to the editor: I am concerned about increasingly popular “one-size-fits-all” screening recommendations. Dr. Warniment and colleagues provide an excellent overview of lead poisoning in children and correctly list all of the cited screening recommendations as Strength of Recommendation Taxonomy evidence rating level C. However, I encounter a practical and ethical problem many times a year. I practice in a county with a less than 0.1 percent rate of lead poisoning, according to the Centers for Disease Control and Prevention (CDC). Yet, most of my young patients are enrolled in or eligible for Medicaid. How is it being a good steward of tax dollars to order two blood tests for every child on Medicaid, regardless of his or her risk? How is this practicing good, evidence-based medicine?

My practice remains the same, despite Medicaid laws and the CDC's recommendations. I ask the child's parents or guardians about sources of exposure. If there are no likely sources, I explain to the caretakers that I'm “supposed” to recommend these tests, but that the chances are greater than 1,000 to one (less than 0.1 percent prevalence) that I would be subjecting their child to unnecessary tests. Some caregivers choose to go through with the test anyway and I make arrangements for them to do so, but most agree with me and do not have the tests performed. Consequently, our practice loses revenue because Medicaid often denies most or all of our claim for the well-child visit if we do not order lead screening tests.

What can family physicians do to better educate ourselves, our lawmakers, and the parents of our young patients?

in reply: I appreciate the attention Dr. Viel shows to the effective use of resources for lead screening in the care of his patients. Our article does not recommend a “one-size-fits-all” approach; rather, targeted screening is recommended, and there is more than one way to achieve this goal. The recommendation to screen all children who are Medicaid-enrolled or -eligible is based on strong historical data, and targeted screening of this group was recommended in 1997 (a change from true universal screening of all children that began in 1978). This recommendation has been strongly supported by the American Academy of Pediatrics and the Centers for Disease Control and Prevention (CDC).

However, the CDC has released revised guidelines urging local and state health officials to update screening recommendations for lead poisoning in Medicaid-enrolled or -eligible children based on state and local data rather than on insurance status alone.¹ Recent data suggest that the incidence of elevated blood lead levels is decreasing among the Medicaid population in certain areas, approaching the lower risk seen in children not enrolled in or eligible for Medicaid. For example, Minnesota and Wisconsin are among the first states to report less of a disparity in elevated blood lead levels between children who are Medicaid-enrolled or -eligible and those who are not. In areas where disparities persist, the CDC continues to classify these children as higher risk and recommends that we continue to perform targeted screening until there are enough data to indicate that it is safe to change this practice across the nation.