Abstract Rationale COPD is highly prevalent among veterans. However, the prevalence and testing patterns of alpha-1 antitrypsin deficiency (AATD) in this population are unknown. Despite guideline recommendations for adults with COPD and asthma with irreversible airflow obstruction, AATD is under-recognized. We aimed to determine factors associated with AATD testing and augmentation therapy among veterans with COPD and/or asthma to identify targets for improved management. Methods Retrospective analysis using national VA electronic health records from 2004-2024. We included individuals with COPD and/or asthma using ≥2 ICD codes and/or airflow obstruction on spirometry (FEV1/FVC0.7). AATD testing was defined as having any AAT level, genotype, or augmentation therapy. AATD diagnosis was defined as genotype ZZ, SZ, and SS; AAT level 100mg/dL; ≥2 ICD codes for AATD (ICD-9:273.4 or ICD-10:E88.01); or augmentation therapy. Augmentation therapy was defined as any prescription for AAT replacement therapy. We extracted individual characteristics (age, sex, race/ethnicity, comorbidities, smoking status), geographic and community-level characteristics (rurality, Social Vulnerability Index SVI), and access to care (drive time to specialty care). Multivariable logistic regression analyses adjusted for age, sex, and race/ethnicity, evaluated factors associated with testing and augmentation therapy. Result Among 2,384,913 veterans with COPD and/or asthma, 138,211 (5.8%) underwent AATD testing. Of these, 8,564 (6.2%) were diagnosed with AATD, and among those diagnosed, 320 (3.7%) were prescribed augmentation therapy. In logistic regression analyses for AATD testing, cirrhosis (aOR 6.40,95%CI:6.29-6.51), bronchiectasis (aOR 3.73,95%CI:3.59-3.87), and vasculitis (aOR 1.17,95%CI:1.12-1.22) were associated with higher odds of AATD testing. Conversely, longer drive time to specialty care was associated with progressively lower odds of AATD testing (aOR 0.63,95%CI:0.62-0.65 for drive time 90 vs ≤ 30 minutes)(Figure1A). For augmentation therapy, cirrhosis (aOR 1.49,95%CI:1.07-2.06) and bronchiectasis (aOR 2.98,95%CI:1.90-4.67) were associated with higher odds, while active tobacco use (aOR 0.30,95%CI:0.19-0.48) and drive time to specialty care of 90 min (aOR 0.56,95%CI:0.35-0.91) were associated with lower odds (Figure1B). No differences were observed with rurality or SVI. Conclusions In this national cohort of veterans with COPD and/or asthma, AATD testing was low at only 5.8% of patients with a guideline-concordant indication for testing. Among those diagnosed, augmentation therapy was also low at 3.7%, suggesting potential gaps in both identification and management of AATD among veterans. Barriers related to accessing specialty care are linked to lower AATD testing and treatment. Improved access to diagnostic testing and adherence to testing guidelines may enable earlier diagnosis, improved management, and better outcomes for veterans with COPD. This abstract is funded by: Alpha-1 Foundation
Baldomero et al. (Fri,) studied this question.