Home oxygen therapy in British Columbia

Long-term home oxygen therapy reduces mortality and improves quality of life for hypoxemic patients with respiratory disease. Four randomized controlled trials have help­­ed establish the indications for home oxygen use in patients with chronic obstruc­tive pulmonary disease (COPD),[1-4] and more trials are currently underway.[5] There is limited evidence concerning the efficacy of home oxygen in other respiratory diseases but it is presumed to be effective based on the COPD data for hypoxemic patients with other respiratory diseases such as pulmonary hypertension and fibrosis. There is also limited evidence concerning the efficacy of long-term home oxygen therapy for pa­tients with intermittent hypoxemia during either exercise or sleep.[6] There is no evidence to support the use of supplemental oxygen to reduce dyspnea in patients with respiratory disease without hypoxemia. Long-term home oxygen has no adverse effects if administered correctly.

The Canadian Thoracic Society COPD guidelines currently support long-term home oxygen for stable COPD patients with a partial pressure of oxygen (PaO₂) 55 mm Hg or less, or when PaO₂ is less than 60 mm Hg in the presence of bilateral ankle edema, cor pulmonale, or a hematocrit of 56%.[7] These guidelines also state that there is no evidence for the use of nocturnal oxygen to improve survival, sleep quality, or quality of life in patients with isolated nocturnal desaturation. The majority of Canadian provinces have guidelines for home oxygen therapy.[8-10]

BC’s Home Oxygen Program
Previously, the Home Oxygen Program (HOP) for all regions in British Columbia was managed by Pharmacare. Since 2002, HOP has been the responsibility of the regional health authorities. Although home oxygen therapy is managed separately by each authority, all follow the same medical criteria and similar practice standards. 

Three providers, VitalAire, MedPro, and Alliance, are currently contracted by the health authorities to provide home oxygen services. MedPro and Alliance serve patients in the Vancouver Island Health Authority. VitalAire and MedPro serve patients in the Vancouver Coastal Health, Fraser Health, and Interior Health Authorities. Vital­Aire is the sole provider of services in the Northern Health Authority.

Home oxygen may be funded by extended health benefits, if available to the patient, and by Veterans Affairs, Non-Insured Health Benefits, and WorkSafeBC under specific circumstances. The health authority may cover the remain­der of any costs not covered by these primary funders. The Palliative Care Benefits Program (PCBP) does not have its own oxygen funding program or eligibility criteria, so patients registered with PCBP must meet HOP medical criteria. Contracted oxygen pro­vi­ders and other companies not con­tracted by the health authorities are also available to serve patients who wish to pay privately. 

To access home oxygen therapy through BC’s HOP, patients must be referred by a physician or nurse practitioner. Applicants must submit re­sults from a recent arterial blood gas, oximetry, and other studies to confirm comorbid disease if present. Upon receipt of the application, HOP adjudicates the information. If there is hypoxemia consistent with the medical criteria, the patient will be provided with oxygen through a contracted oxygen company. The company supplies equipment based on the criteria and guidelines established by the health authority. 

Approximately 1 month after setup, patients are contacted by the health authority’s respiratory therapist and assessed using HOP medical criteria. Equipment may be changed following these assessments, according to the criteria and patient needs and goals. Patients who are not approved for HOP funding after they apply or who become ineligible after a reassessment may consider paying privately if they still want oxygen therapy.

Costs
For the 2011–2012 fiscal year, British Columbia health authorities spent approximately $9 million to provide oxygen to more than 5500 patients. With limited health care funds available, HOP resources need to be used by patients who will benefit the most—that is, in cases where there is clear evidence that oxygen will treat hypoxemia and reduce mortality, or improve exercise tolerance. 

Oxygen providers are paid a daily rate for an oxygen concentrator, a portable system, or both. A flat rate is paid for cylinders of compressed oxygen or kilograms of liquid oxygen, regardless of the quantity used. 

Many patients require home oxygen for only a few weeks or months while they re­cover from an exacerbation of their di­sease. Some patients remain oxygen-dependent for months or years. 

Although most oxygen-dependent patients have COPD, some have pulmonary fibrosis, lung cancer, or cardiac disease. Some HOP patients have hypoxemia during sleep despite maximum treatment for sleep apnea with continuous positive airway pressure (CPAP) devices. A small number of children require home oxygen therapy and are usually under the care of a pediatric respirologist.

Criteria
Since 3 July 2012, new criteria based on a recent review by BC HOP physicians and managers have been in effect (see box).

Oxygenation requirements
The oxygenation requirements remain unchanged in the new criteria. Arterial oxygen saturation (SpO₂) must still be less than 88% or the PaO₂ must be 55 mm Hg or less. Furthermore, pa­tients with a comorbid disease still qualify for oxygen with a PaO₂ of = 60 mm Hg. As previously required, pa­tients must have sleep apnea ruled out and must always take safety precautions while using oxygen. 

Comorbid disease requirements
The ambiguous terms “cor pulmonale” and “polycythemia” have been eliminated from the BC HOP criteria. The term “significant CHF” has been changed to “heart failure.” Pulmonary hypertension is still considered a co­morbid disease. It is necessary to provide documents such as a consultation note, discharge summary, spi­rometry report, or echocardiogram to confirm the presence of comorbid disease.

Ambulatory oxygen
To qualify for ambulatory oxygen, patients must be able to walk more than 1 minute. In accordance with the criteria in effect since 2007, outpatient testing requires an exercise ox­imetry study on room air versus oxygen while measuring distance walked and calculating the percentage of change. Desaturation to less than 88% and a distance improvement of 30 m (100 feet) and 25% change must be present to qualify for ambulatory oxygen.

Nocturnal oxygen
To qualify for nocturnal oxygen, pa­tients must show evidence of daytime hypoxemia (resting and/or with ambulation) in addition to arterial oxygen desaturation to less than 88% for more than 30% of the night. Sleep apnea must be ruled out or treated (e.g., with CPAP, oral appliances) before oxygen is funded. 

Oxygen on discharge
To qualify for oxygen to expedite discharge from hospital, studies confirming hypoxemia must be obtained within 48 to 72 hours of discharge.

Safety
Safe use of home oxygen remains a concern and continues to be an issue for some patients. For example, in Vancouver Coastal Health in 2011, seven safety incidents were reported, four of which resulted in facial burns. 

Most often safety problems occur when patients are smoking while using oxygen. The health authorities currently provide oxygen for patients who smoke and meet the medical criteria. Patients are given the opportunity to be safe, but if they are not (e.g., they smoke within 1.5 m or 5 feet of oxygen equipment or have a fire incident), they are re-educated and may be given a second chance. If during a follow-up assessment the patient continues to ignore safety re­quirements, the funding will usually be stopped regardless of the medical need for oxygen. Safety to the public and property takes priority in these situations. 

On occasion, patients may be restarted with oxygen. However, in order to ensure safety, access to oxygen may be limited or the patient may be moved to an environment where oxygen treatment can be closely monitored. 

Patients may request a formal re­view if they disagree with any aspects of HOP services. The HOP coordinator will attempt to resolve the issue. If the issue cannot be resolved, a formal review may be undertaken involving the medical consultant. The patient can also consider alternative review processes through the Patient Care Quality Review Board or the Office of the Ombudsperson.

For more information
A mail-out to physicians was distributed by each health authority in 2012 outlining the new home oxygen eligibility criteria. If additional information concerning these criteria or the application process is required, physicians should contact their regional Home Oxygen Program.

Competing interests
None declared.

Mr Sandberg is coordinator and Dr Fleetham is medical consultant with the Vancouver Coastal Health Home Oxygen Program.