News


Issues and Answers in Long-Term Oxygen Therapy

The oxygen consensus conferences bring together professionals and patients who collaborate to clarify issues that confront long-term oxygen therapy.

Oxygen is the drug of choice for patients with chronic hypoxemia. Oxygen has been used therapeutically for more than 100 years and has been routinely used in the home on a long-term basis for more than 40. Science has documented the benefits and effects of proper patient oxygenation, and industrial manufacturing and packaging of oxygen have evolved. So what are the issues in long-term oxygen therapy (LTOT)?

There are many challenges in the practical application of LTOT in the home. Each segment of the home oxygen industry has specific issues that impact the care of a patient, and LTOT is a total program rather than a specific product.

Consensus Conferences for LTOT
There are consensus conferences for LTOT because each area of the market does have unique issues. Specific segments (HME, manufacturers, etc) identify their problems and educate the appropriate individuals who can help work toward solutions. Since LTOT is a combination of segments, a solution in one area might not address the problem in another area and could complicate the overall situation. There are many “moving parts,” and that is why practical, patient-friendly LTOT has not happened to date.

There have been six consensus conferences for LTOT. To see recommendation from the previous five consensus conferences,1-5 please visit www.ltotnet.org. This site provides an overview of the LTOT conferences and some specifics on the 6th conference.

Consensus conferences use a novel approach to the problems in LTOT. Each segment of LTOT is invited to represent their issues to the consensus conference. No one person or group manages or controls the meeting, and the chairman acts only as a facilitator. The format is different from most meetings, since each group educates the others on specific problems they face. Presentations are given by the representatives of each area of LTOT to raise the awareness of problems that may not be known to all. The entire group can ask for clarification or specific questions of the presenter. The most beneficial aspect of the consensus conference process is when individual breakout groups meet to discuss issues and attempt to identify solutions. The breakout groups develop recommendations that are then presented to the main body for debate, modification, and acceptance as the final recommendations from the consensus conference.

Thomas L. Petty, MD, professor of medicine, University of Colorado, Denver, has been the chairman of all the LTOT consensus conferences, and this year he shared the chair with Dennis Doherty, MD, professor of medicine, University of Kentucky, Lexington. The process that Petty has used for consensus development in the breakout groups is the Group Techniques for Program Planning by Delbecq.6 This uses the Nominal Group Process for organizational decision-making and problem-solving.

The NGP produces a prioritized list of ideas in 2 hours or less. The balance of the time is spent in small groups identifying solutions to the specific issue the group was assigned. The chairman of each breakout group presents the recommendation to the main body of the consensus conference. These recommendations are debated and final consensus is accomplished.

What Is Consensus and What Does It Mean?
Consensus is a process of decision-making. It is a method by which an entire group of people can come to an agreement. The input and ideas of all participants are gathered and discussed to arrive at a final decision acceptable to all. Through consensus, better solutions are achieved and the growth of community and trust is promoted.

Consensus does not mean that everyone thinks that the decision made is necessarily the best one possible, or even that the recommendations are sure to work. What it does mean is that a decision is made; no one feels that their position on the matter was misunderstood or that it was not given a proper hearing. The hope is that everyone will think it is the best decision; this often happens because, when it works, collective intelligence does come up with better solutions than could individuals.

Consensus takes more time and member skills, because it uses many resources before a decision is made; but taking this time creates commitment to the decision and often facilitates creative decisions. It gives everyone some experience with new processes of interaction and conflict resolution, which is basic but important skill-building. For consensus to be a positive experience, it is best if the group has common values; some skill in group process and conflict resolution, or a commitment to let these be facilitated; commitment and responsibility to the group by its members; and sufficient time for everyone to participate in the process.

Voting Versus Consensus
Voting is a means by which we choose one alternative from several. Consensus, on the other hand, is a process of synthesizing many diverse elements.

Voting is a win or lose model, in which people are more often concerned with the numbers it takes to “win” than with the issue itself. Voting does not take into account individual feelings or needs. In essence, it is a quantitative, rather than qualitative, method of decision-making.

The fundamental right provided by consensus is that all people are able to express themselves in their own words and of their own will. The fundamental responsibility of consensus is to assure others of their right to speak and be heard. Coercion and trade-offs are replaced with creative alternatives and compromise with synthesis.

When a proposal seems to be well understood by everyone, and there are no new changes asked for, the facilitator(s) can ask if there are any objections or reservations to it. If there are no objections, there can be a call for consensus. If there are still no objections, then you have your decision. Once consensus does appear to have been reached, it really helps to have someone repeat the decision to the group so everyone is clear on what has been decided.

The 6th Consensus Conference for LTOT
The 6th Consensus Conference for LTOT met in Denver on August 25-28, 2005. It was convened because, once again, oxygen therapy in the home is in crisis. Economic pressures from reimbursement groups are causing manufacturers to produce new products, home oxygen providers to modify services, clinicians to react to patient needs, and patients to be concerned about access to appropriate therapeutic oxygen.

Due to the greater involvement of patients in these changes, the focus of the 6th consensus conference was on patient issues. Although this was a by-invitation-only meeting, the conference had the highest attendance of any other LTOT consensus conference, with a good mix of representation from each segment.

Although technology improvements have allowed patients to travel, Denver was a challenge for the oxygen-dependent participants. Oxygen therapy was needed to compensate for the altitude in Denver. The oxygen patients were highly motivated to attend and were willing to accept the challenge of the location of the meeting. Meeting planners ensured the patients were met at the airport and had adequate oxygen before, during, and after the meeting and on their way back to the airport. Clinicians, manufacturers, and even a respiratory therapy school worked together to make the patients feel safe at the meeting. Participants at the meeting were able to see first hand the issues patients face and gained a better perspective of the total program of LTOT.

The agenda included 1¼ days of preliminary lectures, ¼ day of breakout discussion, and ¼ day of presentations to the group and final consensus development. In hindsight, it would have been better to focus more attention on consensus development, as there was lively debate and good discussions.

The breakout groups were a balanced blend of all participants with two physicians as chair and cochair. The breakout groups required open discussion, documentation of all the input, and an organized coordination of the group’s recommendations. The assigned scribes for each room had their hands full keeping up with the flurry of ideas and recommendations.

Recommendation of the 6th Consensus Conference for LTOT
The recommendations from the 6th consensus conference have been submitted for publication in a peer-reviewed journal, which has been the procedure for the previous five conferences. The goal for the 6th conference is to expand the visibility of the conference proceedings and have the recommendations paraphrased and printed in other publications. The reason for initial publication in a scientific journal is to have reference in Medline (the National Library of Medicine database) so all clinicians researching LTOT can see the recommendations and also to be visible to clinicians that may not read trade journals. Clinicians are a key component of the LTOT program, yet as mentioned earlier, only one segment of many. The science is the foundation for therapy, yet the practical application of the science is the key issue and the stumbling block in overall LTOT.

Where Do We Go From Here?
The consensus process is an excellent template for finding solutions to our complex health care system. For oxygen therapy, it is an opportunity to have all groups use the recommendations to work on solutions that are comprehensive, practical, and supported by the entire industry. There are many segments that provide education, support, lobbying, and visibility for LTOT. In the past, these groups have not worked well together due to their focus on specific segments. The consensus recommendations look at the big picture, which can help the payors and public understand the problem and solution.

We need to clearly understand the issues facing LTOT and keep the patient as the focal point of therapy. Providing oxygen therapy that is economical, yet not therapeutic, will cost the health care system in the long run. Thinking beyond the traditional model will be important, as we have been doing LTOT the same way for 20 years and reimbursement has continued to decline. If we do it right this time, there should not be a need for a 7th consensus conference.

The Focus of the Breakout Groups
Clinical issues
•    new technologies now and pending
•    standard of care
•    clinical education
Manufacturer issues
•    specifications for new products
•    research and development
•    sponsorship
•    funding
Home medical equipment provider issues
•    level of service
•    outcomes
•    reimbursement
Patient issues
•    access to oxygen
•    availability of products
•    level of service and education
•    traveling with oxygen

Research
•    medical facilities
•    home studies

Robert B. McCoy, RRT, is managing director, Valley Inspired Products Inc, Apple Valley, Minn.

References
1. Problems in prescribing and supplying oxygen for Medicare patients. Am Rev Respir Dis. 1986;134(2):340-1.
2. Conference Report. Further recommendations for prescribing and supplying long-term oxygen therapy. Am Rev Respir Dis. 1988;138:745-7.
3. New problems in supply, reimbursement, and certification of medical necessity for long-term oxygen therapy (Summary of the Third Consensus Conference held in Washington, DC, March 15-16, 1990). Am Rev Respir Dis. 1990;142:721-4.
4. Petty TL, O’Donohue WJ Jr. Further recommendations for prescribing, reimbursement, technology development, and research in long-term oxygen therapy. Summary of the Fourth Oxygen Consensus Conference, Washington, DC, October 15-16, 1993. Am J Respir Crit Care Med. 1994;150(3):875-7.
5. Petty TL, Casaburi R. Recommendations of the Fifth Oxygen Consensus Conference. Writing and Organizing Committees. Respir Care. 2000;45(8):957-61.
6. Delbecq AL, Van de Ven AH, Gustafson DH. Group Techniques for Program Planning: A Guide to Nominal Group Technique and Delphi Processes. Glenview, Ill: Scott Foresman; 1975:174.