A focus on outcomes is driving RTs to expand their delivery of oxygen therapy (and other care) out of the hospital and into the home.
By Renee Diiulio
Difficulté à respire. Dificultad para respirar. Trouble breathing. Around the world, it’s a common complaint. The World Health Organization (WHO) reports that respiratory symptoms are the major reason patients seek consultation at primary care facilities. According to the organization, surveys conducted in 9 countries found the proportion of patients (older than 5 years) with respiratory symptoms who visited primary healthcare centers ranged from 8.4% to 37.0%.1
Of course, not all of these patients were diagnosed with respiratory disorders and an even smaller number required oxygen therapy, but looking ahead, a greater proportion is expected to receive positive diagnoses and extended care. Few contest predictions of a growing patient population (particularly with the increasing proportion of elderly)—it’s the impact that carries some debate.
Respiratory therapy has not been immune to the overall trend of decreasing reimbursements and increasing requirements. “Doing more with less” has become not only clichéd, but also downright frustrating. At some point, no more can be done and no more should be taken away. However, the situation has forced “out-of-the-tank” thinking, and the field is now undergoing a quiet revolution.
“Respiratory care as a profession is at a crossroads,” said Kenneth Miller, MEd, RRT-NPS, AE-C, ACCS, educational coordinator and dean of wellness for Respiratory Care Services at Lehigh Valley Health Network (LVHN), Allentown, Pa. Miller believes the growing patient population, combined with changes in healthcare laws, has opened a tremendous opportunity for patient education and care outside the hospital, areas in which RTs have not historically participated. Similarly, there are also opportunities for growth within the hospital, where RTs are challenged to incorporate value-added responsibilities as members of a multidisciplinary clinical team.
This means they actually are doing more with less, and despite the difficulties, they are getting better at it. Using evidence-based medicine to guide decisions, they are seeking to ensure maximum care at minimum expense. And this same approach applies to their tools. Equipment also needs to offer evidence and value, to both the clinician and the consumer, who together are driving development.
A market report by Global Industry Analysts Inc, San Jose, Calif, suggests that in response to the rise in respiratory disease, oxygen therapy equipment will undergo significant innovation over the next few years.2 Advances are expected to revolve around the provision of clinically sound therapy, and current research is expected to open new applications2—even discounting the trendy popularity of hyperbaric oxygen therapy. Device-wise, the market can expect to see innovation in intelligence and software, and growth in portable oxygen concentrators (POCs).2
“If you enhance patient comfort, which increases patient compliance, and if you can deliver a certain amount of oxygen to a patient with a less expensive device, you can save on the overall cost. And you can save even more if you can utilize therapy to optimize outcomes,” Miller said.
Out of the ICU, Into the Home
Outcome optimization should be the focus of RTs, rather than the completion of specific tasks. Respiratory professionals still need to perform blood gas testing or a breathing treatment, but they also must consider how these actions might impact outcome and what else could be done to ensure success, Miller suggested. Rather than act as task managers, RTs need to become case managers.
“Although I work in critical care, the goal of our institution is to prevent patients from being admitted to a unit or, if they must be admitted, minimizing their stays,” Miller said. LVHN has initiated a program where patients seen in the emergency department with respiratory ailments, such as asthma or COPD, are assigned an RT.
“A specialist is brought in to develop a rapport and working strategy with the patient that continues when they go home so that we are not waiting until the patient is critically ill to educate them, but preventing escalation of the disease process,” Miller said. Having oxygen therapy devices that can be used in non-critical care areas, or the home, enables seamless therapy as patients transfer between environments. “We can use the same device at the beginning that we can at the end. We don’t want patients stuck in the ICU because they need oxygen,” Miller explained.
Traditionally, RTs have not been very involved in home oxygen therapy, with many hospitals referring these patients to their case management departments, but that is changing. “With the pressures of payments regarding readmissions of COPD, asthma, and other higher-risk patients, we are starting to see more RT departments take an active role in patient education and transitional care,” said Joe Lewarski, DS, RRT, FAARC, vice president of clinical affairs for Invacare Corporation, Elyria, Ohio.
Their involvement may help to improve outcomes, although research would need to bear this out. Patient education focuses on both compliance and proper use of devices, as well as follow-up care, which would indicate a positive impact. Inside the hospital, RTs can expand their roles and influence by constantly updating interventions and protocols based on evidence, supporting their decisions with their own evidence, attending rounds, and generally getting involved in all levels of decision-making. In these ways, RTs can not only make a difference in the outcome of a patient but also help their departments show their value.
High Value Leads to High Flow
In the same way RTs must prove their own value to their institutions, vendors have to prove the value of their products to their customers—both clinicians and consumers. For clinicians, it’s all about evidence and outcomes; for patients, it’s convenience and ease.
“Before we bring any device into our facility, we always look at outcomes data. We want real evidence showing it helps to optimize results, not just the word of the manufacturer,” Miller said.
Analysis at LVHN looks at whether the device fits the patient population and whether it has been used on similar populations elsewhere. The supporting research also must be patient-applicable as well as scientifically sound. “There is no sense bringing in technology that applies to patients that we do not see,” Miller said.
In-hospital systems do tend to have a broader patient base, while in-home systems are designed to meet the needs of smaller population segments. Some of the biggest buzz on the floor has stemmed from high-flow oxygen therapy. Miller cites devices that deliver gases through the nasal cannula—such as the Optiflow line of Fisher and Paykel Healthcare, Irvine, Calif, and Precision Flow by Vapotherm Inc, Stevensville, Md—as the type of value-adding equipment RT departments seek.
The use of humidification and other optimal conditioning of gases with high-flow equipment allows oxygen to be delivered through nasal cannula at precise FiO2 levels of 30% to 100% while meeting the patient’s respiratory drive and flow demands, according to Miller. The use of nasal cannula instead of a mask improves patient comfort and compliance. “These avenues together allow a wider spectrum of patients to use the device for oxygen therapy,” he said.
Light as Air, Please
Outside the hospital, efficiency, comfort, and compliance are still concerns, but broad use gives way to consumer appeal—and freedom is appealing. Portable units continue to increase in popularity and are one of the most active areas in the market, though they still represent a relatively small portion, according to Lewarski.
“As a sophisticated machine that makes oxygen, a POC is a delicate unit, but it needs to live like an oxygen cylinder, so the greatest challenge for these devices is durability and reliability,” Lewarski said. Conceptually, the ideas have been around a long time, he noted, but the industry has been struggling to integrate small size with sufficient oxygen delivery.
“We have been able to make more oxygen in a smaller package as a result of improvements in the compressor technologies, batteries, chemicals, and knowledge, such as our better understanding of the operation of sieve materials,” Lewarski said. Today’s units are smaller, quieter, and more efficient in oxygen delivery than in the past, though many expect greater technological leaps in the coming years. At present though, smaller is not always better.
The type of device most appropriate for a patient is dependent on the disease state. Patients with lower oxygen needs will have more options in portability. “For patients with higher oxygen requirements, smaller units may not be able to provide adequate therapy,” said Eli Diacopoulos, vice president and general manager of Home Healthcare Solutions for Philips Respironics, Murrysville, Pa.
Each type of technology and model offers advantages and disadvantages, and so vendors strive to offer a line of options that will best suit various patient populations. “Now within the category, we have systems that range from supersmall to small to medium to large,” Diacopoulos said.
Healthcare professionals can make recommendations to consumers, but ultimately the choice lies with patients. For this reason, education by RTs that covers the reasons why certain recommendations are made can direct patients to exercise a more appropriate choice, one that will ideally provide a better outcome.
The Cost of Freedom
Unfortunately, not all equipment decisions are based solely on needs and desires; economics play a role too. Today’s devices must meet end user demands (an attractive, inconspicuous design and function) at the same time they have to address clinician requirements regarding high efficacy and low expense. Home oxygen therapy suppliers must, in turn, develop effective models within the constraints of the payment system.
Reimbursement does not directly cover home respiratory therapy but is often paid for out of the rental or purchase cost for the equipment. “For the majority of patients on oxygen therapy, payment is provided by Medicare or another insurance agency to the home oxygen care provider at low fixed rates that have been declining steadily over the past 20 years,” Lewarski explained.
But during that same time, patients have become more informed about choice and have demanded lifestyle-friendly devices that can often cost more than reimbursement covers. Those who can afford it will pay out of pocket for a more convenient system. “We are seeing more patients decide to purchase a device out of pocket if they cannot obtain it throughthe reimbursement path,” Diacopoulos said. Options in price are therefore as important as options in size and delivery.
The good news is that a more custom, convenient, or costly device may encourage compliance, particularly if its features are designed with an eye toward patient comfort and ease of use. “Patients in later stages of disease often comply with treatment because they need it for survival. It’s the early-stage COPD patient, for instance, who is more likely to think they can do without oxygen therapy,” Diacopoulos said.
Miller concurred, noting that asthma patients may not use their maintenance inhalers or take their corticosteroid medications if they feel good, but consistent treatment is associated with better outcomes. For these patients, education and follow-up become a greater factor in successful therapy, but reimbursement is even less in these areas. “We are trying to create models that increase hospital reimbursement through the allocation of services outside of the pure critical care arena, such as outpatient services,” Miller said. The redistribution of workflow will, ideally, mean more care is provided in early and less severe disease states so that less care is needed in the ICU.
Changing the Mindset
Market forecasts predict the home oxygen therapy segment will continue to grow. “Historically, the home oxygen patient population has averaged an annual growth rate of 4% to 8%, with a 5% net year-over-year increase in the number of domestic patients,” Lewarski said, stipulating that the numbers may be skewed by lack of relevant reporting by payors. In addition, the current patient population is often seen in an earlier disease state, meaning interventions are now occurring sooner than they did in the past. “Today’s patients are very different than those seen 30 years ago: they’re more active, ambulatory, and informed about choice,” Lewarski explained. Home oxygen therapy serves them much better than a trip to the ICU.
“So we want to move more therapists from the ICU into these other environments at the same time that we look for reimbursement opportunities,” Miller said. For many therapists and departments, this means a culture change. “The greatest challenge today is that you can’t practice the way you were practicing yesterday. We need to move from being a task-based department to an outcomes-based department and position ourselves where we can influence patient outcomes,” Miller said. That means when a patient complains of trouble breathing, RTs are the ones to deliver oxygen—in any language. RT
HBOT: Hyperbaric Oxygen Therapy
Today, hyperbaric oxygen therapy is all the rage—not necessarily among RTs, but certainly among the media. Stories about the wonders of this new miraculous treatment (more familiarly known as HBOT) abound online, in print, and on television. Celebrity doctors like Dr. Oz and Dr. Phil tout its clinical benefits as new centers devoted to the treatment are opening throughout the country.
First developed in the early 1900s, hyperbaric oxygen chambers did not find a proven clinical use until the 1940s, when they were used to treat decompression sickness in deep-sea divers by the military (according to the American Cancer Society). Since then, research has borne out some medical value, but many more claims exist than does evidence.
According to the hype, HBOT can help with a long list of ailments that includes AIDS/HIV, Alzheimer’s disease, asthma, Bell’s palsy, brain injuries, cerebral palsy, depression, heart disease, hepatitis, migraines, multiple sclerosis, Parkinson’s disease, spinal cord injuries, sports injuries, and stroke. However, in August 2013 the FDA issued a consumer update warning that specifically stated that the safety and effectiveness of HBOT had yet to be established for the aforementioned ailments, among others.3
Additional claims cited by dedicated centers include anti-aging effects and immunity boosting powers as well as a long list of treatable conditions: autism, pollen and food allergies, chronic fatigue syndrome, dementia, fibromyalgia, jet lag, irritable bowel syndrome, Gulf War syndrome, post-traumatic stress disorder (PTSD), reflex sympathetic dystrophy, and rheumatoid arthritis. Some offer even broader applications, suggesting the treatment can have a positive impact on chronic illness, digestive problems, fertility issues, rehab/detox, and skin disorders.
The problem is not that hyperbaric oxygen therapy is bad or disproven—although there are risks that range from the mild (such as sinus pain) to the severe (such as paralysis). The FDA’s concern is that by seeking unproven treatment, patients may experience a lack of improvement and/or worsening of existing condition(s).3
“Patients may incorrectly believe that these devices have been proven safe and effective for uses not cleared by the FDA, which may cause them to delay or forgo medical therapies,” Nayan Patel, a biomedical engineer for the organization’s Anesthesiology Devices Branch, was quoted in the release.3
There are approved uses for HBOT, with the treatment of decompression sickness being one of the most well known. The UCLA Hyperbaric Medicine Division of UCLA Health lists the conditions for which it offers treatment and which includes those approved for reimbursement by Medicare.4 These include air or gas embolisms; carbon monoxide poisoning; gas gangrene; crush injury, compartment syndrome, and other acute traumatic ischemias; healing of problem wounds; central retinal artery occlusion; severe anemia; intracranial abscess; necrotizing soft tissue infections; osteomyelitis (refractory); delayed radiation injury; compromised grafts and flaps; acute thermal burn injury; and idiopathic sudden sensorineural hearing loss.4
Even for these conditions, hyperbaric oxygen therapy is just one option among treatment choices for patients. But with the increased attention in the media, respiratory care departments will likely see more patients inquiring. Education about this topic is just one of many today’s RTs must be prepared to provide.
Renee Diiulio is a contributing writer for RT Magazine. For further information, contact [email protected].
- World Health Organization. Chronic Respiratory Diseases. Accessed here.
- Global Industry Analysts, Inc. Medical Oxygen Systems—A Global Strategic Business Report. Accessed here.
- U.S. Food and Drug Administration. “Hyperbaric Oxygen Therapy: Don’t Be Misled.” Consumer Updates. 22 Aug 2013. Accessed here.
- UCLA Hyperbaric Medicine. Indications for hyperbaric oxygen therapy. Accessed from: http://www.uclahealth.org/site.cfm?id=1804