A comparison of screening strategies for elevated blood lead levels.
OBJECTIVE
To calculate and compare the average expected cost per child screened (hereafter referred to as COST) among various screening strategies.


METHODS
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 mumol/L or higher (> or = 15 micrograms/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 mumol/L (10-14 micrograms/dL) and 0.72 mumol/L or higher (> or = 15 micrograms/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 mumol/L or higher (> or = 15 micrograms/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%.


CONCLUSIONS
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.
Department of Pediatrics, University of Rochester School of Medicine and Dentistry, NY, USA.
J R
JR
Campbell
M
M
Paris
S J
SJ
Schaffer
D003365:Costs and Cost Analysis; D003661:Decision Support Techniques; D006801:Humans; D007854:Lead / Q000097:blood*; D018962:Phlebotomy / Q000191:economics*; D018570:Risk Assessment; D012680:Sensitivity and Specificity
D007854:Lead