Follow-up testing among children with elevated screening blood lead levels
Article Outline
Kemper AR, Cohn LM, Fant KE, Dombkowski KJ, Hudson SR. JAMA 2005;293:2232-7
Context Follow-up testing after an abnormal screening blood lead level is a key component in lead poisoning prevention.
Objectives To measure the proportion of children with elevated screening lead levels who have had follow-up testing and to determine the factors associated with such care.
Design Retrospective, observational cohort study.
Participants 3682 Michigan Medicaid-enrolled children age 6 years or younger who had a screening blood lead level of at least 10 μg/dL (0.48 μmol/L) between January 1, 2002, and June 30, 2003.
Main Outcome Measure Testing within 180 days of an elevated screening lead level.
Results Follow-up testing was received by 53.9% (95% confidence interval [CI], 52.2% to 55.5%) of the children. In multivariate analysis adjusting for age, screening blood lead level results, and local health department catchment area, the relative risk of follow-up testing was lower for Hispanic and other nonwhite children than for white children (0.91; 95% CI, 0.87 to 0.94), for children living in urban areas than in those living in rural areas (0.92; 95% CI, 0.89 to 0.96), and for children living in high–lead risk areas than in those living in low–lead risk areas (0.94; 95% CI, 0.92 to 0.96). Among children who did not have follow-up testing, 58.6% (95% CI, 56.3% to 61.0%) had at least 1 medical encounter in the 6-month period after the elevated screening blood lead level, including encounters for evaluation and management (39.3%; 95% CI, 36.9% to 41.6%) or preventive care (13.2%; 95% CI, 11.6% to 14.8%).
Conclusions The rate of follow-up testing after an abnormal screening blood lead level was low, and those children at increased risk for lead poisoning were less likely to receive follow-up testing. At least half of the children had a missed opportunity for follow-up testing. The observed disparities of care may increase the burden of cognitive impairment among at-risk children.
Comment There is currently little information about the follow-up testing that children receive after they are identified as having lead toxicity. In this well-designed retrospective cohort, Kemper et al demonstrated that 46% of the children who had elevated blood lead levels (≥10 μg/dL) did not receive appropriate follow-up testing. Moreover, the children at greatest risk for lead poisoning—nonwhite children, children living in urban areas/areas with high risk of exposure, and children living in areas with the greatest prevalence of elevated screening blood lead levels—were the least likely to receive follow-up testing. Whereas the use of a Michigan Medicaid database may limit the generalizability of the results to children from other states and other insurance carriers, the results are likely to reflect typical scenarios among those children at highest risk for lead toxicity.
This study highlights other deficiencies of our health system. By the time a child is identified as having an elevated blood lead level using the CDC criteria (≥10 μg/dL), he or she has already been exposed to levels associated with adverse neurodevelopmental effects.1, 2 Although it is inappropriate to wait until a child is unduly exposed, this study suggests that too often we fail even in secondary prevention efforts. A shift toward the primary prevention of childhood lead poisoning by screening high-risk, older housing and reducing allowable levels of lead in house dust, soil, and water is long overdue.
References
PII: S0022-3476(05)00821-8
doi:10.1016/j.jpeds.2005.08.054
© 2005 Elsevier Inc. All rights reserved.
