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Difficulties in evaluating abnormal lead screening results in children
Insights
A computer-aided system improved follow-up for children with high blood lead levels, but most still missed mandated testing due to logistical issues. Focus on higher lead levels may be more beneficial.
Area of Science:
- Pediatric Environmental Health
- Public Health Surveillance
- Healthcare Management
Background:
- Children with abnormal whole blood lead concentrations require follow-up care.
- The 1991 Centers for Disease Control and Prevention (CDC) guidelines established follow-up protocols.
- Efforts to implement these guidelines were studied at the Family Health Center at Shadyside Hospital.
Purpose of the Study:
- To evaluate the effectiveness of a nurse-centered, computer-aided system in improving follow-up care for children with elevated blood lead levels.
- To assess the outcomes and costs associated with mandated follow-up testing.
- To identify barriers to successful follow-up care.
Main Methods:
- An automated surveillance module identified children with abnormal lead concentrations (≥10 µg/dL) between January 1994 and July 1995.
- Automated physician reminders and nursing case management were employed to enhance care and documentation.
- Longitudinal case summaries were used to evaluate the care process.
Main Results:
- All 99 children with lead levels ≥10 µg/dL had a documented follow-up plan.
- Follow-up lead concentration measurements were documented for 47% (10-14 µg/dL), 100% (15-19 µg/dL), and 100% (≥20 µg/dL) of children.
- Despite system improvements, follow-up was incomplete for over 70% of children, with significant costs and limited need for environmental intervention.
Conclusions:
- The nurse-centered, computer-aided system enhanced follow-up care for children with abnormal blood lead levels.
- Logistic obstacles prevented most patients from receiving mandated follow-up testing.
- Mandated follow-up for lead concentrations of 10-19 µg/dL showed no apparent benefit and may divert resources from higher-risk children.
Background:
This report chronicles efforts to provide follow-up care for children with abnormal whole blood lead concentrations using the 1991 Centers for Disease Control and Prevention (CDC) guidelines in the Family Health Center at Shadyside Hospital in Pittsburgh.
Methods:
An automated surveillance module found all children with abnormal lead concentrations obtained between January 1994 and July 1995 and singled out children who were overdue for follow-up. Automated physician reminders and nursing case management were used to improve care and documentation. Longitudinal case summaries were used to evaluate care.
Results:
All 99 children with a lead concentration of 10 micrograms/dL or greater had a documented follow-up plan. Twenty-nine children (47 percent) who had a lead concentration of 10 to 14 micrograms/dL, 23 (100 percent) who had a lead concentration of 15 to 19 micrograms/dL, and 8 (100 percent) who had a lead concentration of 20 micrograms/dL or greater had at least one follow-up lead concentration measurement by the end of the data collection in July 1995. Follow-up was incomplete in more than 70 percent of children. Nineteen children (19 percent) with initially abnormal lead concentrations had follow-up testing with persistently normal results. The yearly cost of follow-up was $15,888, with only 7 children requiring county health environmental intervention.
Conclusions:
The nurse-centered, computer-aided system improved follow-up care of children with abnormal lead concentrations, but most patients still did not receive mandated follow-up testing because of logistic obstacles. The effort and cost associated with CDC-mandated follow-up of children with lead concentrations between 10 and 19 micrograms/dL provides no apparent benefit and might detract from the care of children at higher risk.