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November 1996, Vol 150, No. 11 >
Article | November 1996

A Comparison of Screening Strategies for Elevated Blood Lead Levels FREE

James R. Campbell, MD, MPH; Mary Paris, MPH; Stanley J. Schaffer, MD, MS
Arch Pediatr Adolesc Med. 1996;150(11):1205-1208. doi:10.1001/archpedi.1996.02170360095016.
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Objective:  To calculate and compare the average expected cost per child screened (hereafter referred to as COST) among various screening strategies.

Design:  A decision analysis of 5 strategies: (1) conduct risk assessment and screen high-risk children by venipuncture, low-risk children by fingerstick; (2) screen all children by fingerstick; (3) screen all children by venipuncture; (4) conduct risk assessment, screen high-risk children by fingerstick; and (5) conduct risk assessment, screen high-risk children by venipuncture. We assumed all fingerstick blood lead levels of 0.72 μmol/L or higher (≥15 μg/dL) would be confirmed by venipuncture. Baseline variables taken from the literature included prevalence of elevated blood lead levels in the pediatric population (2%), sensitivity and specificity of fingerstick blood lead assay (90% each), specificity of risk assessment (50%), sensitivity of risk assessment at blood lead levels of 0.48 to 0.68 μmol/L (10-14 μg/dL and 0.72 μmol/L or higher (≥15 μg/dL) (65% and 85%, respectively), cost of blood lead assay ($6), cost to obtain blood by venipuncture ($4) and fingerstick ($2), and cost to get a child who has a fingerstick blood lead level of 0.72 μmol/L or higher (≥15 μg/dL) to return ($0.18). Sensitivity analysis determined whether selected variables affected the COST.

Results:  The COSTs for strategies 1 through 5 were $9.07, $8.16, $10, $4.13, and $5.04, respectively. Among the universal strategies, screening children by fingerstick had the lowest COST at a prevalence of less than 38% and fingerstick blood lead assay a specificity of greater than 62%. Among the selective strategies, screening high-risk children by fingerstick had the lowest COST at a prevalence of less than 38% and fingerstick blood lead an assay specificity of greater than 63%.

Conclusion:  At a readily attainable specificity of the fingerstick blood lead assay, practices serving a patient population with a prevalence of elevated blood lead levels of less than 38% will have the lowest COST when a fingerstick screening strategy is used.Arch Pediatr Adolesc Med. 1996;150:1205-1208

REFERENCES

1 +
Centers for Disease Control. Preventing lead poisoning in young children . Atlanta, Ga: US Dept of Health and Human Services; 1991;.
2 +
Baker B.  Like politics, all lead screening should be local . Pediatric News . 1995;; 29:1-2.
3 +
Glotzer DE, Bauchner H, Freedberg KA, Palfrey S.  Screening for childhood lead poisoning: a cost-minimization analysis . Am J Public Health . 1994;;84:110-112.
4 +
Campbell JR, Schaffer SJ, Szilagyi PG, O'Connor K, Briss P, Weitzman M. Blood lead screening practices among US pediatricians. Pediatrics. In press.
5 +
Sargent JD, Dalton M, Stukel TA, Roda S, Klein RZ.  Evaluation of methods to reduce lead contamination of capillary blood specimens . Arch Pediatr Adolesc Med . 1995;;149:P70.
6 +
Brody DJ, Pirkle JL, Kramer RA, et al.  Blood lead levels in the US population: phase 1 of the Third National Health and Nutrition Examination (NHANES III, 1988 to 1991) . JAMA . 1994;;272:277-283.
7 +
Binns HJ, LeBailly SA, Poncher J, Kinsella TR, Saunders SE, and the Pediatric Practice Research Group.  Is there lead in the suburbs? risk asessment in Chicago suburban pediatric practices . Pediatrics . 1994;;93:164-171.
8 +
Schaffer SJ, Kincaid MS, Endres N, Weitzman M.  Lead poisoning risk determination in a rural setting . Pediatrics . 1996;;97:84-90.
9 +
Rifai N, Cohen G, Wolf M, et al.  Incidence of lead poisoning in young children from inner-city, suburban and rural communities . Ther Drug Monit . 1993;;15:71-74.
10 +
Taubman B, Wiley C, Henretig F.  Prevalence of elevated blood lead levels in a suburban middle class private practice . Arch Pediatr Adolesc Med . 1994;;148: 757-760.
11 +
Rifai N, Faser C, Cohen G, Wolf M, DePalma L.  Lead poisoning in young children in Washington, DC . AJDC . 1992;;146:1259-1260.
12 +
Casey R, Wiley C, Rutstein R, Pinto-Martin J.  Prevalence of lead poisoning in an urban cohort of infants with high socioeconomic status . Clin Pediatr . 1994;; 33:480-484.
13 +
Cook M, Chappell WR, Hoffman RE, Mangione EJ.  Assessment of blood lead levels in children living in a historic mining and smelting community . Am J Epidemiol . 1993;;137:447-455.
14 +
Norman EH, Bordley C, Hertz-Picciotto I, Newton DA.  Rural-urban blood lead differences in North Carolina children . Pediatrics . 1994;;94:59-64.
15 +
Schaffer SJ, Szilagyi PG, Weitzman M.  Lead poisoning risk determination in an urban population through the use of a standardized questionnaire . Pediatrics . 1994;;93:159-163.
16 +
Jiang H, Moy F, Frey MJ, et al.  Fingerstick microsampling for lead toxicity screening . Pediatr Res . 1994;;35:115A.
17 +
McGregor RS, Jones J, Maksimak JF, Malone WJ.  Comparison of venipuncture lead determination vs standard fingerstick methodology . AJDC . 1993;;147:438.
18 +
Schonfeld DJ, Cullen MD, Rainey PM, et al.  Screening for lead poisoning in an urban pediatric clinic using samples obtained by fingerstick . Pediatrics . 1994;; 94:174-179.
19 +
Schlenker TL, Fritz CJ, Mark D, et al.  Screening for pediatric lead poisoning . JAMA . 1994;;271:1346-1348.
20 +
Sargent JD, Klein RZ.  Rethinking the threshold for blood lead elevation in the clinical setting . Arch Pediatr Adolesc Med . 1995;;149:P78.
21 +
Tejeda DM, Wyatt DD, Rostek BR, Solomon WB.  Do questions about lead exposure predict elevated lead levels? Pediatrics . 1994;;93:192-194.
22 +
Rooney BL, Hayes EB, Allen BK, Strutt PJ.  Development of a screening tool for prediction in a midwestern clinical setting . Pediatrics . 1994;;93:183-187.
23 +
Nordin JD, Rolnick SJ, Griffin JM.  Prevalence of excess lead absorption and associated risk factors in children enrolled in a midwestern health maintenance organization . Pediatrics . 1994;;93:172-177.
24 +
Lyngbye T, Jorgensen PJ, Grandjean P, Hansen ON.  Validity and interpretation of blood lead levels . Scand J Clin Lab Invest . 1990;;50:441-449.
25 +
Sargent JD, Dalton M, Stukel T, Klein RZ.  An easily applied barrier method reduces lead contamination of capillary blood specimens . AJDC . 1993;;147:435.
26 +
Mitchell DG, Aldous KM, Ryan FJ.  Mass screening for lead poisoning . N Y State J Med . 1974;;74:1599-1603.
27 +
Finkler SA.  The distinction between costs and charges . Ann Int Med . 1982;; 96:102-109.
28 +
Campbell JR, McConnochie KM, Weitzman M.  Lead screening among high-risk urban children . Arch Pediatr Adolesc Med . 1994;;148:688-693.
29 +
Hollenberg J. SMLTREE: The All Purpose Decision Tree Builder . Version 2.9; New York, NY: 1989;.
30 +
Pirkle JL, Brody DJ, Gunter EW, et al.  The decline in blood lead levels in the United States . JAMA . 1994;;272:284-291.
31 +
Gellert GA, Wagner GA, Maxwell RM, Moore D, Foster L.  Lead poisoning among low-income children in Orange County, California . JAMA . 1993;;270:69-71.
32 +
Gammage B, McLaine P. Implications of universal blood lead screening. Poster presentation at the Alliance to End Childhood Lead Poisoning, Washington, DC, October 1991.

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References

1 +
Centers for Disease Control. Preventing lead poisoning in young children . Atlanta, Ga: US Dept of Health and Human Services; 1991;.
2 +
Baker B.  Like politics, all lead screening should be local . Pediatric News . 1995;; 29:1-2.
3 +
Glotzer DE, Bauchner H, Freedberg KA, Palfrey S.  Screening for childhood lead poisoning: a cost-minimization analysis . Am J Public Health . 1994;;84:110-112.
4 +
Campbell JR, Schaffer SJ, Szilagyi PG, O'Connor K, Briss P, Weitzman M. Blood lead screening practices among US pediatricians. Pediatrics. In press.
5 +
Sargent JD, Dalton M, Stukel TA, Roda S, Klein RZ.  Evaluation of methods to reduce lead contamination of capillary blood specimens . Arch Pediatr Adolesc Med . 1995;;149:P70.
6 +
Brody DJ, Pirkle JL, Kramer RA, et al.  Blood lead levels in the US population: phase 1 of the Third National Health and Nutrition Examination (NHANES III, 1988 to 1991) . JAMA . 1994;;272:277-283.
7 +
Binns HJ, LeBailly SA, Poncher J, Kinsella TR, Saunders SE, and the Pediatric Practice Research Group.  Is there lead in the suburbs? risk asessment in Chicago suburban pediatric practices . Pediatrics . 1994;;93:164-171.
8 +
Schaffer SJ, Kincaid MS, Endres N, Weitzman M.  Lead poisoning risk determination in a rural setting . Pediatrics . 1996;;97:84-90.
9 +
Rifai N, Cohen G, Wolf M, et al.  Incidence of lead poisoning in young children from inner-city, suburban and rural communities . Ther Drug Monit . 1993;;15:71-74.
10 +
Taubman B, Wiley C, Henretig F.  Prevalence of elevated blood lead levels in a suburban middle class private practice . Arch Pediatr Adolesc Med . 1994;;148: 757-760.
11 +
Rifai N, Faser C, Cohen G, Wolf M, DePalma L.  Lead poisoning in young children in Washington, DC . AJDC . 1992;;146:1259-1260.
12 +
Casey R, Wiley C, Rutstein R, Pinto-Martin J.  Prevalence of lead poisoning in an urban cohort of infants with high socioeconomic status . Clin Pediatr . 1994;; 33:480-484.
13 +
Cook M, Chappell WR, Hoffman RE, Mangione EJ.  Assessment of blood lead levels in children living in a historic mining and smelting community . Am J Epidemiol . 1993;;137:447-455.
14 +
Norman EH, Bordley C, Hertz-Picciotto I, Newton DA.  Rural-urban blood lead differences in North Carolina children . Pediatrics . 1994;;94:59-64.
15 +
Schaffer SJ, Szilagyi PG, Weitzman M.  Lead poisoning risk determination in an urban population through the use of a standardized questionnaire . Pediatrics . 1994;;93:159-163.
16 +
Jiang H, Moy F, Frey MJ, et al.  Fingerstick microsampling for lead toxicity screening . Pediatr Res . 1994;;35:115A.
17 +
McGregor RS, Jones J, Maksimak JF, Malone WJ.  Comparison of venipuncture lead determination vs standard fingerstick methodology . AJDC . 1993;;147:438.
18 +
Schonfeld DJ, Cullen MD, Rainey PM, et al.  Screening for lead poisoning in an urban pediatric clinic using samples obtained by fingerstick . Pediatrics . 1994;; 94:174-179.
19 +
Schlenker TL, Fritz CJ, Mark D, et al.  Screening for pediatric lead poisoning . JAMA . 1994;;271:1346-1348.
20 +
Sargent JD, Klein RZ.  Rethinking the threshold for blood lead elevation in the clinical setting . Arch Pediatr Adolesc Med . 1995;;149:P78.
21 +
Tejeda DM, Wyatt DD, Rostek BR, Solomon WB.  Do questions about lead exposure predict elevated lead levels? Pediatrics . 1994;;93:192-194.
22 +
Rooney BL, Hayes EB, Allen BK, Strutt PJ.  Development of a screening tool for prediction in a midwestern clinical setting . Pediatrics . 1994;;93:183-187.
23 +
Nordin JD, Rolnick SJ, Griffin JM.  Prevalence of excess lead absorption and associated risk factors in children enrolled in a midwestern health maintenance organization . Pediatrics . 1994;;93:172-177.
24 +
Lyngbye T, Jorgensen PJ, Grandjean P, Hansen ON.  Validity and interpretation of blood lead levels . Scand J Clin Lab Invest . 1990;;50:441-449.
25 +
Sargent JD, Dalton M, Stukel T, Klein RZ.  An easily applied barrier method reduces lead contamination of capillary blood specimens . AJDC . 1993;;147:435.
26 +
Mitchell DG, Aldous KM, Ryan FJ.  Mass screening for lead poisoning . N Y State J Med . 1974;;74:1599-1603.
27 +
Finkler SA.  The distinction between costs and charges . Ann Int Med . 1982;; 96:102-109.
28 +
Campbell JR, McConnochie KM, Weitzman M.  Lead screening among high-risk urban children . Arch Pediatr Adolesc Med . 1994;;148:688-693.
29 +
Hollenberg J. SMLTREE: The All Purpose Decision Tree Builder . Version 2.9; New York, NY: 1989;.
30 +
Pirkle JL, Brody DJ, Gunter EW, et al.  The decline in blood lead levels in the United States . JAMA . 1994;;272:284-291.
31 +
Gellert GA, Wagner GA, Maxwell RM, Moore D, Foster L.  Lead poisoning among low-income children in Orange County, California . JAMA . 1993;;270:69-71.
32 +
Gammage B, McLaine P. Implications of universal blood lead screening. Poster presentation at the Alliance to End Childhood Lead Poisoning, Washington, DC, October 1991.

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