P2.288: Reducing Gaps in Care through Implementation of Universal Lead Testing

Purpose/Objectives: Early detection of childhood lead poisoning helps prevent further exposure and connects children to services to mitigate health impact. In 2023, a lead test was completed at only 37% of well visits in our primary care network among children 9 to 24 months old without a previous blood lead level (BLL) (range 5-93%). Lead testing was routine among publicly insured children (66%), compared to risk-based testing of commercially insured children (27%). The CDC and AAP recommend universal lead testing in high-risk areas. With 33% of Pennsylvania housing predating 1950 and insufficient public health management, lead exposure remains a concern. The Pennsylvania Department of Health reports similar lead poisoning rates in rural and urban areas. Our network adopted universal lead testing to improve screening, identify lead exposure and enhance prevention. Our SMARTIE aim was to increase completed BLLs at well visits among children 9 to 24 months old without a previous BLL by 23 percentage points (to 60%) by June 2025, regardless of race, ethnicity, payor type and preferred language.

Design/Methods: Our interdisciplinary QI team used our institution's improvement framework to guide this work. The team identified key drivers and potential process changes (Figure 1). The highest impact and most feasible interventions were: 1) replacing risk-based screening with universal testing and 2) using clinical decision support (CDS) to automate lead test ordering during well visits.
We developed CDS for universal lead testing that reduced clinician’s cognitive burden through preselected lead orders for eligible patients, automatic lab company selection based on insurance, and association of appropriate diagnoses. CDS launched at two pilot offices in May 2024, four offices in July 2024 and six offices in October 2024. We made iterative changes based on feedback from project participants. For project monitoring, a data visualization dashboard was developed that was reviewed with pilot offices biweekly and with network leadership monthly.

Results: Pilot groups (12 of 31 offices in our network) improved lead testing rates quickly after CDS implementation, reaching and surpassing the goal of 60%. Our overall network rates also reached 60% and demonstrated special cause variation with a centerline shift (Figure 2). With the implementation of universal lead testing, our network de-implemented lead risk questionnaires in August 2024, which is predicted to save >1700 hours of data entry by families annually. All sites reduced a gap in lead testing rates between patients with commercially insured (baseline median 27%) and publicly insured patients (baseline median 66%) from 39% to 16%.

Conclusion/Discussion: Implementation of CDS-supported universal lead testing increased lead testing in our pediatric primary care network. Next steps include spreading universal lead testing throughout the network through CDS deployment and exploring the potential impact of point-of-care lead testing in offices without on-site phlebotomy.