A Statewide Assessment of Lead Screening Histories of Preschool
Children Enrolled in a Medicaid Managed Care Program
Patrick M. Vivier, MD, PhD*‡; Joseph W. Hogan, ScD‡§; Peter Simon, MD, MPH*; Tricia Leddy, MS¶;
Lynne M. Dansereau, MSPH*‡; and Anthony J. Alario, MD*
ABSTRACT. Objectives. Despite the prominence of
lead poisoning as a public health problem, recent Gov-
ernment Accounting Office reports indicate that only one
fifth of children who are covered by Medicaid have been
screened for lead poisoning. The purpose of this study
was to examine the lead screening histories of children
who were enrolled in a statewide, Medicaid managed
care plan to determine the relative impact of the type of
primary care provider site and family sociodemographic
characteristics on the likelihood of being screened. The
study also examined the prevalence of and risk factors
for lead poisoning of children who had been screened.
Methods. A random sample of 2000 preschool-age
children was chosen from those who were enrolled con-
tinuously in the statewide, expanded, Medicaid managed
care program for a 1-year period and between the ages of
19 and 35 months at the end of that year. Sociodemo-
graphic characteristics and lists of primary care providers
were obtained from administrative data sets. Medical
record audits at primary care provider sites were per-
formed to obtain the lead screening histories of the chil-
dren, including test dates and results.
Results. Data on 1988 children were used for study
analyses, and 80% of these children had at least 1 docu-
mented blood lead level. Children whose primary care
provider was an office-based physician were less likely
to be screened as compared with patients of health cen-
ters, hospital-based clinics, and staff model health main-
tenance organizations (68%, 86%, 89%, and 91% respec-
tively). Variation in screening rates persisted in a
multivariate analysis controlling for family sociodemo-
graphic characteristics and practice level variation. Of the
1587 children who had a documented blood lead test, 467
children (29%) had a blood lead level of >10 mg/dL on at
least 1 test.
Conclusions. Blood lead screening rates in Rhode
Island’s Medicaid managed care program are dramati-
cally higher than national estimates for children who are
enrolled in Medicaid. Potential explanations for this
finding are 1) a high sensitization to the problem of
lead poisoning in Rhode Island, 2) the primary care
focus of the Medicaid program in Rhode Island facili-
tates the delivery of preventive services, and 3) the med-
ical record audit approach used in this study was more
comprehensive in identifying blood lead screens than
techniques used in national studies. The high prevalence
of elevated blood lead levels found in this study empha-
sizes the importance of screening among children who
are enrolled in Medicaid. Pediatrics 2001;108(2). URL:
http://www.pediatrics.org/cgi/content/full/108/2/e29; lead
screening, Medicaid managed care.
ABBREVIATIONS. NHANES, National Health and Nutrition Ex-
amination Survey; HMO, health maintenance organization; MCO,
managed care organization; CI, confidence interval; OR, odds
ratio.
T
he deleterious effects of lead poisoning on
young children have been well documented.
1–6
Blood lead levels as low as 10 g have been
associated with negative effects on a child’s develop-
ment, and it has been estimated that a blood lead
level of 20 g can lead to a loss of 2 to 3 IQ points in
young children.
1
Although mean blood lead levels
have been on the decline, lead poisoning remains a
prevalent public health problem in the United
States.
7–11
According to a recent analysis of the Third
National Health and Nutrition Examination Survey
(NHANES), 8.6% of children aged 1 to 2 years have
blood lead levels of 10 g/dL.
7
Despite the seri-
ousness of lead poisoning as a public health problem
and national recommendations to screen all chil-
dren
2,12
or at least all children who do not live in
clearly documented low prevalence areas,
1,13
many
children are not screened. A 1994 national telephone
survey estimated that less than one quarter of chil-
dren younger than 6 years had been tested for ele-
vated blood lead levels.
14
Data from NHANES III
indicated that only 10% of 1- to 5-year-old children in
the United States had been tested before participa-
tion in the NHANES III survey.
7
Particular concern has focused on low screening
rates among children who are enrolled in Medicaid
as they are at substantially increased risk of having
elevated blood lead levels.
15–17
According to an anal-
ysis of the NHANES III, 62% of children in the
United States who were between the ages of 1 and 5
years and had elevated blood lead levels (10 g/
dL) were enrolled in Medicaid.
7
The findings are
even more pronounced at higher lead levels: 83% of
preschool-age children with blood lead levels at 20
g/dL or greater are enrolled in Medicaid.
15
Health
Care Financing Administration regulations require
that all children who are enrolled in Medicaid be
screened for lead poisoning.
15
The blood lead screen-
From the Departments of *Pediatrics and ‡Community Health and §Center
for Statistical Sciences, Brown University, Providence, Rhode Island; Divi-
sion of Family Health, State of Rhode Island, Providence, Rhode Island; and
¶Department of Human Services, State of Rhode Island, Cranston, Rhode
Island.
Received for publication Jan 24, 2001; accepted Apr 9, 2001.
Reprint Requests to (P.M.V.) Department of Pediatrics, Hasbro Children’s
Hospital/Rhode Island Hospital, 593 Eddy St, Providence, RI 02912. E-mail:
patrickvivier@brown.edu
PEDIATRICS (ISSN 0031 4005). Copyright © 2001 by the American Acad-
emy of Pediatrics.
http://www.pediatrics.org/cgi/content/full/108/2/e29 PEDIATRICS Vol. 108 No. 2 August 2001 1 of 6
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