Alpha1-antitrypsin Deficiency


Figure 1: An Algorithm for Testing at the Pulmonary Function Test Laborarories


Notify referring physicisns of automatic testing at the PFT laboratory


Solutions to Improve Alpha1-antitrypsin Deficiency Detection


Evaluate each patient for candidacy: FEV1


/FVC<0.7, FEV1 <80% post-BD


Starting with the barriers we identified, we can consider looking at possible solutions (see Table 2). A major imperative is towards efforts that focus on improving the knowledge of physician and patients. This is an old horse, but indeed there is more ground to cover. Not only do we need to expand our efforts, but also we need to change how we go about it. Physicians, for instance, need to be approached in the formative years in colleges and residency and fellowship programs to develop better habits and ingrained knowledge.28


Mention ATS/ERS criteria, discuss the merits of AAT testing and obtain consent


If patient agrees, perform testing using kits or send patient to lab (orders signed by PFT lab director)


Notify patient of status: Negative or heterozygote: via mail with information about status. Positive/deficient: Phone call from PFT lab director to patient (and primary MD)


With regard to continuing education, we need to change our approach. It is clear that the old way of lecturing to physicians has insufficient impact in changing physician behavior. We should continue to seek innovative approaches to physician education. In AATD, education should be directed to diagnosis, rationale and methodology for testing, but also on the general merits of genetic testing and familiarity with the Genetic Information Non-discrimination Act (GINA). In 2008, President Bush signed GINA into law. It remains obscure and not very well understood by patients. It was written to protect Americans against discrimination based on their genetic information, specifically regarding health insurance and employment (but not life insurance). Our experience has been that physician awareness of GINA is not up to par. In referring physicians surveyed in our institution, 36.4% were not aware of the extent of the protections provided by GINA.29


Deficient patients complete work-up: Considered for replacement therapy if indicated/continued follow-up


AAT = alpha1-antitrypsin deficiency; ATS = American Thoracic Society; BD = bronchodilator; ERS = European Respiratory Society; FEV1 = forced expiratory volume in one second; PFT = pulmonary function test.


understand recommendations much more often. Moreover, research has shown that more specific behavioral terms in guidelines such as what, who, when, where, and how would make implementing guidelines much more acceptable in practice. This is why rewriting guidelines into simple concrete terms is much more effective than well-reasoned, referenced, but complex guidelines. Bloom et al. suggest that there are known, proven continuing medical education (CME) techniques, but the least effective ones predominate in practice. The most effective CME techniques include interactive methods of educating such as audit/feedback, academic detailing/outreach, and reminders, which could lead to changing physician care and patient outcomes. Moreover, clinical guidelines and didactic lectures had no beneficial effects on physician practice.27


As for the target of educational efforts, the majority of educational efforts have been targeted at pulmonologists. However, primary care physicians treat the majority of COPD patients. This makes the primary care physicians an often ignored but important asset in identifying and improving the diagnosis and management of COPD patients who may have AATD.28


50


There are many steps that physicians should consider in changing their approach to CME. One approach we have discussed in the article is increasing the effectiveness of CME by including interactive methods of educating such as audit/feedback, academic detailing/outreach, and reminders, which could lead to changing physician care and patient outcomes. But to do this physicians have to abandon old habits and transform didactic lectures into more interactive workshops that involve auditing, positive reinforcement, more incentives to physicians, and feedback. These tactics could result in improving recall, accepting new challenges and approaching diagnostic learning through a more effective method.


The misconceptions of AATD previously identified and reviewed in this article should be addressed and information made available in a clear, concise manner. Simple and concrete guidelines regarding testing can also be helpful in encouraging widespread implementation. The ATS is in process of updating the 2003 guidelines. Another major direction is to take away procedural barriers to testing. This could be accomplished by either recruiting non-physician healthcare providers, or by helping and guiding the physicians to appropriate testing. Respiratory therapists have been shown to achieve better outcomes than physicians when it comes to following extubation protocols.30


It is then natural to recruit


them in the AATD screening process. This could take place across multiple sites: in the hospital or ER and, in particular, in the pulmonary function laboratory.


The Alpha-1 Foundation has just completed a study of the feasibility and the prevalence of AATD, providing routine resting for individuals with


GOLD II and above (FEV1/forced vital capacity (FVC) ratio <0.70 and FEV1 <80% after bronchodilator (BD) response). Our own experience has


US RESPIRATORY DISEASE


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