Quality statement 4	Patients with advanced stable cardiorespiratory disease who have resting saturations on air that meet the qualifying criteria should be referred for an LTOT assessment.
Rationale	LTOT improves life expectancy in patients with chronic obstructive pulmonary disease (COPD) with chronic stable hypoxaemia. Although data are lacking, it is assumed that this holds true for other cardiorespiratory diseases, including pulmonary fibrosis, cystic fibrosis (CF), pulmonary hypertension and cardiac failure. Measuring peripheral oxygen saturations is an easily accessible measure that quickly and reliably identifies potential patients who may benefit from LTOT and therefore require further assessment by a home oxygen assessment service. All healthcare professionals should be alert to the presence of hypoxia in advanced cardiorespiratory disease. The routine 6 monthly monitoring of patients with very severe COPD (ie, forced expiratory volume in 1 s of <30%) in primary care offers an opportunity for the timely identification of potential candidates for LTOT in this particular patient cohort6 (See online Supplementary appendix 2 for NICE assessment criteria). Where similar opportunities exist for other cardiorespiratory conditions (eg, specialist clinics), these should be used in a similar way. Optimisation and treatment of underlying conditions as well as clinical stability (ie >8 weeks post infection) are essential prior to measurement and referral as both can have a positive impact on hypoxaemia, thus avoiding unnecessary LTOT assessments. Providing verbal or written information about the assessment process at the time of referral can improve understanding and increase the likelihood of subsequent attendance. This information could be provided to the patient by the referrer or sent out to the patient by the assessment team prior to their appointment.
Quality measure	Structure: Evidence that oxygen saturation is documented at least twice a year in the primary care clinical record for all patients with very severe COPD. Evidence that patients are referred appropriately to a local home oxygen assessment service. Evidence this pathway allows the transfer of appropriate information to the home oxygen assessment team (See online Supplementary appendix 3 for Home Oxygen Assessment Referral Form in Guideline). Evidence that locally relevant written information is provided to patients at the time of referral to a home oxygen assessment service. Process: The proportion of patients with very severe COPD on a primary care register with a documented oxygen saturation within the previous 6 months. The proportion of patients with very severe COPD meeting the qualifying criteria for LTOT referred to the home oxygen assessment service. The proportion of patients given written information before assessment by the home oxygen assessment service. The proportion of inappropriate referrals received by a home oxygen assessment service. Numerator 1: The number of patients with very severe COPD on a primary care register with a documented oxygen saturation in the previous 6 months. Denominator 1: The number of patients with very severe COPD on a primary care register. Numerator 2: The number of patients with very severe COPD on a primary care register with stable resting oxygen saturations ≤92% referred for a home oxygen assessment within the last 6 months. Denominator 2: The number of patients with very severe COPD on a primary care register with documented stable resting oxygen saturations ≤92% within the last 6 months. Numerator 3: The number of patients given written information prior to their assessment by the home oxygen assessment service. Denominator 3: The number of patients referred to the home oxygen assessment service. Numerator 4: The number of inappropriate referrals received by a home oxygen assessment service for patients who did not meet the qualifying criteria for an LTOT assessment, for example, SpO2 well above threshold (ie, above 94%), clinical instability and treatment not optimised. Denominator 4: The number of referrals received by a home oxygen assessment service.
Description of what the quality statement means for each audience	Service providers: Ensure that all health professionals involved in the management of patients with advanced cardiorespiratory disease have access to a pulse oximeter. Ensure systems are in place to make health professionals aware of the criteria for referral to the home oxygen assessment service and how to refer to this service. Healthcare professionals: Ensure oxygen saturations are recorded at least 6 monthly in primary care for all patients with more advanced COPD. Ensure oxygen saturations are checked for patients with advanced cardiorespiratory disease where LTOT may be considered. Ensure oxygen saturations are measured during a period of stability when all other treatment has been optimised. Ensure all patients referred to the home oxygen assessment service are given verbal or written information prior to their assessment. Commissioners: Ensure that home oxygen assessment services have sufficient facilities, staff and equipment to undertake assessments for all patients appropriately referred for an LTOT assessment.
	People who require home oxygen: Are given an explanation as to why they are being referred to the home oxygen assessment service with written information to support this.
Relevant existing indicators/data sources	For example, local data collection/audit.
Source references	BTS Guideline for Home Oxygen Use in Adults.3 NHS Service Specification: Home Oxygen Assessment and Review Service 2012.7 NICE chronic obstructive pulmonary disease in over 16 s: diagnosis and management, 2010 CG101.6
Other information	Online Supplementary file 3, BTS Guideline for Home Oxygen Use in Adults (2015): Home Oxygen Assessment Referral Form.3