post-REcovery LIbEration From Oxygen in Exacerbated COPD (RELIEF)

急性慢性阻塞性肺病 (COPD) 恢复后的氧气释放（缓解）

• 批准号: 9927924
• 负责人: Laura Cecere Feemster
• 金额: --
• 依托单位: VA PUGET SOUND HEALTHCARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-07-01 至 2022-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9927924
• 关键词: Acute; Address; Adopted; American; Attention; Belief; Caring; Chronic Obstructive Airway Disease; Clinical; Clinical Trials; Collection; Data; Educational process of instructing; Evaluation; Exercise; Exertion; Fire - disasters; Frequencies; Goals; Health; Healthcare Systems; Hospitalization; Hospitals; Hypoxemia; Improve Access; Injury; Internal Medicine; Intervention; Interview; Knowledge; Lead; Learning; Medical; Methods; Oxygen; Oxygen Therapy Care; Patients; Population; Publishing; Quality of Care; Randomized; Recommendation; Recovery; Reporting; Research; Resistance; Rest; Risk; Safety; Site; Supplementation; Surveys; Symptoms; System; Testing; Time; Veterans; Work; base; care outcomes; care systems; clinical practice; cohort; control trial; cost; evidence base; falls; functional status; improved; medical specialties; patient population; patient subsets; programs; secondary outcome; sound; therapy design; treatment as usual; treatment risk; treatment trial

Projects such as the American Board of Internal Medicine’s “Choosing Wisely” campaign emphasize the importance of identifying and de-implementing ineffective, harmful and/or wasteful practices to improve the quality and safety of delivered care. Among patients with chronic obstructive pulmonary disease (COPD), oxygen has been shown to improve survival among a specific subset of patients with severe resting hypoxemia. The provision of oxygen therapy has been extrapolated to other populations leading to the prescription of oxygen to patients with COPD who do not have an evidence-based indication for its use. For example, oxygen is frequently prescribed upon discharge from hospital after an exacerbation of COPD, then continued indefinitely, resulting in patients who become habituated to having oxygen readily accessible. Published in 2016, the Long-Term Oxygen Treatment Trial (LOTT) demonstrated that the use of supplemental oxygen conferred no benefit to patients with COPD who have moderate resting or ambulatory hypoxemia. In addition to being ineffective in this patient population, supplemental oxygen can pose risks of harm, such as the potential for fire or injury due to falls caused by entanglement in oxygen tubing. It is in this setting that we now have an opportunity, as well as a challenge, to learn how best to improve care quality by de-implementing a therapy that has no demonstrable benefit, is not without risk, but is deeply entrenched in clinical practice. To address this knowledge gap, our proposed study aims to use a mixed-methods approach to inform VA about their current practices for prescribing oxygen therapy to patients with COPD, as well as to identify anticipated barriers and facilitators to its de-implementation among patients in whom it has been shown to be ineffective. To achieve these goals, we will first identify a nationwide cohort of Veterans discharged with supplemental oxygen after hospitalization for a COPD exacerbation and identify patient-, clinician- and system level factors associated with appropriate reassessment of oxygen need within 90 days of discharge. We will then identify a range of high- to low-performing sites in regards to timeliness of oxygen need reassessment. Using a sequential mixed methods approach incorporating quantitative survey collection and in-depth qualitative interviews, we will elicit patient and clinician perspectives 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. Using these initial results, we will develop, refine, and test a patient-, organizational-, and operational partner- informed pilot intervention to increase value-based care by decreasing inappropriate oxygen use. 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. If successful, this study has the potential to lead to a larger randomized control trial of our de-implementation intervention throughout VA. In addition, the results of this study could be extended to other clinical contexts to inform interventions designed to de-implement therapies that are pervasive in clinical practice but of low-value.

美国内科委员会的“明智选择”运动等项目强调 确定和取消实施无效、有害和/或浪费做法的重要性，以改善 提供的护理的质量和安全。在慢性阻塞性肺疾病(COPD)患者中， 已有证据表明，氧气可以改善严重休息患者的特定亚群的存活率 低氧血症。氧疗的提供已经被推断到其他人群，导致了 为没有循证适应症的COPD患者开出氧气处方。为 例如，慢性阻塞性肺疾病恶化后出院时经常开氧气，然后 无限期持续，导致患者习惯于随时获得氧气。 2016年发表的长期氧气治疗试验(LOTT)表明，补充氧治疗的使用 氧气对中度静息或动态低氧血症的COPD患者没有任何好处。在……里面 除了对这些患者无效外，补充氧气还可能带来伤害的风险，例如 由于氧气管道缠绕而导致跌倒而导致火灾或受伤的可能性。正是在这样的背景下，我们 现在既有机会也有挑战，学习如何通过取消实施来最好地提高医疗质量 这种疗法没有明显的好处，也不是没有风险，但在临床实践中根深蒂固。至 为了解决这一知识差距，我们提议的研究旨在使用混合方法向退伍军人管理局通报 他们目前为COPD患者开出氧疗的做法，以及确定预期的 在那些已被证明无效的患者中，阻碍其取消实施的障碍和促进者。 为了实现这些目标，我们将首先确定全国范围内退伍军人的队列，并补充 COPD急性加重患者入院后的氧疗和确定患者、临床医生和系统水平的因素 在出院后90天内适当地重新评估氧气需求。然后，我们将确定一个 在氧气的及时性方面，一系列高绩效到低绩效的网站需要重新评估。使用 结合定量调查收集和深度定性的序贯混合方法 访谈中，我们将征求患者和临床医生对停止补充氧气的看法。 在一系列高绩效和低绩效网站以及我们计划干预的网站上。vbl.使用 这些初步结果，我们将开发、完善和测试患者、组织和运营合作伙伴- 知情的飞行员干预，通过减少不适当的氧气使用来增加基于价值的护理。我们会 在两个VA地点(VA Puget Sound和Bedford VA)随机选择50名患者接受常规护理或我们的治疗 实施干预。除了评估干预的可行性和可接受性外，我们还将 评估二次结局，包括12周内功能状态和症状的变化。如果 成功，这项研究有可能导致我们取消实施的更大规模的随机对照试验 在整个退伍军人事务部进行干预。此外，这项研究的结果可以扩展到其他临床情况，以 告知旨在取消实施在临床实践中普遍存在但价值较低的疗法的干预措施。