Abstract
Opportunities for lead exposure are common in the United States. The American Academy of Pediatrics, in collaboration with the Centers for Disease Control and Prevention, launched the Increasing Capacity for Blood Lead Testing Extension for Community Healthcare Outcomes (ECHO) project to educate pediatricians on the importance of testing children for lead exposure and to assess practice behavior change. We found that two weeks to one month after receiving training, more than 80% of participants reported increased lead testing and practice changes. Our results support use of the ECHO model as a mechanism for practice change. (Am J Public Health. 2022;112(S7):S647–S650. https://doi.org/10.2105/AJPH.2022.307084)
Pediatric lead exposures are common in the United States, and the adverse health effects of lead poisoning are wide ranging. Increasing lead screening and testing in pediatric patients is crucial to ensure the health and safety of children.
INTERVENTION AND IMPLEMENTATION
The American Academy of Pediatrics (AAP), in collaboration with the Centers for Disease Control and Prevention (CDC), launched the Increasing Capacity for Blood Lead Testing Extension for Community Healthcare Outcomes (ECHO) project to increase understanding and implementation of federal, state, and local blood lead testing and reporting requirements. The project provides interpretative guidance for use of the CDC blood lead reference value among pediatricians and their teams. The ECHO project is an innovative hub and spoke program designed to create knowledge networks bringing together primary care providers in rural and underserved areas and specialty care providers through a telementoring program involving brief lectures and case‐based presentations. The ultimate goal is to increase the capacity of primary care providers to identify, treat, and manage the care of their patients within medical homes.
Participants learn from experts and peers; experts also learn from the participants and each other. This bidirectional virtual knowledge network allows primary care providers to improve knowledge, confidence, and treatment practices related to the targeted condition, building their capacity to deliver best-in-practice care to their patients.1 The AAP offers training for new ECHO hubs, provides technical assistance to the pediatric ECHO community, and fosters interprofessional collaboration and sharing of best practices in pediatric care.2
A multidisciplinary faculty team developed the ECHO curriculum, and the team has offered training on topics including lead exposure in the United States and AAP–CDC recommendations, lead risk assessment and testing, blood lead testing and the COVID-19 pandemic, screening during telehealth visits, sources of lead and mitigation techniques, interpretation of screening results, clinical treatment of children with elevated blood lead levels, counseling of caregivers, resources and referral, and unusual lead exposure cases from the field. Common barriers addressed included a lack of understanding of current recommendations around screening guidelines, interpretation of blood lead levels, and best practices for treatment and referral.
The ECHO project was implemented over a consecutive seven-month period. A quality improvement component offered a framework and resources to support practice-level changes; clinical quality measures were informed by guidance from the CDC Childhood Lead Poisoning Prevention Program and experts from the Pediatric Environmental Health Specialty Unit network. Participants attended monthly one-hour virtual learning sessions over Zoom consisting of brief lectures followed by deidentified case reviews and discussions. Cases were generated by the learners. Pediatric practices also received quality improvement coaching, conducted Plan, Do, Study, Act cycles to test changes made in the practices, and tracked progress on clinical quality measures (Table 1) through monthly chart reviews using the AAP Quality Improvement Data Aggregator system. Continuing medical education and maintenance of certification credits were available to participants.
TABLE 1—
QI Lead ECHO Measures and Target Improvements From National Cohort Retrospective Chart Pull Data: United States, 2019–2021
| QI Measure | Measure Definition | Target Improvement Over Baseline, % (Expected % Increasea) |
| Documented initial blood lead test | Documented venous or capillary lead screening testing for children aged 6–72 mo | 10 (6.1) |
| Blood lead testing (Medicaid) | Number of Medicaid-eligible patients aged 24–72 mo who received at least two blood lead screening tests | 10 (5.7) |
| Blood lead result interpretation (follow-up testing) | Follow-up testing of children with initial blood lead test results above the reference value | 10 (9.2) |
| Counseling of parents | Documented counseling regarding lead exposure health risks, management, and resources for children aged 6–72 mo with blood lead test results above the reference value | 10 (2.3) |
| Referral to academic programming | Referrals to academic support for preschool-aged children with blood lead test results above the reference value | 10 (2.8) |
Note. ECHO = Extension for Community Healthcare Outcomes; QI = quality improvement. Deidentified chart data were entered into and pulled from the American Academy of Pediatrics’ Quality Improvement Data Aggregator system.
Calculated by taking the baseline reported percentage and multiplying by the 10% improvement target (baseline × 0.10 = expected percentage increase).
As a means of expanding the program’s reach, the AAP leveraged its network of state and regional chapters to partner with chapters in Arizona, New York, Pennsylvania, Puerto Rico, and Wisconsin to implement state-based lead testing ECHO programs. The AAP trained each chapter to serve as a stand-alone ECHO hub; chapters used national program curricula, case forms, and evaluation metrics tailored as needed to account for state and local recommendations. The AAP coordinated evaluation of all ECHO program activities.
PLACE, TIME, AND PERSONS
The AAP lead testing program was national in scope and included participants representing 21 states. The program included three national cohorts; cohort 1 participated from January through July 2019, cohort 2 from January through July 2020, and cohort 3 from July through December 2021. Also included were five state-based cohorts led by AAP chapters in Arizona, New York, and Wisconsin (January–July 2020) and Pennsylvania and Puerto Rico (July–December 2020). An additional cohort from the Michigan chapter launched in spring 2022.
The AAP testing program recruited participants through academy memberships and included primary care pediatricians, family physicians, internists, nurse practitioners, physician assistants, nurses, and other team members. Across the three national cohorts, 84 individuals from 24 practices participated. The chapter programs recruited up to 15 practices from their respective states or territories.
PURPOSE
Childhood lead poisoning affects half a million children in the United States today.3 Consequences associated with lead exposure include decreased IQ scores, poor impulse control, learning difficulties, and conduct disorders.4 Pediatricians are in a unique position to offer anticipatory guidance, identify and treat the condition, educate, and advocate policies that protect children.5 The American Academy of Pediatrics (AAP) Increasing Capacity for Blood Lead Testing Extension for Community Healthcare Outcomes (ECHO) project builds awareness of and capacity for lead screening among doctors who treat children.
EVALUATION AND ADVERSE EFFECTS
The ECHO project used a mixed-method approach to evaluate program effectiveness. Evaluation results are available for the three national ECHO cohorts. A two-phase evaluation strategy was used to collect quantitative and qualitative data through an integrated feedback structure with prospective postsession surveys, retrospective postprogram surveys, and postprogram focus groups. Clinical quality measures (Table 1) were assessed through monthly chart reviews and abstraction of at least 20 charts for each participating practice team. Deidentified chart data were entered into the AAP’s Quality Improvement Data Aggregator system, which allowed practices to access real-time run charts to view progress against program goals and aggregate the performance of all participating teams.
A total of 44 individuals (52%) completed postprogram retrospective surveys. Self-reported participant feedback documented gains in knowledge and self-efficacy and high program satisfaction. After participating in ECHO, 100% of respondents reported increased knowledge of CDC and AAP recommendations regarding blood lead testing, blood lead reference values, and recommendations regarding case management for children affected by lead poisoning. More than 80% of respondents reported conducting more lead testing up to one month after completion of the program. The program led to achievement of quality improvement goals in three of the five clinical quality measures (Table 2). There was a statistically significant change in the number of patients who had a documented initial blood lead test, which increased by 9.4 percentage points during the project. No adverse effects were observed during the ECHO project.
TABLE 2—
QI Lead ECHO Measure Outcome Change Between Baseline and End of Program From National Cohort Retrospective Chart Pull Data: United States, 2019–2021
| Lead ECHO Measure | Baseline % (No. of Charts) | % at ECHO Conclusion (No. of Charts) | % Difference | Z | P |
| Documented initial blood lead test | 61.2 (490) | 70.6 (436) | 9.4a | 3.12 | .001b |
| Blood lead testing (Medicaid) | 56.8 (81) | 69.6 (69) | 12.8a | 1.61 | .053 |
| Blood lead result interpretation (follow-up testing) | 91.7 (12) | 90.9 (11) | −0.8 | 0.06 | .47 |
| Counseling of parents | 22.6 (62) | 14.5 (69) | −8.1 | 1.19 | .12 |
| Referral to academic programming | 27.8 (54) | 37.2 (121) | 9.4a | 1.21 | .11 |
Note. ECHO = Extension for Community Healthcare Outcomes; QI = quality improvement. Deidentified chart data were entered into and pulled from the American Academy of Pediatrics’ Quality Improvement Data Aggregator system.
Target improvement over baseline met or exceeded.
Statistically significant change (P < .05) post-ECHO relative to pre-ECHO baseline.
SUSTAINABILITY
The AAP remains an ongoing partner and resource in supporting pediatricians in sustaining improvements in preventing and addressing pediatric lead exposures and providing quality health care to children and families. The evaluation data showed that participants made systemic practice changes leading to sustainable improvements, enhancing their blood lead testing practices long term. These improvements included increases in initial blood lead testing and referrals to academic support for preschool-aged children with blood lead levels above the CDC reference value.6 ECHO initiatives will aid in quality of care improvements by supporting the uptake of lead screening guidelines and documentation of screening.
PUBLIC HEALTH SIGNIFICANCE
The COVID-19 pandemic has been a challenge for providers, families, and the system of care for pediatrics, affecting the scope of provider work content and the clinical workflow. There have been adjustments in the delivery of routine care such as wellness visits and immunizations to limit transmissions. These changes could explain the lower levels of parent counseling in the final data cycle and may have affected overall screening rates.
The ECHO model is a powerful mechanism for facilitating practice changes and integrating quality improvement methodologies. It has a reputation for building capacity in the health care workforce, integrating quality practice improvements, and building trust in learning communities.7 Through sharing practice experiences, clinicians engage in the process of improving patient care.8,9 The AAP lead testing ECHO is the first of its kind to our knowledge. The evaluation findings suggest that the program met many of its objectives and provided an innovative and meaningful learning experience for participants, fostering practice- and system-level improvements in lead-related testing, referral, care management, family education, and community engagement.
ACKNOWLEDGMENTS
This article includes data from a project supported by cooperative agreements 5NU38OT000282-02-00 and 5NU38OT000282-03-00 from the CDC.
Childhood Lead Poisoning ECHO Workgroup members were Elizabeth Harris, MD; Jennifer Lowry, MD; Kari Gali, DNP, CPNP, CPHQ; Mark Anderson, MD; Perry Sheffield, MD, MPH; Ruth Gubernick, PhD, MPH, PCMJH CCE; Susan Buchanan, MD, MPH; and Alan Woolf, MD, MPH.
We recognize and thank the subject matter experts and the many learners who generously shared their cases and contributed their experiences.
Note. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC or the US Department of Health and Human Services.
CONFLICTS OF INTEREST
The authors have no conflicts of interest to report.
HUMAN PARTICIPANT PROTECTION
This study was reviewed and determined as exempt by the institutional review board at the American Academy of Pediatrics.
REFERENCES
- 1.Arora S, Thornton K, Murata G, et al. Outcomes of treatment for hepatitis C virus infection by primary care providers. N Engl J Med. 2011;364(23):2199–2207. doi: 10.1056/NEJMoa1009370. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.American Academy of Pediatrics. Project ECHO (Extension for Community Healthcare Outcomes). Available at. 2021. https://www.aap.org/projectecho
- 3.Centers for Disease Control and Prevention. 2022. https://www.cdc.gov/nceh/features/leadpoisoning/index.html
- 4.Centers for Disease Control and Prevention. 2022. https://stacks.cdc.gov/view/cdc/31182
- 5.Council on Environmental Health. Prevention of childhood lead toxicity. Pediatrics. 2016;138(1):e20161493. doi: 10.1542/peds.2016-1493. [DOI] [PubMed] [Google Scholar]
- 6.Ruckart PZ, Jones RL, Courtney JG, et al. Update of the blood lead reference value—United States, 2021. MMWR Morb Mortal Wkly Rep. 2021;70(43):1509–1512. doi: 10.15585/mmwr.mm7043a4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Hess D, Reed G, Turco M, Parboosingh J, Bernstein H. Enhancing engagement in practice improvement: a conceptual framework. J Contin Educ Health Prof. 2015;35(1):71–79. doi: 10.1002/chp.21260. [DOI] [PubMed] [Google Scholar]
- 8.Aveling EL, Martin G, Armstrong N, Banerjee J, Mary Dixon-Woods M. . Quality improvement through clinical communities: eight lessons for practice. J Health Organ Manag. 2012;26(2):158–174. doi: 10.1108/14777261211230754. [DOI] [PubMed] [Google Scholar]
- 9.Bernstein HH, Calabrese T, Corcoran P, et al. The power of connections: AAP COVID-19 ECHO accelerates responses during a public health emergency. J Public Health Manag Pract. 2022;28(1):E1–E8. doi: 10.1097/PHH.0000000000001466. [DOI] [PubMed] [Google Scholar]