Projects such as the American Board of Internal Medicine's "Choosing Wisely" campaign emphasize the importance of de-implementing ineffective, harmful and/or wasteful practices to improve care quality and safety. Among patients with chronic obstructive pulmonary disease (COPD) and severe resting hypoxemia, oxygen improves survival. The provision of oxygen therapy has been extrapolated to other populations, leading to prescription of oxygen to patients with COPD without evidence to support its use. For example, oxygen is frequently prescribed at discharge from hospital after an exacerbation of COPD, then continued indefinitely. Published in 2016, the Long-Term Oxygen Treatment Trial (LOTT) demonstrated that supplemental oxygen conferred no benefit to patients with COPD with moderate resting or ambulatory hypoxemia. We now have an opportunity, as well as a challenge, to learn how to improve care quality by de-implementing a therapy that has no demonstrable benefit for this group of patients, is not without risk, but is deeply entrenched in clinical practice.
The overarching goal of this study is to inform VA about their current practices for the provision of oxygen therapy among patients with COPD (Aim 1), as well as identify anticipated barriers and facilitators to its de-implementation among patients in whom it has been shown to be ineffective (Aim 2). We will use our results to develop and test a patient-, organizational-, and operational partner-informed pilot intervention to increase value-based care among patients with COPD (Aim 3).
Aim 1: Using combined VA-Medicare data, we will first identify a nationwide cohort of patients 40 years and older discharged from hospital with supplemental oxygen after an exacerbation of COPD between Fiscal Year (FY) 2011-2016. We will perform analysis using a hierarchical (logistic mixed random effects) model to identify patient-, clinician-, and system-level factors associated with reassessment of oxygen need within 90 days of discharge. Aim 2: Using a sequential mixed methods approach incorporating quantitative survey collection and in-depth qualitative interviews, we will elicit patient and clinician views on the discontinuation of supplemental oxygen across a range of the high- and low-performing sites as well as at the sites of our planned intervention. Aim 3: We will use these initial results to refine a patient level-intervention designed to decrease inappropriate oxygen use after discharge from hospital for an exacerbation of COPD. We will randomize 50 patients at two VA sites (VA Puget Sound and Bedford VA) to receive usual care or our de-implementation intervention. In addition to assessing feasibility and acceptability of the intervention, we will assess secondary outcomes, including changes in functional status and symptoms over 12 weeks.
Based on our pilot data, we expect to find significant variation in rates of oxygen reassessment and discontinuation across VA sites nationwide. We anticipate that our study will provide a better understanding of the patient-, clinician-, and system-level factors that contribute to this variation in care quality. In addition, we expect to gain insight into barriers and facilitators to de-implementing oxygen. The project will create an actionable deliverable in the form of a targeted patient-level intervention that we will have piloted by the end of the study.
Our proposal will provide valuable insights into challenges faced when de-implementing widespread accepted practice, even when data refutes benefit and demonstrates possible harm. The results of this study have the potential to improve our understanding of how to best deliver high-value care to Veterans with COPD. The novel scientific knowledge that will result from this study could be extended to other clinical contexts to inform interventions designed to de-implement low-value but entrenched practice.
External Links for this Project
Grant Number: I01HX002499-01
None at this time.