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.

美国内科委员会的“明智选择”运动等项目强调了识别和实现无效，有害和/或浪费的实践的重要性，以改善交付护理的质量和安全。在慢性阻塞性肺疾病（COPD）的患者中，氧气已被证明可以改善严重休息患者的特定子集的生存率低氧血症。氧疗法的提供已被推断到其他人群中为没有证据指示的COPD患者的氧气处方。为了例如，氧气经常在COPD加重后从医院出院时开处方，然后无限期继续，导致患者习惯于容易获得氧气。长期氧气治疗试验（Lott）于2016年发布，证明了补充的使用氧气对患有中等静止或卧床低氧血症的COPD患者没有任何好处。在除了在该患者人群中无效，补充氧气还会构成伤害的风险，例如由于氧气管中的纠缠引起的火灾或受伤的可能性。正是在这种情况下，我们现在有机会，也有挑战，可以学习如何通过降级来最好地提高护理质量没有明显益处的疗法并非没有风险，而是在临床实践中深深地根深蒂固。到解决这个知识差距，我们提出的研究旨在使用混合方法的方法来告知VA 他们目前为COPD患者开氧疗法的实践，以及确定预期的在被证明无效的患者中，其障碍和促进因子的障碍和促进因素。为了实现这些目标，我们将首先确定全国范围的退伍军人队列住院后，COPD加重后的氧气并确定患者，临床和系统水平因素与出院后90天内的适当重新评估氧气需求相关。然后，我们将确定一个关于氧气的及时性，需要重新评估的高度绩效位点范围。使用顺序混合方法方法增加定量调查收集和深入定性访谈，我们将引起患者和临床观点，以终止补充氧气在整个高性能和低表现的地点以及我们计划干预的地点。使用这些最初的结果，我们将开发，完善和测试患者，组织和运营伙伴 - 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）中随机将50名患者随机接受，以接受常规护理或我们的服务实施干预。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果，包括在12周内功能状态和符号的变化。如果成功，这项研究有可能导致我们的启动更大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告知旨在消除临床实践但低价值的实施疗法的干预措施。