on "how curt of jiff she/he felt," and 29% adjusted period during exertion based on pulse oximeter readings. The majority (65%) related that they did not take their oxygen saturation checked when equipment was delivered to their abode. Sources of instruction varied; the majority (64%) reported beingness trained by the delivery person. Only viii% were trained past a clinician and x% related they did not receive educational activity (Table one). Even afterwards receiving instruction, 35% reported existence either "very" or "somewhat" unprepared to operate equipment.
Respondents reporting "yep" to having oxygen problems more frequently lived in suburban areas (54%); had lymphangioleiomyomatosis (LAM; 70%), pulmonary arterial hypertension (PAH; 61%), alpha-1 antitrypsin disease (AATD; threescore%), or ILD (51%); used oxygen longer (57% > 5 twelvemonth) and at higher menstruum rates (56% ≥ 5 Fifty/min); had more frequent rates of emergency room or hospital admissions during the by year (56 and 57%, respectively); reported higher dyspnea levels off of oxygen (mMRC, 2.vii vs. 2.5); and had non received oxygen education (64%). At that place was no divergence in PR omnipresence rates between those groups reporting oxygen issues (53%) and those that did not (47%).
Equipment
Virtually respondents (80%) used a portable arrangement outside the home, including portable oxygen concentrators (POCs) (33%), modest compressed gas tanks (20%), compressed gas "E" tanks (16%), compressed gas home-make full units (10%), and liquid oxygen home-fill units (13%). The type of portable system was not related to participants' reports of problems with their oxygen systems (Table 2).
| Variable | Total Sample (%) | Reported Problems (%) | ||
|---|---|---|---|---|
| Yeah | No | P Value | ||
| Type of portable oxygen system used | 0.12 | |||
| Portable oxygen concentrator | 33 | 53 | 47 | |
| Pocket-size compressed gas tanks | 20 | 49 | 51 | |
| Large "E" compressed gas tanks | 16 | 52 | 48 | |
| Liquid organisation | 13 | l | fifty | |
| Dwelling fill organisation | thirteen | 62 | 38 | |
| Length of time oxygen lasts abroad from domicile | 0.060 | |||
| Nearly ane h or less | 11 | 59 | 41 | |
| Up to ii h | 38 | 56 | 44 | |
| Up to 4 h | 32 | 49 | 51 | |
| 4–6 h | 15 | 52 | 48 | |
| More than 6 h | four | 49 | 51 | |
| Current portable organization limits activities outside habitation | <0.001 | |||
| Not at all | 13 | 39 † | 61 † | |
| Sometimes | 35 | 52 | 48 | |
| Frequently | 23 | 57 | 43 | |
| All the time | 21 | 59 † | 41 † | |
| Out-of-pocket oxygen copayment | <0.001 | |||
| $0 | 52 | 47 † | 53 † | |
| $1–$l | 31 | 53 | 47 | |
| $51–$100 | 9 | 61 † | 39 † | |
| $101–$200 | v | 66 † | 34 † | |
| >$200 | three | 54 | 46 | |
When leaving home, 44% used pulse settings and 26% used continuous flow, sixteen% switched between pulse and continuous, and 1% were unsure of their type of flow setting (13% did not use oxygen when leaving the firm).
Of the fourteen% of respondents who were employed, 53% used oxygen at work, 29% did not demand oxygen at work, and 18% responded that they should have but did not because of inadequate oxygen supply or concern for job security. The nigh common portable system used past those who worked was a POC (28%).
Mobility
Mobility was a concern; 38% reported beingness able to exit their home for up to ii hours because of portable arrangement capacity whereas 66% of respondents wanted their portable arrangement to last 5–half-dozen hours (Effigy 1 ). Respondents reported their ability to travel (30%), socialize (22%), and continue their saturations at more than 90% (twenty%) was express by their portable system.
Figure 1. Actual versus desired hours that portable oxygen lasts.
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Finances
Costs varied, with the majority (82%) citing a $0–$l/calendar month copay (Table 2). Most respondents (threescore%) were unaware of copay amounts earlier receiving equipment. Numerous respondents reported paying out-of-pocket for equipment including POCs by 286 participants, batteries by 194 participants, and other items by 302 participants.
Problems Experienced
When asked "Have you ever had any type of problems related to your oxygen?," 51% of respondents answered "yep." About respondents cited a broad range of problems, with an average of at to the lowest degree three or more than issues per private (average, 3.6 ± two.3; range, 1–12) (Effigy ii ). The "biggest problem" identified by respondents was equipment malfunction (15%), lack of physically manageable portable systems (xiii%), and lack of a portable system that delivers high-plenty flow (13%).
Figure 2. Frequency of types of oxygen problems reported past respondents who replied "yes" to having oxygen issues (north = 899; able to check more than i response).
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When asked what "one thing" they would alter to improve their oxygen experience, the most frequent response was "more than portable tanks/supplies and then I can leave home more often and for longer periods of time" (17%), followed by "providing a POC when I travel," and "service/check equipment on a regular basis." Almost half (twoscore%) noted waiting for servicing requests or supply deliveries. Most (70%) were unaware of a number or person to call to file a complaint about their oxygen issues. Patients living in a CBP expanse reported oxygen problems more oftentimes than those who did not (P = 0.025).
The frequency of patients reporting "yes" to problems did not significantly (P = 0.10) vary by geographic location, with the reported charge per unit of bug ranging from a high in the West of 56% to a low in the South Midwest of 43% (Figure 3 and Tabular array E1).
Figure 3. Percentage of respondents past region answering "yes" to having oxygen bug.
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Differences across Diagnostic Groups
There was no departure in self-reported hospital access rates in the previous year beyond diagnostic groups, simply self-reports of emergency room visit rates varied with COPD the highest (39%) and ILD the lowest (29%) (P < 0.01). At that place was no deviation in the source of oxygen education between the diagnostic groups. Patients across all disease categories were equally afflicted in restrictions to mobility considering of their portable oxygen equipment (Tabular array iii).
| Feature | COPD | ILD | PAH | AATD | LAM | Other | P Value |
|---|---|---|---|---|---|---|---|
| No. of participants, n (%) | 743 (39) | 509 (26) | 344 (18) | 156 (8) | 69 (iv) | 93 (5) | |
| Age, mean (SD), yr | 67 (nine)3–6 | 66 (xi)three–5 | 60 (13)1,2,v | 61 (9)1,2,5 | 55 (11)1–4,6 | 62 (12)ane,5 | <0.001 |
| Female person sex, n (%) | 533 (72) | 311 (61)* | 300 (88)* | 95 (61)* | 69 (100)* | 67 (72) | <0.001 |
| Residence, due north (%) | <0.003 | ||||||
| Suburban | 360 (49) | 278 (55) | 178 (52) | 76 (49) | 38 (56) | 44 (48) | |
| Rural | 225 (xxx) | 122 (24) | 89 (26) | 54 (35)* | 15 (22) | 15 (17)* | |
| Urban | 152 (21) | 103 (21) | 75 (22) | 24 (16)* | 15 (22) | 32 (35) | |
| Duration of oxygen use, n (%) | <0.001 | ||||||
| <1 yr | 109 (15) | 119 (24) | 45 (14) | seven (5) | 10 (15) | 16 (xix) | |
| 1–v yr | 352 (48) | 287 (59) | 177 (54) | 58 (40)* | 32 (48) | 40 (47) | |
| >v yr | 266 (37) | 83 (17)* | 106 (32) | 80 (55)* | 25 (37) | 29 (34) | |
| Oxygen requirement, north (%) | |||||||
| Continuous (24 h/d) | 487 (66)* | 298 (56) | 191 (56) | 94 (60) | 22 (xl)* | 49 (53) | <0.001 |
| ≥5 50/min | 133 (18)* | 229 (47)* | 103 (32) | 48 (33) | 29 (44)* | 27 (33) | <0.001 |
| mMRC score, mean (SD) | |||||||
| Not using oxygen | ii.8 (1.2)iii,5 | 2.7 (i.2)3,5 | 2.2 (1.2)1,2 | 2.vi (1.2) | 2.1 (ane.2)1,2 | 2.4 (ane.3) | <0.001 |
| Using oxygen | ane.seven (1.2)2,3,v | ane.4 (1.ii)1,five | one.3 (i.1)one | 1.vi (1.2)5 | 0.nine (1.0)i,2,4,6 | 1.6 (ane.2) | <0.001 |
| Health care utilize in 12 mo, n (%) | |||||||
| Hospital admission | 223 (31) | 138 (29) | 95 (29) | 29 (twenty) | 21 (30) | 32 (37) | 0.062 |
| Emergency room | 287 (39) | 145 (29)* | 107 (31) | 47 (30) | 23 (35) | 30 (34) | <0.008 |
| Pulmonary rehab, due north (%) | 476 (65) | 345 (69) | 159 (48)* | 110 (71) | 46 (67) | 61 (66) | <0.001 |
| Domicile oxygen education, northward (%) | 0.696 | ||||||
| Oxygen delivery personnel | 463 (64) | 310 (63) | 219 (67) | 86 (60) | 40 (60) | 49 (57) | |
| Health care professional | 56 (8) | 36 (8) | 29 (9) | ten (7) | three (4) | 8 (nine) | |
| None | 76 (10) | 55 (eleven) | 26 (8) | 18 (12) | 6 (9) | 12 (14) | |
| Other | 129 (eighteen) | 89 (xviii) | 53 (16) | 30 (21) | xviii (27) | 17 (twenty) | |
| Current system limits activities outside of home, n (%) | 0.430 | ||||||
| Not at all | 92 (14) | 56 (13) | 42 (15) | sixteen (12) | 8 (13) | 8 (11) | |
| Sometimes | 237 (37) | 165 (38) | 122 (45) | 53 (39) | 30 (48) | 29 (twoscore) | |
| Frequently | 166 (26) | 112 (26) | 49 (18) | 37 (27) | 15 (24) | 16 (22) | |
| All the fourth dimension | 149 (23) | 105 (24) | 59 (22) | 29 (22) | nine (15) | 19 (26) |
Compared with other lung diseases, respondents with AATD lived in rural areas more often, and rarely used oxygen at settings equal to or greater than 5. Respondents with COPD had the highest rated dyspnea both on and off of oxygen and also had the virtually frequent emergency room admissions in the by year, in dissimilarity to patients with ILD, who rarely received oxygen for more than v years, most frequently used oxygen at settings of 5 or higher, and had significantly lower frequency of emergency room employ. Respondents with LAM used high-flow oxygen, were younger, and more likely female person, as were respondents with PAH. Respondents with AATD included the highest number using oxygen longer than 5 years.
The frequency of oxygen problems was significantly different across disease categories (P < 0.01); respondents with LAM reported the highest frequency (lxx%) and respondents with COPD the lowest (44%) (Tabular array i and Figure iv ).
Figure four. Percent of respondents reporting oxygen problems according to diagnosis (n = 887 respondents who checked "yes" to having oxygen problems). AATD = blastoff-1 antitrypsin affliction; COPD = chronic obstructive pulmonary disease; ILD = interstitial lung affliction; LAM = lymphangioleiomyomatosis; Other = infection, lung cancer, congestive heart failure, post lung transplantation, other; PAH = pulmonary arterial hypertension.
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Discussion
Department:
This survey is the first to elicit patient-reported experiences in a large cohort of supplemental oxygen users and reveals that more than 1-half of respondents noted numerous and wide-ranging oxygen bug. Experiencing problems with oxygen was associated with greater use of health intendance resources that could, potentially, be lessened with pedagogy. Key themes revealed a focus on equipment office, portability, and adequacy of systems to support a mobile lifestyle. Respondents who were younger, more dyspneic, used high-period oxygen, and received no oxygen instruction were more likely to report having oxygen problems.
Other patient advocacy groups accept assessed oxygen problems in response to their oxygen-dependent constituents' demands for action. The LAM Foundation surveyed 161 oxygen users in 2014. Of those, 33% reported problems obtaining oxygen (personal communication, LAM Foundation). The Pulmonary Hypertension Association surveyed 91 patients receiving supplemental oxygen and institute that more than 60% experienced the following service bug: 25% waited more than 5 days for equipment to go far, 42% had missing supplies, and more than 45% had misinformation or no back up from the DME travel department (personal communication, Pulmonary Hypertension Association). The problems identified by respondents in this survey are consistent with those described in previous investigations (8, 21–23).
The impacted population of oxygen users is significant. Approximately 45–70% of patients with COPD use long-term oxygen therapy for 15 or more hours per mean solar day (24). A qualitative COPD study by Arnold and colleagues (21) explored factors comparable to those in our survey and identified 1) inappropriate equipment, 2) lack of individualized information and pedagogy from health care providers, iii) fearfulness of "running out of oxygen," 4) questioning or non experiencing the benefit of the intervention, and 5) non wanting to be seen with oxygen equipment in public. Issues of worry, physically unmanageable systems, automobile breakdown, lack of instruction, and feeling "tethered" to stationary equipment were consistent with our results and those of others (22, 23). Informal caregivers report similar burdens of home oxygen use (25). In-depth interviews of v oxygen-dependent patients with ILD over a period of 12 months highlighted the demand for "clearer expectations and trustworthy educational resource" (26).
Acuity level varied amidst these respondents, with thirty% using high-catamenia oxygen. The perceived benefit of oxygen on dyspnea as measured by the mMRC was significant in this cohort, although one review found a range of furnishings of oxygen therapy on dyspnea at residuum and during exercise in patients with ILD (27). The mMRC is a widely used scale that correlates well with other scales and health status scores, and with clinical and pulmonary parameters (28). Objectively measured physical inactivity has been reported to be the strongest contained predictor of bloodshed in patients with COPD (29) and idiopathic pulmonary fibrosis (30). At that place is a strong relationship betwixt the mMRC and physical action levels in patients with COPD (31). Chiefly, the level of dyspnea has a more significant event on survival than disease severity based on FEV1, and correlates with 5-year survival rates (32).
The combination of worse dyspnea when off oxygen with physically unmanageable portable systems contributed to respondent descriptions of substantial mobility limitations across all illness groups. Our analysis also confirmed that experiencing worse dyspnea off oxygen was associated with respondents reporting problems with their oxygen and greater use of wellness intendance resource (emergency room visits). Patients may have varied responses in terms of their perceived bear upon of oxygen on their dyspnea (26). Considering many have few options, it should exist evaluated on an individual basis.
In our survey, patients who received instruction from health care personnel were less likely to study oxygen problems compared with those educated by the delivery person or who received no education. The difference may exist in the technical focus of instruction past the equipment delivery person compared with the clinical plus psychosocial approach past clinicians ("a conversation with the patient as a whole") (8). Pépin and colleagues confirmed that pedagogy past a nurse or physiotherapist improved oxygen compliance in a cohort of patients with COPD (33). Katsenos and colleagues confirmed that lack of a clear oxygen prescription and instructions limited patient adherence in a accomplice of patients with COPD (22), and other investigators annotation the importance of "managing expectations" for patients with ILD who take been newly prescribed oxygen (34, 35). Patients with COPD who did not have routine home follow-up by specialized staff have likewise been noted to experience worse survival rates than those who did (36). More recently, the training of patients using oxygen as peer oxygen educators is being investigated equally some other option to support habitation oxygen users (37), every bit well every bit utilizing respiratory care professionals to improve hospital belch oxygen education for patients with COPD (38).
Completing a PR program did not make a difference in experiencing oxygen problems, which highlights the persistence of oxygen issues despite receiving education on indications for oxygen, use with exercise, and monitoring in a PR setting. Further investigation is needed to decide whether equipment issues reverberate reimbursement constraints experienced by DME oxygen suppliers equally opposed to patient education. Only i-third of respondents titrated their oxygen in accordance with their saturations—a surprising finding given the high PR omnipresence rate.
In this accomplice, 65% of respondents did not have their oxygen saturations tested on their delivered equipment. Recent reimbursement reductions to DME providers preclude using licensed respiratory intendance practitioners in the abode. Assessment of exertional hypoxemia on pulse systems rarely occurs in the clinic setting considering exercise oximetry is commonly done using continuous period, but portable units usually apply pulse flow.
Most noteworthy is that half of respondents reported problems with their oxygen; with an estimated 1–1.5 million U.S. oxygen users the potential bear upon is enormous. The acme iii issues cited include equipment not working, lack of physically manageable portable systems, and lack of high-menstruum portable systems. The issues revolving around equipment service from oxygen suppliers were described in gratis-text response options including wait times, equipment malfunction, being "stuck" in contracts, wrong billing, and the inability to "mix" types of oxygen systems. Patients were unclear about equipment and service standards. Although virtually patients reported that their trouble was eventually resolved, 70% of patients were unaware of the Medicare Ombudsman or COPD Information Line to written report unresolved problems.
The restrictions on patients being able to exist abroad from their habitation for more than than 2–four hours were substantial. These respondents listed having more portable systems to leave the business firm or travel for longer periods of time as the "i thing" they would alter to improve their oxygen feel. CMS guidelines currently are entitled "Home Oxygen," just these results confirm that the majority of this cohort of supplemental oxygen users prioritizes the power to be out of the habitation.
Problems related to oxygen were more than ofttimes reported by women, those using oxygen for longer lengths of fourth dimension, and those who experienced more breathlessness without their oxygen. Duration of therapy and symptom severity intuitively place an oxygen user at risk for problems; the impact of sexual practice needs to be tested in a sample with a larger male person population. Respondents with LAM, PAH, and AATD had the highest rate of reporting problems, suggesting the need to identify ways to better run into the mobility needs of these individuals.
Time to come Directions
The complexity of optimizing supplemental oxygen for our patients is articulate; there are issues of educational activity, adherence, equipment, benefit, reimbursement, service quality, and clinician compliance. Equally health intendance professionals we tin ameliorate the oxygen prescription process, brainwash patients, and monitor treatment responses. However, if reimbursement constraints keep to impact oxygen suppliers, patients' access to adequate portable oxygen systems will keep to exist afflicted. The disappearance of liquid oxygen, the disability to provide adequate portable systems, and the limitations on actress tanks and batteries inhibit patients' mobility, exercise, socialization, travel, and work.
After the get-go full year of implementation of the CBP, CMS reported no alter in beneficiary health status outcomes. Although isolation and inactivity are not generally measured health outcomes, they are clearly documented by this survey'southward results as a negative impact from limited electric current portable oxygen options. Data exist that poor adherence to prescribed oxygen is associated with higher use of wellness care resources (39). Less clear, yet important, is that patients with hypoxemic lung disease may feel frailty and fatigue that challenges their ability to navigate the CMS complaints process and advocate for their needs.
There were suggestions of differences in respondent experience that back up the demand for studies designed to elicit issues influenced past diagnosis. Respondents with COPD reported a greater number of emergency room visits in the previous year and the highest dyspnea levels when off of oxygen, despite being the group reporting the lowest charge per unit of "yep" to having problems with oxygen. Patients with ILD and LAM reported more frequent bug meeting their high oxygen flow needs.
Limitations
Findings of this survey describe the experience of a large cohort of oxygen users from all geographic regions of the United States. Yet, our respondents were a convenience sample of English-speaking oxygen users who responded voluntarily to an online survey, needed access to a calculator, and may not represent the general population of oxygen users. Providing a paper selection may accept captured a wider spectrum of oxygen users. Most respondents stated they used pulse oximeters and an unusually high number attended a PR plan and, therefore, may have had stronger motivation for mobility exterior the home. There was as well a predominance of women; information technology is unknown whether (or how) sex activity influences responses.
Improved survey instructions might have decreased duplicate responses. Wording of some questions may not take provided enough options for patients, a limitation evident from the multiple responses received when "other" was offered as a free text option. Ethnicity and income levels were not assessed and may have provided important oxygen access variables. Selection bias therefore limits the generalizability of these results to all oxygen users.
Conclusions
Section:
More than half of supplemental oxygen users in this study experienced numerous and varied bug, with the overarching theme being one of restricted mobility and isolation. Equipment malfunction, lack of patient testing and instruction, and economical constraints were common. The demand for high-menses and physically manageable portable oxygen systems to support mobility is a priority that professional societies, patient organizations, and durable medical equipment companies should urgently address.
The authors thank the ATS Oxygen Working Group consultants who provided critical survey content review: Jessica Armstrong, Pulmonary Hypertension Association (PHA); Phabian Barrett, CMS; Valerie Cheng, Hawaii COPD Coalition; Tangita Daramola, CMS; Karen Erickson, Blastoff-1 Foundation; Gary Ewart, ATS Governmental Affairs; Mary Harbaugh, LAM Foundation; Elaine Hensley, CMS; Tom Kallstrom, American Association of Respiratory Care; Katherine Kroner, PHA; Sarah Latham, COPD Foundation; Ann McKenna, LAM Foundation; Jennifer Mefford, Pulmonary Fibrosis Foundation; Sue Morris, patient; Jason Moury, COPD Foundation; Tim Meyers, American Clan of Respiratory Care; Jeanne Rommes, patient, Public Advisory Roundtable (PAR), ATS; Sue Sherman, LAM Foundation; Jamie Sullivan, COPD Foundation; Erika Sward, ALA; Dona Upson, ATS Health Policy. The authors thank Leslie Hoffman for helpful input on the manuscript; Miriam Rodriguez and PAR of the ATS for their support of this projection; Sandra Wilson (Palo Alto Medical Foundation Inquiry Institute and Schoolhouse of Medicine, Stanford University) for input on survey development; and Joshua Mooney (School of Medicine, Stanford Academy) for assistance during initial project development.
References
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| 1 . | Doherty DE , Little TL , Bailey W , Carlin B , Cassaburi R , Christopher Grand , et al. Recommendations of the 6th long-term oxygen therapy consensus conference. Respir Care 2006;51:519–525. Medline, Google Scholar |
| ii . | American Thoracic Society. Problems in prescribing and supplying oxygen for Medicare patients [conference report]. Am Rev Respir Dis 1986;134:340–341. Medline, Google Scholar |
| 3 . | American Thoracic Society. Further recommendations for prescribing and supplying long-term oxygen therapy: summary of the second conference on long-term oxygen therapy held in Denver, CO, Dec. xi–12, 1987 [conference report]. Am Rev Respir Dis 1988;138:745–747. Abstract, Google Scholar |
| iv . | American Thoracic Society. New issues in supply, reimbursement, and certification of medical necessity for long-term oxygen therapy: summary of the third consensus conference held in Washington, DC, March fifteen–sixteen, 1990. Am Rev Respir Dis 1990;142:721–724. Abstract, Google Scholar |
| 5 . | Petty TL , O'Donohue WJ Jr. Further recommendations for prescribing, reimbursement, technology development, and inquiry in long-term oxygen therapy: summary of the Fourth Oxygen Consensus Briefing, Washington, DC, October 15–16, 1993. Am J Respir Crit Care Med 1994;150:875–877. Abstract, Medline, Google Scholar |
| 6 . | Petty TL , Casaburi R ; Writing and Organizing Committees. Recommendations of the Fifth Oxygen Consensus Briefing. Respir Care 2000;45:957–961. Medline, Google Scholar |
| 7 . | Clini E , Veale D , Winck JC . Advances in ambulatory oxygen workshop and long-term oxygen therapy in existent-life practice. Eur Med J 2015;iii:63–lxx. Available from: http://emjreviews.com/therapeutic-area/respiratory/advances-in-convalescent-oxygen-workshop-and-long-term-oxygen-therapy-in-real-life-practice/. Google Scholar |
| 8 . | Lehoux P , Saint-Arnaud J , Richard 50 . The utilize of technology at home: what patient manuals say and sell vs. what patients face and fear. Sociol Health Illn 2004;26:617–644. Crossref, Medline, Google Scholar |
| nine . | Husbands J . More sufficient information needed to evaluate patient impact of abode oxygen cuts. The Hill [blog] [2016; accessed 2017 Feb 12]. Available from: http://thehill.com/blogs/congress-web log/healthcare/286329-more-sufficient-information-needed-to-evaluate-patient-bear upon-of-homeoxygen-patients-industry/. Google Scholar |
| 10 . | Hanlon P . CMS cuts detrimental to domicile oxygen patients, industry. RT [online magazine] [2016 Jul 31; accessed 2016 Aug 5]. Available from: http://www.rtmagazine.com/2016/07/cms-cuts-detrimental-home-oxygen-patients-industry/. Google Scholar |
| eleven . | Anonymous. Manufacture news: Senate passes PADME Human action. RT [online magazine] [2016 Jun 22; accessed 2016 Jul eighteen]. Available from: http://www.rtmagazine.com/?s=Senate+Passes+PADME+Act. Google Scholar |
| 12 . | Alpha-1 Foundation. Growing scarcity of liquid oxygen endangers patients, advocates say [2016 Apr 21; accessed 2016 Apr 25]. Available from: https://www.alpha1.org/Alphas-Friends-Family/Resources/News/ArtMID/5952/ArticleID/6927/Growing-scarcity-of-liquid-oxygen-endangers-patients-advocates-say. Google Scholar |
| thirteen . | Croxton TL , Bailey WC . Long-term oxygen treatment in chronic obstructive pulmonary disease: recommendations for future research: an NHLBI workshop report. Am J Respir Crit Intendance Med 2006;174:373–378. Abstract, Medline, Google Scholar |
| 14 . | Centers for Medicare and Medicaid Services. Medicare coverage of durable medical equipment and other devices [revised Sept 2016; accessed 2017 Mar 12]. Bachelor from: https://www.medicare.gov/Pubs/pdf/11045-Medicare-Coverage-of-DME.pdf. Google Scholar |
| 15 . | Centers for Medicare and Medicaid Services. Home oxygen therapy. [Oct 2016; accessed 2017 Mar 12]. Bachelor from: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Dwelling-Oxygen-Therapy-ICN908804.pdf. Google Scholar |
| sixteen . | Medicare.gov. Supplier directory [accessed 2016 Aug 01]. Bachelor from: https://www.medicare.gov/supplierdirectory/search.html. Google Scholar |
| 17 . | Eysenbach 1000 . Improving the quality of web surveys: the Checklist for Reporting Results of Cyberspace Due east-Surveys (CHERRIES). J Med Internet Res 2004;6:e34. Crossref, Medline, Google Scholar |
| 18 . | Kelley K , Clark B , Brown V , Sitzia J . Good practise in the bear and reporting of survey enquiry. Int J Qual Health Care 2003;15:261–266. Crossref, Medline, Google Scholar |
| 19 . | Siegel SC , Castellan NJ . Nonparametric statistics for the behavioral sciences. New York: McGraw-Loma; 1988. Google Scholar |
| 20 . | Pett MA . Nonparametric statistics for wellness care enquiry: statistics for modest samples and unusual distributions. Thousand Oaks, CA: Sage Publications; 2016. Google Scholar |
| 21 . | Arnold Eastward , Bruton A , Donovan-Hall M , Fenwick A , Dibb B , Walker E . Ambulatory oxygen: why do COPD patients not use their portable systems as prescribed? A qualitative report. BMC Pulm Med 2011;11:9. Crossref, Medline, Google Scholar |
| 22 . | Katsenos S , Charisis A , Daskalopoulos G , Constantopoulos SH , Vassiliou MP . Long-term oxygen therapy in chronic obstructive pulmonary disease: the employ of concentrators and liquid oxygen systems in north-western Greece. Respiration 2006;73:777–782. Crossref, Medline, Google Scholar |
| 23 . | Karamanli H , Ilik F , Kayhan F , Pazarli Air-conditioning . Cess of cerebral impairment in long-term oxygen therapy–dependent COPD patients. Int J Chron Obstruct Pulmon Dis 2015;ten:2087–2094. Crossref, Medline, Google Scholar |
| 24 . | Blackstock FC , ZuWallack R , Nici L , Lareau SC . Why don't our patients with chronic obstructive pulmonary affliction listen to u.s.? The enigma of nonadherence. Ann Am Thorac Soc 2016;thirteen:317–323. Abstract, Medline, Google Scholar |
| 25 . | Graney BA , Wamboldt FS , Baird Southward , Churney T , Fier K , Korn 1000 , et al. Informal caregivers experience of supplemental oxygen in pulmonary fibrosis. Health Qual Life Outcomes 2017;15:133. Crossref, Medline, Google Scholar |
| 26 . | Graney BA , Wamboldt FS , Baird S , Churney T , Fier Thou , Korn M , et al. Looking ahead and behind at supplemental oxygen: a qualitative written report of patients with pulmonary fibrosis. Heart Lung 2017;46:387–393. Crossref, Medline, Google Scholar |
| 27 . | Bell EC , Cox NS , Goh N , Glaspole I , Westall GP , Watson A , et al. Oxygen therapy for interstitial lung affliction: a systematic review. Eur Respir Rev 2017;26:26. Crossref, Google Scholar |
| 28 . | Jones P , Miravitlles Grand , van der Molen T , Kulich K . Beyond FEV1 in COPD: a review of patient-reported outcomes and their measurement. Int J Chron Obstruct Pulmon Dis 2012;7:697–709. Crossref, Medline, Google Scholar |
| 29 . | Waschki B , Kirsten A , Holz O , Müller Yard-C , Meyer T , Watz H , et al. Concrete activity is the strongest predictor of all-cause mortality in patients with COPD: a prospective cohort study. Breast 2011;140:331–342. Crossref, Medline, Google Scholar |
| xxx . | Nishiyama O , Taniguchi H , Kondoh Y , Kimura T , Kato K , Kataoka Grand , et al. A uncomplicated assessment of dyspnoea as a prognostic indicator in idiopathic pulmonary fibrosis. Eur Respir J 2010;36:1067–1072. Crossref, Medline, Google Scholar |
| 31 . | DePew ZS , Garofoli Air conditioning , Novotny PJ , Benzo RP . Screening for severe physical inactivity in chronic obstructive pulmonary affliction: the value of unproblematic measures and the validation of two concrete activity questionnaires. Chron Respir Dis 2013;10:19–27. Crossref, Medline, Google Scholar |
| 32 . | Nishimura 1000 , Izumi T , Tsukino M , Oga T . Dyspnea is a better predictor of 5-twelvemonth survival than airway obstruction in patients with COPD. Chest 2002;121:1434–1440. Crossref, Medline, Google Scholar |
| 33 . | Pépin JL , Barjhoux CE , Deschaux C , Brambilla C ; ANTADIR Working Group on Oxygen Therapy; Clan Nationale de Traitement à Domicile des Insuffisants Respiratories. Long-term oxygen therapy at dwelling house: compliance with medical prescription and constructive use of therapy. Chest 1996;109:1144–1150. Crossref, Medline, Google Scholar |
| 34 . | Khor YH , Goh NSL , McDonald CF , Kingdom of the netherlands AE . Oxygen therapy for interstitial lung disease: a mismatch between patient expectations and experiences. Ann Am Thorac Soc 2017;14:888–895. Abstract, Medline, Google Scholar |
| 35 . | Swigris JJ . Supplemental oxygen for patients with interstitial lung disease: managing expectations. Ann Am Thorac Soc 2017;14:831–832. Abstract, Medline, Google Scholar |
| 36 . | Hjalmarsen A , Melbye H , Wilsgaard T , Holmboe JH , Opdahl R , Viitanen Grand . Prognosis for chronic obstructive pulmonary disease patients who receive long-term oxygen therapy. Int J Tuberc Lung Dis 1999;3:1120–1126. Medline, Google Scholar |
| 37 . | ClinicalTrials.gov. Comparative effectiveness of a peer-led O2 Infoline for patients and caregivers (PELICAN) [primary investigator, J. A. Krishnan]. NCT02098369. Google Scholar |
| 38 . | Tan A-YM , Vines DL , Prieto-Centurion V , Gutierrez-Kapheim M , Krishnan JA , Kallstrom TJ . Respiratory Therapist Dwelling Oxygen for Chronic Obstructive Pulmonary Affliction (RisOTTO) study: a national survey [abstract]. Am J Respir Crit Care Med 2017;195:A7573. Google Scholar |
| 39 . | Hernandez C , Aibar J , de Batlle J , Gomez-Cabrero D , Soler N , Duran-Tauleria Due east , et al.; NEXES Consortium. Assessment of wellness status and program performance in patients on long-term oxygen therapy. Respir Med 2015;109:500–509. Crossref, Medline, Google Scholar |
Supported by the American Thoracic Order, which provided survey formatting and electronic information capture. Author Contributions: S.S.J.: idea and survey generation, manuscript generation, project oversight; M.O.50.: survey review, manuscript generation, topic insight; Due east.1000.C., C.K.G., C.H., South.M., A.M.S.: survey review, manuscript review, specified literature review; P.K.M.: statistical guidance and assay, manuscript review. This article has an online supplement, which is accessible from this result'southward table of contents at world wide web.atsjournals.org. Author disclosures are available with the text of this commodity at world wide web.atsjournals.org.
Source: https://www.atsjournals.org/doi/full/10.1513/AnnalsATS.201703-209OC
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