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A comparison of screening strategies for elevated blood lead levels
J R Campbell1, M Paris, S J Schaffer
1Department of Pediatrics, University of Rochester School of Medicine and Dentistry, NY, USA.
Insights
Screening children for elevated blood lead levels using a fingerstick strategy is the most cost-effective approach for practices with a prevalence below 38%. This method offers the lowest average expected cost per child screened, especially with high assay specificity.
Area of Science:
- Pediatric Health
- Public Health Policy
- Biomedical Cost Analysis
Background:
- Elevated blood lead levels pose significant health risks to children.
- Various screening strategies exist, each with different cost implications.
- Optimizing screening protocols is crucial for efficient public health interventions.
Purpose of the Study:
- To calculate and compare the average expected cost per child screened (COST) across five distinct blood lead screening strategies.
- To identify the most cost-effective screening approach for pediatric populations.
Main Methods:
- A decision analysis model was employed to evaluate five different screening strategies.
- Strategies included combinations of risk assessment, fingerstick, and venipuncture blood lead testing.
- Key variables such as test sensitivity, specificity, and associated costs were incorporated.
Main Results:
- Strategy 4 (risk assessment followed by fingerstick screening for high-risk children) yielded the lowest COST at $4.13.
- Strategy 5 (risk assessment followed by venipuncture screening for high-risk children) cost $5.04.
- Universal fingerstick screening (Strategy 2) was the most cost-effective universal approach at $8.16.
Conclusions:
- Fingerstick screening strategies are most cost-effective for practices with a prevalence of elevated blood lead levels below 38%.
- High specificity of the fingerstick blood lead assay further enhances the cost-effectiveness of these strategies.
- Selective screening of high-risk children using fingersticks presents a highly economical approach.
Objective:
To calculate and compare the average expected cost per child screened (hereafter referred to as COST) among various screening strategies.
Design:
A decision analysis of 5 strategies: (1) conduct risk assessment and screen high-risk children by venipuncture, low-risk children by fingerstick; (2) screen all children by fingerstick; (3) screen all children by venipuncture; (4) conduct risk assessment, screen high-risk children by fingerstick; and (5) conduct risk assessment, screen high-risk children by venipuncture. We assumed all fingerstick blood lead levels of 0.72 mumol/L or higher (> or = 15 micrograms/dL) would be confirmed by venipuncture. Baseline variables taken from the literature included prevalence of elevated blood lead levels in the pediatric population (2%), sensitivity and specificity of fingerstick blood lead assay (90% each), specificity of risk assessment (50%), sensitivity of risk assessment at blood lead levels of 0.48 to 0.68 mumol/L (10-14 micrograms/dL) and 0.72 mumol/L or higher (> or = 15 micrograms/dL) (65% and 85%, respectively), cost of blood lead assay ($6), cost to obtain blood by venipuncture ($4) and fingerstick ($2), and cost to get a child who has a fingerstick blood lead level of 0.72 mumol/L or higher (> or = 15 micrograms/dL) to return ($0.18). Sensitivity analysis determined whether selected variables affected the COST.
Results:
The COSTs for strategies 1 through 5 were $9.07, $8.16, $10, $4.13, and $5.04, respectively. Among the universal strategies, screening children by fingerstick had the lowest COST at a prevalence of less than 38% and fingerstick blood lead assay a specificity of greater than 62%. Among the selective strategies, screening high-risk children by fingerstick had the lowest COST at a prevalence of less than 38% and fingerstick blood lead an assay specificity of greater than 63%.
Conclusion:
At a readily attainable specificity of the fingerstick blood lead assay, practices serving a patient population with a prevalence of elevated blood lead levels of less than 38% will have the lowest COST when a fingerstick screening strategy is used.