Impact of a Computerized Clinical Decision Support System to Improve COPD Diagnosis and Testing for Alpha-1 Antitrypsin Deficiency.

Rationale : Chronic obstructive pulmonary disease (COPD) and alpha-1 antitrypsin deficiency (AATD) are under-recognized diseases. This is in part due to the underdiagnosis and lack of confirmation of COPD, but also from poor adherence to AATD screening recommendations. Objectives : A clinical decision support system (CDSS) to guide primary care providers improves spirometry testing and confirmation of COPD diagnosis in subjects at risk and improves AATD screening in patients with confirmed COPD. Methods : A CDSS was created to be applied to all Veterans attending a single center Veteran's Affair primary care clinics. The CDSS had an algorithmic dialogue with components executed in phases during different clinic visits: screening for COPD risk using the COPD population screening (COPD-PS) questionnaire, spirometry recommendation and ordering tool for subjects with a prior diagnosis of COPD or subjects considered "high-risk" by the COPD-PS, dialog to confirm or discard the diagnosis of COPD and recommendations for AATD screening in subjects with confirmed COPD. The latter was performed by ordering alpha-1 antitrypsin serum (AAT) levels. Each step of the CDSS algorithm approach was recorded and available to be retrieved at a later date for analysis. Results : During 6 years, a total of 6,235 Veterans older than 40 years completed the CDSS. According to the COPD-PS questionnaire, 962 (18.5%) subjects were identified as "high-risk" for COPD. An additional 579 subjects with a prior diagnosis of COPD also entered the subsequent steps of the CDSS algorithm. Of the high-risk cohort, the CDSS led to an increase in spirometry testing from 24% to 83% and led to a new diagnosis of COPD in 342 (43%). In the prior COPD diagnosis group, spirometry testing increased from 58% to 84% leading to COPD re-confirmation in only 326 (67%). A total of 489 (68%) of the subjects with confirmed COPD completed AAT testing prompted by the CDSS, with 23 subjects identified with AATD and one with severe AATD. Conclusions : In the Veterans Affairs system, the use of a clinical decision support system algorithm that incorporates screening for COPD and AATD, improves COPD over- and under-diagnosis and screening rates of AATD in a primary care setting.