use of medicaid data to inform lead screening policy alex r. kemper, md, mph, ms june 25, 2005 chear...
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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
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