The Science Journal of the American Association for Respiratory Care

2000 OPEN FORUM Abstracts

Home Oxygen is Over Utilized in the United States (Pro)

Patrick J. Dunne, MEd, RRT, FAARC Fullerton, California

For over 30 years now, the clinical benefits of properly prescribed and appropriately utilized long-term home oxygen therapy (LTOT) have been firmly established in the worldwide medical literature. LTOT helps to mitigate the serious side effects of chronic arterial hypoxemia secondary to chronic obstructive lung diseases. By so doing, LTOT reduces mortality and the incidence of hospitalization, thereby contributing to an overall increase in the quality of life. Few would argue that this modality represents a vital, cost-effective component in the management of individuals with severe but stable chronic pulmonary diseases who likewise exhibit serious arterial oxygen desaturation, as evidenced by a room air PaO2 £ 55 mm Hg or SaO2 £ 88%.
However, in the United States, the per capita utilization of LTOT, at 241 per 100,000 individuals, is staggering 8-fold higher than what is found in other major industrialized nations. For example, the next closest per capita utilization, 60/100,000, is found in Canada. In France, the utilization is a modest 26/100,000. In England and Japan, LTOT per capita utilization is even less, at 20/100,000 and 19/100,000 respectively. It should be pointed out that using LTOT to manage chronic arterial hypoxemia in patients afflicted with chronic lung disease in the stable state is no less of a priority for physicians and public health officials in any of these countries.
Several explanations have been proffered for the higher utilization in the US, including: (a) greater overall access to health care services; (b) greater awareness of the benefits of LTOT; (c) widespread availability of providers of LTOT, and (d) historically favorable reimbursement rates, especially by Medicare. While each of these explanations provide some degree of insight, it should be noted that over the years favorable Medicare reimbursement fostered an unprecedented eagerness on the part of providers to aggressively pursue new Medicare LTOT referrals on a continuing basis. In fact, even today revenue derived for Medicare oxygen customers is one of the critical factors in determining the market value of a home care company during an acquisition.
There is another explanation worthy of serious consideration. In the US, due to cost-containment pressures, it is not uncommon for hospitals to pursue aggressive discharge planning. Patients admitted for an acute exacerbation of a chronic condition are sent home well before full recovery to the pre-existing chronic stable state is achieved. Thus, patients with chronic lung diseases are often discharged to home in an unstable state. As expected, many of these patients exhibit significant arterial oxygen desaturation (e.g. room air PaO2 £ 55 mm Hg or SaO2 £ 88%) at the time of discharge, thereby qualifying for LTOT. However, there is currently no requirement that retesting of arterial oxygen saturation be conducted once these patients have recovered to the pre-exacerbation stable state, usually 6 to 8 weeks later. Among the countries mentioned previously, the US is alone in this respect. Recent investigations have suggested that this may well contribute to reimbursement in the US being made for LTOT that is neither clinically indicated nor medically necessary.
LTOT in the US is therefore not provided according to the strictest of internationally recognized coverage guidelines, with the end result that this important therapeutic regimen may be seriously over utilized.

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