1. Improving Lead Screening Rates Through The Use of Statewide Immunization Registry Data Jacob L. Bidwell, MD Medical Director, Aurora Clarke Square Family Health Center Jared E. Collins, MS, MPH Center for Urban Population Health

2. Project Partners: o Dennis J. Baumgardner, MD o Jeff Havlena o Elizabeth Albino, RN o The Center for Urban Population Health o Aurora Clarke Square Family Health Center / Aurora UW Medical Group Staff

3. Introduction  Lead is an environmental toxin linked to neurological, developmental, and behavioral problems in children.  Screening for elevated lead levels and early intervention are effective in limiting these effects.  Sources of lead exposure o Lead-based paint and lead-contaminated dust found in deteriorated buildings o Hobbies- stained glass work o Occupational o Drinking water o Home health remedies

4. Background  Approx. 310,000 U.S. children aged 1-5 years have blood lead levels (BLLs) greater than 10 mcg/dL, the level at which the CDC recommends public health actions be initiated  In 2009 o 2.9% of children tested in WI for lead have EBLL o 7.0% of children tested in Milwaukee for lead have EBLL o 8.8% of children tested in the 53204 zip code (Milwaukee) have EBLL o 9.6% of children tested at Aurora Clarke Square Family Health Center (53204 zip code) have EBLL

5. Background (cont.)  At risk populations  Children under the age of 6 years  Children from all social and economic levels  Children of some racial and ethnic groups  Lead exposure is very costly to treat.  $43.4 billion annually  Lead poisoning and its sequelae are preventable. Dearth of information exists regarding how to increase lead screening compliance

6. Case Example 12 month old male BLL 10 mcg/dL Family moved into old home (built in 1905) in Milwaukee suburb at 6 months old

7. Case Example (Cont.) Mother reports significant time spent playing on painted porch floor Tested paint found to be 80% lead by weight Home abated

8. Case Example (Cont.) Recheck at 15 months BLL decreased to 3 mcg/dL Levels have remained low since Pt currently doing well in K4 with no obvious sequelae

9. Overview  Objective: Determine whether the use of a clinic database using information from a statewide immunization registry improves lead screening rates in a residency affiliated community clinic in Milwaukee, WI.  Design: Longitudinal cohort study of children age birth to 84 months.

10. Instrument A clinic lead screening database was developed including all children between 0 and 6 years of age who are seen at the Aurora Clarke Square Family Health Center. The database combined information from the Wisconsin Immunization Registry and the state lead screening database. This was used to identify and track patients needing lead screening.

11. Intervention Patients were contacted by letter and a follow-up telephone call every 3 months to arrange screening based on Milwaukee Public Health Department lead screening guidelines This included children who either needed to be screened or who had documented EBLL.

12. Intervention  Clinic staff checked the responses received from the letters that were mailed the month before o Who has come in for screening? o Who has a future appointment scheduled? Parents who did not respond to the letter within 1 month received a follow-up phone call.

13. Results

14. Results (cont.) 12% absolute increase in patients screened Yet just over half met lead screening guidelines in Milwaukee County Stable percent with EBLL Chi square test with Yates correction = 4.17 p = 0.041

15. Discussion  Strengths of our intervention  Cost effective  Utilizes information from a database that is already being used to track youth immunizations (ease of implementation)  Intervention poses very low risks to patients  Limitations  Lead screening differs from immunization in public perception of importance  Clinic manager time to maintain clinic database and generate letters

16. Discussion (cont.) Our hypothesis that tracking lead screening using statewide immunization registry data will result in increased lead screening compliance was confirmed.  Our short term goal to increase lead screening compliance in our clinic was successful.  However, we did not reach our goal of 90% compliance during the study period reported.  Similar results had been obtained for immunization rates in the same setting using a similar tracking system.  Our long-term goal is to improve adherence to public health department recommendations county and statewide, using this public health model.

17. Conclusion  Including lead screening data in the statewide immunization registry may be an effective intervention to improve lead screening rates in children.

18. Thanks Staff at Aurora Clarke Square Family Health Center