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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）

基本信息

批准号：
10920451
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
项目类别：
财政年份：
2018
资助国家：
美国
起止时间：
2018-07-01 至 2023-09-30
项目状态：
已结题

来源：
https://reporter.nih.gov/project-details/10920451
关键词：
Acute Address Adopted American Attention Belief Caring Chronic Obstructive Pulmonary Disease Clinical Clinical Trials Collection Data Deimplementation 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 Learning Medical Methods Outcome Oxygen Oxygen Therapy Care Patient Discharge Patients Population Publishing Quality of Care Randomized Randomized, Controlled Trials Recommendation Recovery Reporting Research Resistance Rest Risk Safety Site Supplementation Surveys Symptoms System Testing Time Tube Veterans Work acceptability and feasibility care systems clinical practice cohort cost evidence base falls functional status habituation implementation intervention improved medical specialties patient population patient subsets programs risk mitigation secondary outcome sound supplemental oxygen therapy design treatment as usual treatment risk treatment trial

项目摘要

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.

美国内科医学委员会的“明智选择”运动等项目强调识别和消除无效、有害和/或浪费做法的重要性，以改善所提供护理的质量和安全性。在患有慢性阻塞性肺疾病（COPD）的患者中，吸氧已被证明可以提高部分严重休息患者的生存率低氧血症。氧疗的提供已推广到其他人群，导致为没有循证证据的慢性阻塞性肺病患者提供氧气处方。为了例如，慢性阻塞性肺病 (COPD) 恶化后出院时经常需要吸氧，然后无限期地持续下去，导致患者习惯于随时获取氧气。 2016 年发表的长期氧气治疗试验 (LOTT) 表明，使用补充药物吸氧对于患有中度静息或动态低氧血症的慢性阻塞性肺病患者没有任何益处。在除了对此类患者无效之外，补充氧气还可能造成伤害风险，例如由于氧气管缠绕而导致坠落，可能导致火灾或受伤。我们正是在这样的环境下现在有机会，也有挑战，学习如何通过取消实施来最好地提高护理质量这种疗法没有明显的益处，也并非没有风险，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 他们目前对 COPD 患者进行氧疗的做法，以及确定预期的治疗方案在已被证明无效的患者中，阻碍和促进其实施的因素。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补充金因 COPD 恶化住院后吸氧，并确定患者、临床医生和系统层面的因素与出院后 90 天内适当重新评估氧气需求相关。然后我们将确定一个需要重新评估氧气及时性方面表现从高到低的一系列场所。使用序贯混合方法结合定量调查收集和深入定性访谈中，我们将征求患者和临床医生对停止补充氧气的看法跨越一系列高绩效和低绩效地点以及我们计划干预的地点。使用根据这些初步结果，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。我们将在两个 VA 站点（VA Puget Sound 和 Bedford VA）随机抽取 50 名患者接受常规护理或我们的治疗实施干预。除了评估干预措施的可行性和可接受性之外，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。如果如果成功的话，这项研究有可能对我们的取消实施进行更大规模的随机对照试验整个 VA 的干预。此外，这项研究的结果可以扩展到其他临床环境为旨在取消临床实践中普遍但价值低的疗法的干预措施提供信息。