Tuesday, March 1, 2011

Lead screening recommendations: not "one size fits all"

In a Letter to the Editor in the March 1st issue of AFP, Dr. Matt Viel challenges a previous review article's "one size fits all" recommendation to test all Medicaid-enrolled or eligible children for elevated lead levels at one and two years of age. (This recommendation is based on a 2007 practice guideline from the Centers for Disease Control and Prevention.) Pointing out that his county has a known lead poisoning prevalence of less than 0.1 percent, making it unlikely that screening will yield appreciable health benefits, Dr. Veil reports that "our practice loses revenue because Medicaid often denies most or all of our claim for the well-child visit if we do not order lead screening tests."

In her response, Dr. Crista Warniment endorses a more targeted approach to lead screening:

The CDC has released revised guidelines urging local and state health officials to update screening recommendations for lead poisoning in Medicaid-enrolled or -eligible children based on state and local data rather than on insurance status alone. Recent data suggest that the incidence of elevated blood lead levels is decreasing among the Medicaid population in certain areas, approaching the lower risk seen in children not enrolled in or eligible for Medicaid. For example, Minnesota and Wisconsin are among the first states to report less of a disparity in elevated blood lead levels between children who are Medicaid-enrolled or -eligible and those who are not.

It is also worth mentioning that the U.S. Preventive Services Task Force and the AAFP consider the evidence to be "insufficient to recommend for or against routine screening for elevated blood lead levels in asymptomatic children one to five years of age who are at increased risk," and recommend against screening children at average risk. AFP's Putting Prevention Into Practice case study provides further information.

Financial considerations, evidence limitations, and conflicting recommendations make it tempting to simply take a "one size fits all" approach to lead screening, even if this approach is not necessarily in the best interest of our patients. What strategy does your practice use to manage lead screening and similar clinical issues?

1 comment:

  1. Odette Batik, MD, MPHMarch 20, 2011 at 11:24 PM

    Our area has historically documented quite rare instances of elevated lead levels in Medicaid and non-Medicaid children, several population surveys over the last two decades have established this fact conclusively. Regardless, we are now seeing families who are being told that if their child is not screened for lead the child will not be admitted to Head Start. I believe this is an example of lead screening requirements leading to potential harm, rather than benefit to the child. Lead poisoning is not contagious, and identification at age 4 is unlikely to prevent damage to the child, but will penalize those families who elect not to subject their child to an invasive, for the child frightening, and if we are honest, medically unnecessary test.

    A fundamental principle of a screening test is that when a condition is rare the majority of positives will be false positives. Current policies appear to be poorly informed.

    ReplyDelete