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

美国内科医学委员会的“明智选择”运动等项目强调， 必须查明和取消无效、有害和/或浪费的做法， 提供的护理的质量和安全。在慢性阻塞性肺疾病（COPD）患者中， 氧已被证明可以改善严重静息状态患者的特定亚组的存活率， 低氧血症。氧疗的提供已推广到其他人群， 为没有循证适应症的COPD患者开具氧气处方。为 例如，在COPD恶化后出院时经常开氧气处方， 无限期地持续，导致患者习惯于随时获得氧气。 发表于2016年的长期氧气治疗试验（LOTT）表明，使用补充氧气 吸氧对中度静息或非卧床低氧血症的COPD患者无益处。在 除了在该患者群体中无效之外，补充氧气还可能造成伤害的风险，例如 氧气管缠绕引起的福尔斯坠落可能导致火灾或受伤。正是在这种情况下，我们 现在有机会，也有挑战，学习如何最好地提高护理质量， 没有明显益处的疗法并非没有风险，但在临床实践中根深蒂固。到 为了解决这一知识差距，我们提出的研究旨在使用混合方法来告知VA 他们目前为COPD患者开氧疗处方的做法，以及确定预期的 在已证明无效的患者中取消该方案的障碍和促进因素。 为了实现这些目标，我们将首先确定一个全国性的退伍军人队列， COPD急性加重住院后的氧气，并确定患者、临床医生和系统水平因素 与出院后90天内适当重新评估需氧量相关。然后我们将确定一个 在氧气需求重新评估的及时性方面，从高性能到低性能的研究中心范围。使用 结合定量调查收集和深入定性调查的顺序混合方法 通过访谈，我们将引出患者和临床医生对停止补充氧气的看法 在一系列高性能和低性能站点以及我们计划干预的站点中。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- 知情的试点干预，通过减少不适当的氧气使用来增加基于价值的护理。我们将 在两个VA站点（VA Puget Sound和贝德福德VA）随机分配50名患者，接受常规护理或我们的设计， 实施干预。除了评估干预措施的可行性和可接受性外，我们还将 评估次要结局，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一个更大的随机对照试验，我们的去执行 在整个VA中进行干预。此外，这项研究的结果可以扩展到其他临床环境， 知情的干预措施，旨在取消在临床实践中普遍存在但价值较低的治疗。

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.