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

                                                                                            

                  

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

High Risk Areas for Lead Poisoning

0 40 80 120 16020Miles

­High Risk = Red

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

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?

Data Sources

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

Testing Rates

• Methods– Retrospective analysis of children ≤ 5 years

continuously enrolled in Medicaid in 2002

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%)

Testing Rates

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

Testing Rates Testing

OR (95% CI)

Elevated blood lead level

OR (95% CI)

Age (y)

< 1 0.20 (0.16-0.24) 0.29 (0.26-0.31)

1 1 (Reference) 1 (Reference)

2 0.60 (0.52-0.69) 1.31 (1.29-1.34)

3 0.81 (0.75-0.87) 1.03 (1.03-1.03)

4 0.89 (0.82-0.97) 0.94 (0.94-0.94)

5 0.17 (0.13-0.21) 0.96 (0.96-0.97)

Gender

Female 1 (Reference) 1 (Reference)

Male 1.01 (1.00-1.02) 1.16 (1.15-1.16)

Race/Ethnicity

Non-Hispanic white 1 (Reference) 1 (Reference)

Hispanic or non-white 2.42 (2.12-2.77) 3.07 (2.82-3.35)

Cont’d

Testing Rates Testing Elevated blood lead level

Risk of Lead Exposure

Low-risk 1 (Reference) 1 (Reference)

High-risk 1.51 (1.48-1.54) 3.38 (2.81-4.05)

Residence

Rural 1 (Reference) 1 (Reference)

Urban 1.17 (1.04-1.31) 2.92 (2.82-3.03)

Medicaid enrollment

Mostly fee-for-service 1 (Reference) 1 (Reference)

Mixed fee-for-service/managed care 1.35 (1.00-1.82) 0.86 (0.73-1.00)

Mostly managed care 1.98 (1.46-2.68) 1.13 (0.98-1.31)

Blood sampling method

Capillary -- 1 (Reference)

Venous -- 0.96 (0.95-0.97)

Cont’d

Conclusions: Testing

• The rate of testing is low.

• Testing appears geared to perceived risk.

• Managed care programs doing better than fee-for-service

Follow-up Testing

• Follow-up testing is the cornerstone of management– Confirmatory testing– Repeat testing

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

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)

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.

Follow-up Testing Follow-up

RR (95% CI)

Age (y)

<1 0.95 (0.92-0.99)

1 1 (Reference)

2 1.02 (1.01-1.03)

3 0.96 (0.95-0.97)

4 0.85 (0.81-0.89)

5 0.71 (0.71-0.71)

6 0.43 (0.42-0.43)

Race/Ethnicity

Non-Hispanic white 1 (Reference)

Hispanic or non-white 0.91 (0.87-0.94)

Cont’d

Follow-up Testing Follow-up

Residence

Rural 1 (Reference)

Urban 0.92 (0.89-0.96)

Lead Exposure Risk

Low 1 (Reference)

High 0.94 (0.92-0.96)

Health Department Area

LHD #1 0.88 (0.86-0.89)

LHD #2 1.20 (1.17-1.22)

All Others 1 (Reference)

Cont’d

Cont’d

Follow-up Testing Follow-up

Initial Blood Sample Type

Venous 1 (Reference)

Capillary 1.11 (1.05-1.16)

Initial Blood Lead Level (μg/dL)

10-19 1 (Reference)

20-44 1.36 (1.34-1.39)

≥45 1.82 (1.81-1.82)

Cont’d

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.

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

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

Ongoing Efforts

• Quality Improvement

• Learning from Managed Care plans

• Ongoing Challenges