Can an education and outreach program increase lead screening of low-income young children?

Lead poisoning remains a danger to low-income children who often live in older housing with lead-based paint. Federal policy requires that all children enrolled in Medicaid be screened at ages 1 and 2 years to detect lead poisoning, but rates remain low nationally. Rhode Island achieved a high screening rate through a multifaceted education and outreach program.

Why is this important?

Young children are susceptible to lead poisoning when exposed to lead in their environment, such as deteriorating lead-based paint and paint dust in older housing (NRC 1993). Low-level lead poisoning typically does not manifest in symptoms and cannot be detected without blood testing. Lead poisoning is associated with developmental delays, learning disabilities, and behavioral problems (AAP 1998).

The Centers for Disease Control and Prevention recommends lead screening for young children at risk of lead poisoning—including all low-income children receiving public assistance—to identify those in need of interventions to lower blood lead levels (CDC 1997, 2005). Interventions may include follow-up testing, family education, abatement of the source of lead exposure, and medical management.

Three of five young children with elevated blood levels are enrolled in Medicaid (GAO 1999). Hence, the federal government has required since 1992 that all Medicaid-insured children receive a blood lead test at ages 1 and 2 years, and that children ages 36 to 72 months be tested if they have not previously been screened.

Interventions

The State of Rhode Island requires universal lead screening of all young children and promotes screening through a multifaceted educational and outreach strategy that includes the following components (Rhode Island DOH 2003; Silow-Carroll 2003; Tips 2001; personal communication with Magaly Angeloni 2003):

• A statewide public health tracking system is used to notify managed care plans, health professionals, and clinics of children who are in need of screening.
• Head Start providers and Women, Infants, and Children (WIC) nutrition clinics also check children's status and notify physicians when screening is needed.
• Medicaid managed care plans are eligible for state performance incentives for meeting goals including lead screening rates.
• The state offers bilingual case management services and an abatement program that funds replacement of lead-painted windows.

Findings

During 1996–1997, 80 percent of Rhode Island children (ages 19 to 35 months) who were enrolled in the state's Medicaid managed care program for at least one year had ever received a blood lead test. Medicaid children cared for by physicians in private practice were less likely to be tested than those cared for at community health centers, hospital clinics, and staff-model HMOs. After controlling for site of care, there was no significant difference in testing rates by child or parent sociodemographic status (Vivier et al. 2001).

In comparison, only 21 percent of young children who were enrolled in traditional Medicaid in 15 other states for at least one year during 1995–1996 received a blood lead test within six months of their first or second birthday. State rates ranged from 1 percent to 46 percent (GAO 1999). More recent data from eight states that match Medicaid and surveillance data indicate that 17 percent to 53 percent of Medicaid-enrolled children ages 0–5 received lead testing during 1997–2001, suggesting continuing gaps in quality of care (Meyer et al. 2003).

Implications

A multifaceted statewide education and outreach intervention can increase lead screening rates to high levels among low-income young children. The study authors concluded that "the primary care provider rather than family sociodemographic factors is the key factor in determining whether children are screened for blood lead" (Vivier et al. 2001). The authors speculated that the availability of onsite laboratory services might be an important factor in screening rates.

Improvement Ideas and Resources

Reviews of exemplary state practices to increase lead screening have been compiled by the National Association of State Legislatures (Farmer 2001), the Alliance for Healthy Homes (Tips 2001), and the Coalition to End Childhood Lead Poisoning (CECLP 2005).

The CDC's Lead Poisoning Prevention Program developed a toolkit to assist states in primary prevention efforts, such as establishing programs to screen high-risk homes for lead hazards and to educate and support homeowners in safe renovation and abatement practices (CDC/AFHH 2005).

Measure:

This chart compares two separate retrospective data analyses. Rhode Island data were derived from a random sample of 2,000 children ages 19 to 35 months as of June 30, 1997, who were continuously enrolled (with no more than a 30-day gap) in the Rhode Island Medicaid managed care program from July 1996 through June 1997. Data on lead screening performed from birth to June 30, 1997, were abstracted from the medical records of primary care providers (Vivier et al. 2001). Comparison data were derived from Medicaid claims for 15 states that submitted complete 1994 and 1995 data to the federal government's State Medicaid Research Files. The analysis was limited to 288,963 young children who had an opportunity to receive a blood lead test paid for directly by Medicaid (GAO 1999).

Limitations:

Although medical records might offer more complete documentation of lead testing than claims data, the magnitude of the difference in rates suggests that Rhode Island has achieved a higher rate of screening.

Source:

Rhode Island medical records data were abstracted and analyzed by researchers at Brown University (Vivier et al. 2001). Medicaid administrative claims data were analyzed by staff of the Government Accountability Office (GAO 1999).

References:

* Indicates source of data used in the chart(s).AAP (American Academy of Pediatrics). 1998. Screening for Elevated Blood Lead Levels. American Academy of Pediatrics Committee on Environmental Health. Pediatrics 101(6): 1072–8.

CDC (Centers for Disease Control and Prevention). 1997. Screening Young Children for Lead Poisoning: Guidance for State and Local Public Health Officials. Atlanta, Ga.: U.S. Department of Health and Human Services.

CDC (Centers for Disease Control and Prevention). 2005. Preventing Lead Poisoning in Young Children. Atlanta: U.S. Department of Health and Human Services.

CDC/AFHH (Centers for Disease Control and Prevention/Alliance for Healthy Homes). 2005. Building Blocks for Primary Prevention: Protecting Children from Lead-Based Paint Hazards. Washington, D.C.: U.S. Department of Health and Human Services.

CECLP (Coalition to End Childhood Lead Poisoning). 2005. Testing Children and Homes: The Summit for 2010. Baltimore, Md.: Coalition to End Childhood Lead Poisoning.

Farmer, C. 2001. Lead Screening for Children Enrolled in Medicaid: State Approaches. Denver, Colo.: National Conference of State Legislatures.

* GAO (General Accounting Office). 1999. Lead Poisoning: Federal Health Care Programs Are Not Effectively Reaching At-Risk Children. GAO/HEHS-99-18. Washington, D.C.: General Accounting Office.

Meyer, P. A., T. Pivetz, T. A. Dignam et al. 2003. Surveillance for Elevated Blood Lead Levels Among Children—United States, 1997–2001. Morbidity and Mortality Weekly Report. Surveillance Summaries 52 (10): 1–21.

NRC (National Research Council). 1993. Measuring Lead Exposure in Infants, Children, and Other Sensitive Populations. Washington, D.C.: National Academy Press.

Rhode Island DOH (Rhode Island Department of Health). 2003. Public and Professional Health Education, Health Promotion, and Outreach Plan. Providence, R.I.: Childhood Lead Poisoning Prevention Program.

Silow-Carroll, S. 2003. Building Quality into RIte Care: How Rhode Island Is Improving Health Care for its Low-Income Populations. New York, N.Y.: The Commonwealth Fund.

Tips, N. 2001. The Foundations of Better Lead Screening for Children in Medicaid: Data Systems and Collaboration. Washington, D.C.: Alliance for Healthy Homes (formerly the Alliance to End Childhood Lead Screening).

*Vivier, P. M., J. W. Hogan, P. Simon et al. 2001. A Statewide Assessment of Lead Screening Histories of Preschool Children Enrolled in a Medicaid Managed Care Program. Pediatrics 108 (2): E29.