It used to be easy to describe the various methods of home oxygen delivery. However, oxygen technology is evolving quickly, which makes it difficult to understand the differences.

There has been a steady influx of new devices in the last few years, designed by manufacturers to improve patient ambulation. The devices are smaller and lighter with greater duration for use outside the home. Despite the rapid changes, there are three easy ways to identify the differences in oxygen systems and devices.

1. Determine the number of devices you deliver to meet the clinical and activity needs of your patients.
2. Separate the devices into distinct categories: (i) requires periodic or scheduled home delivery of oxygen contents; and (ii) does not require subsequent delivery of oxygen contents following initial setup of the oxygen system.
3. Identify the current equipment choices from the patient’s perspective for use in the home, outside the home, and for travel (later referred to as patient usage perspective).

Device or System?
A device is an oxygen unit designed for a particular purpose. A combination of units (or devices) forms an oxygen system. When delivering oxygen to patients, ask yourself: Am I delivering a “one device-one system-one solution” or “multiple devices-one system-one solution?” Regardless of the oxygen system, the patient must receive at least one backup compressed oxygen cylinder device (such as an H, D, or E cylinder with a regulator) for emergencies.

Routine Vs NonDelivery
Supplemental oxygen or routine oxygen delivery systems (RODS)—required to deliver oxygen molecules to meet patients’ portability needs—can be described as follows:

• Stationary concentrator and aluminum cylinders with or without an oxygen conserving device (OCD).
• Liquid oxygen (LOX) delivered through one base unit, two base units (tandem system), and one or more liquid portable devices.
• Combination system of one stationary concentrator, one LOX base unit, and one LOX portable unit. In the combination system, the stationary system is used in the home while the LOX portable unit is typically used for activities outside the home.

RODS have a definite place in the armamentarium of oxygen delivery modalities for HME providers. However, as providers are faced with declining Medicare reimbursement, competitive bidding, capped rental, and increasing operational costs, RODS are becoming less attractive choices in some instances.

Nondelivery systems are those devices that manufacture oxygen in the home and provide for portability and/or ambulation through one or more means. There are currently several different types of nondelivery devices (see chart).

• Trans-filling concentrators: a device that meets stationary oxygen needs with an oxygen concentrator that can fill one or more different sized oxygen cylinders for portable use. Portable oxygen derived from this system has an oxygen concentration level of 90% (+- 3%). There are three types of trans-filling concentrators:

1. Single device—Incorporates the concentrator and cylinder filling system as one device. This type of unit provides trans-filling of multiple size oxygen cylinders as one integral system.
2. Multiple device—Incorporates multiple units that, when used together, provide the same functionality. When these different units are used together, they create a system that can fill different size cylinders.
3. Universal device—A new unit that will be released at Medtrade Spring fills cylinders from a dedicated concentrator in the patient’s home. This unit allows HME providers to place “any” new standard stationary concentrator or use the patient’s existing concentrator in their home for the routine delivery of oxygen. This unit is a separate device that is used only to refill aluminum oxygen cylinders. The advantage of this device is that it will allow HME providers to use their existing inventory of concentrators to provide routine delivery of oxygen. Patients can benefit because they can fill their cylinders quickly if an HME supplier provides multiple cylinders with this system. If that happens, portability for the patient will be almost unlimited.

• Trans-filling liquid oxygen—This device has recently received FDA approval but is not yet commercially available. It uses a 5 LPM or above oxygen concentrator to bring oxygen into a cooling device that liquifies concentrator gas to an oxygen concentration level of 90% (+- 3%) and sends it to a portable LOX device, which has been specially adapted to accept this lower oxygen purity level. As you know, normal LOX portable oxygen devices have an oxygen concentration level of 99.9% oxygen. Many pulmonary physicians prefer LOX as a delivery modality. The ability to manufacture LOX in the home would be very appealing to them and to patients.

• Dual-purpose concentrator—These devices manufacture oxygen for use in the home and allow for ambulation and/or portability outside the home. Currently, there are two types of dual-purpose concentrators: one that offers continuous flow and/or pulsed flow, and one that offers pulsed flow only. Dual-purpose concentrators provide oxygen that has an oxygen concentration level of 90% (+-3%). Pulsed-flow-only devices are often referred to as portable oxygen concentrators (POCs).

There has been much discussion about whether patients desaturate while using a pulse-dose concentrator at night. This is an interesting question, but the most important question is “Do any of our patients who use oxygen desaturate at night?” Until and unless we perform overnight oximetry tests on all of our oxygen patients, we cannot satisfactorily answer that question. We need evidence-based clinical data, and in the absence of data, pulse-dose concentrators may simply be used for travel. There are quality clinical studies that have established the clinical effectiveness of pulse dose oxygen delievery in all activities of daily living applications, including sleep. Further clinical research is needed to determine how pulse dose oxygen devices work in oxygen dependent patients and patients with sleep disordered breathing at night. We need facts, not speculation.

Patient Perspective
The home oxygen patient is a misnomer. Most patients do not just use their oxygen at home unless they are under hospice care. Oxygen patients use their oxygen in three areas:

• in the home;
• outside the home; and
• while traveling

When oxygen patients use their oxygen, they desire normality. They want to live their lives the same way as before they required 24-hour supplemental oxygen.

Within their homes, oxygen patients do not want to be tethered to 50 feet of tubing when they get up from a chair, walk into the kitchen, go to the bathroom, or lie down for a nap. They want to take their oxygen system with them, and not just their tubing.

Outside the home, oxygen patients want to go shopping, eat at a restaurant, visit friends, see their physician, and attend church services. The size, weight, ease of use, duration of use, and appearance of oxygen devices are important to oxygen patients. They do not wish to stand out because of their medical impairment.

Travel is important for many oxygen patients, and we define travel as any time a patient leaves an HME provider’s service area, thus requiring arrangements for delivery of oxygen by another HME provider or another branch location. When we look at the patient’s usage perspective, it allows us to group available technology into three distinct areas.

The chart shows that each method of oxygen delivery has limitations for activities of daily living. Stationary concentrators, liquid oxygen, trans-filling liquid oxygen, and trans-filling concentrators do a great job of providing oxygen in the home. To provide the patient with portability, one or several additional devices are required.

If the patient has a stationary or trans-filling concentrator, then the HME provider usually provides a number of aluminum cylinder(s) and an OCD to allow patients to go outside their homes or walk around more freely in their homes. Patients that use liquid oxygen are required to have a stationary and portable device, while those with a trans-filling liquid oxygen device must have at least three different devices. For patients that travel (according to our definition), these oxygen systems are practical but not ideal.

The Ideal Product
Patients require stationary and portable oxygen to meet oxygen requirements inside the home, outside the home, and for travel. An ideal oxygen delivery product is one-device, one-system, and one-solution that patients can wear, carry, or easily move on a cart. This means it is a “single” device and not an assimilation of products.

Portability should be defined by the patient and not by the industry. What is lightweight for one patient is too heavy for another. It is also important that under the Medicare program the device is recognized as both a stationary and portable system for reimbursement purposes. This type of system has several advantages: • it allows oxygen patients to have a single unit to meet their needs; • HME providers are not required to routinely schedule the delivery of oxygen contents/molecules; and • lowers monthly operational costs for HME providers and allows them to focus more on patient management.

As more single-source solutions become available, we can expect to see technology prices decline.

The dual-purpose concentrators appear to be an ideal solution; however, the perfect product is not yet available. Oxygen delivery technology is evolving, and manufacturers seem to be listening to the needs of oxygen patients and HME providers. The years ahead are going to continue to see new and exciting oxygen delivery technologies that will address the active oxygen patient, the cost restraints placed on providers, and the cost-effectiveness demands from the payor community. DP

Thomas J. Williams, MBA, RRT, is managing director of Strategic Dynamics, Scottsdale, Ariz, and has more than 25 years’ experience in health care sales, marketing, operations, and general management. He can be reached through his Web site: www.strategicdynamicsfirm.com. Jacquelyn M. McClure, RRT, is director of respiratory and government relations for the MED Group, Lubbock, Tex. She has more than 30 years’ experience in government relations, reimbursement, sales, and clinical marketing.