1. Use of Medicaid Data to Inform Lead Screening Policy Alex R. Kemper, MD, MPH, MS June 25, 2005 CHEAR Unit, Division of General Pediatrics, University of Michigan

2. Collaborators / Support CHEAR Unit –Kathryn Fant, MPH –Lisa Cohn, MS –Kevin Dombkowski, DrPH –Sarah Clark, MPH Michigan Department of Community Health –Sharon Hudson, RN, MSN, CNM Research supported by the Michigan Department of Community Health

4. High Risk Areas for Lead Poisoning High Risk = Red

5. State Action – 2003 Series of policy responses to combat lead poisoning, including: –Funding for lead abatement –Penalizing rental agencies who fail to remediate –Mandating that 80% of Medicaid-enrolled children ≤ 5 years receive testing

6. Study Questions Questions: –What is the current rate of lead testing among Medicaid-enrolled children? –How many have an elevated blood lead level (≥ 10 μg/dL)? –What predicts who gets tested or who has an elevated blood lead level? –What happens to children after they are found to have an elevated blood lead level? –What predicts follow-up care?

7. Data Sources –Medicaid enrollment files –Medicaid claims data –Reports of blood lead levels

8. Testing Rates Methods –Retrospective analysis of children ≤ 5 years continuously enrolled in Medicaid in 2002

9. Testing Rates N = 216,578 Rate of testing –≤ 5 years: 19.6% (95% CI: 19.4%-19.8%) –1-5 years: 22.8% (95% CI: 22.6%-23.0%) Blood lead level for children 1-5 years –≥ 10 μg/dL: 8.7% (95% CI: 8.4%-9.0%)

10. Testing Rates Associations with testing or elevated blood lead level – Age –Gender –Race/ethnicity –Residence –Urban/rural status –Medicaid enrollment type –Blood sampling method

11. Testing Rates Cont’d

12. Testing Rates Cont’d

13. Conclusions: Testing The rate of testing is low. Testing appears geared to perceived risk. Managed care programs doing better than fee-for-service

14. Follow-up Testing Follow-up testing is the cornerstone of management –Confirmatory testing –Repeat testing

15. Follow-up Testing Methods –Retrospective cohort study –Children ≤ 6 years who had an elevated blood lead level between 1/1/02 and 6/30/03 –Continuously enrolled in Medicaid during the following 180 days –Excluded children who had elevated lead level in 2001

16. Follow-up Testing Methods –For each child, we identified any other lead testing in the 180 days following the first elevated blood lead level –For those without repeat testing, we used claims data to assess for missed opportunities (outpatient office visits)

17. Follow-up Testing N=3,682 Follow-up testing received by 53.9% within 180 days More than half (56.2%) of those who did not have follow-up testing had a missed opportunity. What are the factors associated with follow-up testing? For this, we also considered the effect of local health department catchment area.

18. Follow-up Testing Cont’d

19. Follow-up Testing Cont’d

20. Follow-up Testing Cont’d

21. Conclusions: Follow-up Many children do not have follow-up testing. Those with the greatest initial risk of having lead poisoning have the lowest likelihood of follow-up testing.

22. Implications Defining the role of primary care providers vs. public health –Who should be responsible for testing and follow-up? –How should information be shared – lead registry? Lessons from managed care

23. Future Research Understand barriers –Perspective Health Care Providers Families Define available resources and relationship at the local level between public health departments and private health care providers Designing interventions that can be prospectively evaluated

24. Ongoing Efforts Quality Improvement Learning from Managed Care plans Ongoing Challenges