Background & Introduction: Pediatric lead exposure can cause lifelong cognitive and behavioral problems. Guidelines for management and screening programs remain crucial to public health efforts to address this problem. Consequently, many organizations have developed CDS to improve lead screening rates. While guideline-based clinical decision-support (CDS) may facilitate screening, differing recommendations across guidelines presents challenges for creating shareable CDS. While previous work has explored differences in screening guidelines between states, no previous work has explored differences in outpatient management recommendations. Developing shareable CDS for lead screening and management will require a clear understanding of the needs of potential future users. Objectives/Goal: Identify similarities and differences in lead screening and management recommendations from U.S. public health guidelines as a first step in the development of shareable CDS module for primary care clinicians written in the Clinical Query Language Methods: We reviewed lead guideline documents from the Center for Disease Control (CDC), 60 public health departments, the American Academy of Pediatrics (AAP), and the Center for Medicare and Medicaid Services (CMS). We extracted definitions of elevated lead level, lead screening requirements, laboratory reporting requirements, guidance on medical management, and suggested follow-up frequencies. We evaluated the different lead levels at which each document recommended particular clinical managements. We examined the guidance documents to identify other potential management targets. Results: We identified 51 lead screening and management guidelines with publication dates ranging between 2003 and 2018. The majority of lead screening guidelines were easily accessed from state Department of Health websites but three had broken or missing links and were located through internet searches. Most guidance documents were available as downloadable PDFs (wall flyers), some were multi page guidelines, others were legal statutes, and a few exclusively available as web pages. Not all states provided lead screening or management guidance. Three states only provided the threshold for diagnosing elevated lead level without any guidance for clinicians on management of elevated lead. States provided different thresholds for elevated lead levels, guidance on when to screen for lead, and lead reporting requirements (Table 1). There was also variability in screening and clinical management recommendations (Table 2). We found other recommendations with varying frequency and wording including lead avoidance, nutrition counseling, and reporting to social services agencies (i.e. DHS or DFS). A few states indicated children could not attend daycare or school without documentation of lead screening. Two states provided recommendations to avoid particular actions (i.e. testing teeth, hair, and nails for lead). Most states did not provide references for management recommendations beyond a general reference to the CDC guideline. Conclusion: State policies surrounding lead screening and management have wide variability. Adapting these guidelines into shareable CDS will require support for localization and alignment of recommendations.

From 63 policy or guidance statements reviewed (50 states + District of Columbia, 9 localities funded by CDC (Chicago, Harris Country, Houston, Los Angeles, Marion Country, New York City, Philadelphia, Seattle King County, Salt Lake County), and 3 professional organization policies (American Academy of Pediatrics, Center for Medicare and Medicaid Services, and Centers for Disease Control).

Table 1

Definitions of Elevated Lead Level for 50 States and District of Columbia

Table 1

Definitions of Elevated Lead Level for 50 States and District of Columbia

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