Cost benefit of providing comprehensive case management for lead-burdened children.Background It is sometimes difficult to illustrate the benefits of providing core public health services health services Managed care The benefits covered under a health contract on the local level. The City of Manchester Manchester, city, England Manchester (măn`chəstər, –chĕs'tər), city and metropolitan district (1991 pop. 397,400), NW England, on the Irwell, Medlock, Irk, and Tib rivers. Department of Health in New Hampshire New Hampshire, one of the New England states of the NE United States. It is bordered by Massachusetts (S), Vermont, with the Connecticut R. forming the boundary (W), the Canadian province of Quebec (NW), and Maine and a short strip of the Atlantic Ocean (E). has identified the cost benefits associated with providing comprehensive case management services for lead-poisoned children. The model presented illustrates that minimal resources are applied to providing case management, a service the city of Manchester believes is most beneficial for lead-burdened children. It is presumed that comprehensive case management coupled with community-wide education can help prevent childhood lead poisoning lead poisoning or plumbism (plŭm`bĭz'əm), intoxication of the system by organic compounds containing lead. . The city of Manchester experiences approximately half of the childhood lead poisoning cases in the state of New Hampshire. Historically, the city of Manchester identifies approximately 50 cases of childhood lead poisoning each year (blood lead levels [greater than or equal to] 20 ug/dl). The city of Manchester provides case management services for children with blood lead levels [greater than or equal to] 10 ug/dl. The purpose of providing case management services is to prevent children's blood lead levels from rising above a certain threshold (19 ug/dl), ultimately reducing the incidence of childhood lead poisoning in the city of Manchester. Analysis In this analysis, two groups of children are identified: those considered to be lead poisoned This article is about something other than the meaning of the word poison. For the meaning of the word, see Poison. Poisoned is a free peer-to-peer computer program for Mac OS X. with blood lead levels [greater than or equal to] 20 ug/dl (Group 1) and those children with lead levels ranging from 10-19 ug/dl (Group 2). Unless otherwise noted, all figures are based on one calendar year. Costs associated with Group 1 children can be compared to the costs associated with Group 2 children. Group 1 Costs Examples of costs traditionally associated with Group 1 children include: the cost for funding lead-based paint abatement A reduction, a decrease, or a diminution. The suspension or cessation, in whole or in part, of a continuing charge, such as rent. With respect to estates, an abatement is a proportional diminution or reduction of the monetary legacies, a disposition of property by will, when , inspection costs, basic medical costs, chelation Chelation The process by which a molecule encircles and binds to a metal and removes it from tissue. Mentioned in: Heavy Metal Poisoning chelation costs, special education costs, and the cost for funding Case management services. These categories are examined in detail below. Lead Paint Abatement Costs Abatement Cost A cost borne by many businesses for the removal and/or reduction of an undesirable item that they have created. Abatement costs are generally incurred when corporations are required to reduce possible nuisances or negative byproducts created during production. Environmental lead investigations are usually conducted in homes of Group 1 children. The average size of a dwelling dwelling an abnormality of gait in a horse in which there is a momentary hesitation before the foot is placed on the ground. unit undergoing abatement is usually five rooms. Abatements are sometimes also required in common areas such as play areas, porches, hallways, etc. Hazardous waste Hazardous waste Any solid, liquid, or gaseous waste materials that, if improperly managed or disposed of, may pose substantial hazards to human health and the environment. Every industrial country in the world has had problems with managing hazardous wastes. removal may be included in the cost of lead paint abatement. Therefore, the estimated average cost for lead abatement is approximately $4,000. This figure is based on the average cost of lead-based paint abatement currently conducted in the city of Manchester. Funding lead-based paint abatement is very costly. However, the benefits of abatement must not be understated. The CDC See Control Data, century date change and Back Orifice. CDC - Control Data Corporation action protocol, according to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. blood lead measurements, recommends identification and elimination of environmental lead sources at blood lead levels [greater than] 20 ug/dl (1). Once a unit is abated Abated, an ancient technical term applied in masonry and metal work to those portions which are sunk beneath the surface, as in inscriptions where the ground is sunk round the letters so as to leave the letters or ornament in relief. From 1911 Encyclopædia Britannica of lead hazards, it can remain a safe environment for future generations as well as increase the value of the property. One study conducted in Massachusetts Massachusetts (măsəch  `sĭts), most populous of the New England states of the NE United States. , where children
receiving case management services had their homes abated of lead
hazards, illustrated a significant decrease in blood lead levels
following proper abatement procedures. Because homes of lead-poisoned
children are often the primary source of lead, abatement is essential
for prevention of further exposure (2).
Environmental Investigations and Reinspection Costs The estimated labor cost for using XRF XRF X-Ray Fluorescence XRF X-Ray Flash XRF Cross Reference XRF Extended Recovery Facility (IBM) XRF Extended Reliability Feature XRF Cross Reference File XRF External Reference equipment (x-ray fluorescence X-ray fluorescence (XRF) is the emission of characteristic "secondary" (or fluorescent) X-rays from a material that has been excited by bombarding with high-energy X-rays or gamma rays. lead-based paint analyzer analyzer /ana·ly·zer/ (an´ah-li?zer) 1. a Nicol prism attached to a polarizing apparatus which extinguishes the ray of light polarized by the polarizer. 2. ) when conducting home inspections is approximately $55 per inspection. Following the initial investigation, at least two follow-up follow-up, n the process of monitoring the progress of a patient after a period of active treatment. follow-up subsequent. follow-up plan reinspections are required in order to meet compliance. On average, the health department makes 4-5 reinspections and site visits to a property for the purpose of monitoring abatement activity. In most cases it is only necessary for one individual to conduct reinspections. Any in-place management that is required following a lead abatement is the responsibility of the property owner. Considering the average cost for a private inspection of a five-room unit and all necessary reinspections, the total estimated cost for inspection services provided by the health department for each lead abatement is approximately $300. Basic Medical Costs The medical needs of children with elevated blood lead levels vary on a case-by-case basis. All children require subsequent follow-up blood lead testing according to local medical protocols. In some cases additional studies and treatment may be required (i.e. iron levels, iron therapy, etc.). The average cost for medical expenses for a Group 1 child is approximately $150. Chelation Costs The Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. (CDC) estimates that of all children with lead poisoning, 5% require chelation therapy Chelation Therapy Definition Chelation therapy is an intravenous treatment designed to bind heavy metals in the body in order to treat heavy metal toxicity. at least once. Additionally, 2.5% of all children require at least two rounds of therapy. The cost of chelation is dependent on whether the treatment is administered orally on an out-patient basis or if it is administered intravenously in·tra·ve·nous adj. Abbr. IV Within or administered into a vein. n. A drug, nutrient solution, or other substance administered into a vein. (requiting hospitalization hospitalization /hos·pi·tal·iza·tion/ (hos?pi-t'l-i-za´shun) 1. the placing of a patient in a hospital for treatment. 2. the term of confinement in a hospital. ). The estimated cost for one and two rounds of chelation therapy is $2,500 and $5,000, respectively (3). Special Education Costs The CDC estimates that 20% of Group 1 children require some form of special education services (Note: this estimate is based on a blood lead level [greater than or equal to] 25 ug/dl) (3). Estimates for the percentage of children with blood lead levels [greater than or equal to] 20 ug/dl who would require special education are not available from the CDC. It is expected that the estimate presented is conservative, as more emphasis is placed on the significance of lower-level lead exposure. Examples of special education services include cognitive therapy cognitive therapy n. Any of a variety of techniques in psychotherapy that utilize guided self-discovery, imaging, self-instruction, and related forms of elicited cognitions as the principal mode of treatment. , reading and writing skills, and speech therapy. The amount of time devoted to providing special education is based on each individual child' s needs assessment. For the purpose of this analysis, it is assumed that the average child requires 1.5 class periods of special education per school day. The least expensive avenue for providing special education services is through a public school system. It is estimated that special education will cost approximately $2,392 per child. Case Management Services Costs Comprehensive case management services are provided for all children in the city of Manchester with blood lead levels beginning at 15 ug/dl. Providing comprehensive case management services involves: 1. collaborating with primary care providers to coordinate appropriate medical follow-up; 2. collaborating with the health department staff responsible for overseeing abatement activity; and 3. making home visits for the purpose of conducting visual home inspections and medical assessments and of providing education and nutrition counseling. The nurse case manager remains in frequent contact with families and medical providers until the child is discharged from the childhood lead poisoning prevention program. Case management activities vary from child to child. For children whose blood lead levels are [less than] 15 ug/dl, case management services are usually provided via telephone and mail contact. However, home visits for these children are made upon request from the child's parent or guardian. The city of Manchester has been providing case management services since July 1993. Thus far, only 8% of the children being followed with blood lead levels between 10-14 ug/dl have experienced elevations requiring more extensive services. It is estimated that the nurse case manager devotes approximately five hours of work time annually to provide case management services for each Group 1 child. The cost for providing case management services for these children is estimated to be $112 per child. Lead (TSP TSP - travelling salesman problem ) clean-up kits are provided to all families of Group 1 children. The kit contains a box of TSP, a bucket A reserved amount of memory that holds a single item or multiple items of data. Bucket is somewhat synonymous to "buffer," although buffers are usually memory locations for incoming data records, while buckets tend to be smaller holding areas for calculations. See hash table, buffer and variable. , gloves, wiping See wipe. rags, a clean sponge, and contact paper or duct tape duct tape n. A usually silver adhesive tape made of cloth mesh coated with a waterproof material, originally designed for sealing heating and air-conditioning ducts. Noun 1. (temporarily to cover defective defective adj. not being capable of fulfilling its function, ranging from a deed of land to a piece of equipment. (See: defect, defective title) painted surfaces). The purpose of the kit is to introduce families to the importance of a routine cleaning/maintenance program, especially where the potential for lead dust hazards exist. It is now known that lead dust from deteriorated lead-based paint is a primary source of lead exposure for young children. Controlling lead dust is one measure parents can take to reduce potential sources of lead exposure. The cost for providing each kit is $10. Thirty clean-up kits have been distributed to Group 1 families thus far. Data compiled on these cases indicate that these.children experience an average decrease in blood lead levels of 7 ug/dl upon follow-up testing. This does not include children who have even greater declines in blood lead, levels as a result of chelation therapy. Total preventable expenses associated with Group 1 children Based on the assumption that an average of 60 children are identified in a calendar year with lead levels [greater than] 20 ug/dl, the costs outlined in Table 1 would be incurred. Table 1 illustrates the minimal resources that are applied to providing case management, one of the most beneficial services provided for lead-poisoned children. Group 2 Costs It is also assumed that an additional 350 children (in a calendar year) will receive case management services through the city of ManChester health department. These Group 2 children should not require additional medical services, special education, (as a result of an elevated blood lead level) extensive environmental management, and inspection services. For the purpose of this analysis, it is assumed that 50% of these children will have blood lead levels [less than or equal to] 15 ug/dl. The cost for providing case management for Group 2 children in the city of Manchester is illustrated in Table 2. The total cost for providing a comprehensive case management program (including lead-based paint abatement, special education, medical treatment, etc.) for all children (Group 1 and 2) in the city of Manchester is $345,914.00 ($314,274.00 + $31,640.00). It is assumed that with the benefit of comprehensive case management, all of the 410 children in the city of Manchester with elevated blood lead levels could have levels which never exceed 19 ug/dl (eliminating Group 1). These children should only require basic case management services. It is expected that the only environmental interventions necessary for children with blood lead level s between 15-19 ug/dl would be TSP clean-up kits. The CDC' s "Preventing Lead Poisoning in Young Children" states that "...full environmental investigation and abatement is not recommended as part of the management of children with blood lead levels below 15 ug/dl. Environmental intervention A procedure used in a lawsuit by which the court allows a third person who was not originally a party to the suit to become a party, by joining with either the plaintiff or the defendant. should be considered where possible in cases where blood lead levels persist." Historically, 10-15% of the children receiving case management services for lead poisoning have blood lead levels [greater than or equal to] 20 ug/ dl. For the purpose of this analysis, it is [TABULAR tab·u·lar adj. 1. Having a plane surface; flat. 2. Organized as a table or list. 3. Calculated by means of a table. tabular resembling a table. DATA FOR TABLE 1 OMITTED] assumed that with education and as a result of case management intervention, these children would instead have blood lead levels which would never exceed 15-19 ug/ dl. Therefore, of the 410 children being considered annually, approximately 25% would have levels between 15-19 ug/dl and 75% would have levels which never exceed 14 ug/dl. As a result, the total cost of providing case management services for all children would then be as that exhibited in Table 3. Table 2. Total Expenses Associated with Group 2 Children. Service Cost per Child Total Cost Case Management (4 hours)(ab) $ 97.60 $ 17,080.00 Lead (TSP) Clean-up Kit 10.00 1,750.00 Case Management (3 hours)(c) 73.20 12,810.00 Total Cost for Services $ 95.40(d) $ 31,640.00 a Based on 175 children with blood lead levels between 15-19 ug/dl. b An additional hour of case management services is provided for children with levels between 15-19 ug/dl for the purpose of conducting a home visit(s). c Based on 175 children with blood lead levels between 10-14 ug/dl. d Average cost per child (varies depending on blood lead level). Table 3. Total Cost of Providing Case Management Services for All Lead-Poisoned Children. Service Cost per Child Total Cost Case Management (4 hours)(ab) $ 97.60 $ 10,052.80 Lead (TSP) Clean-up Kit 10.00 1,030.00 Case Management (3 hours)(c) 73.20 22,472.40 Total Cost $ 89.30(d) $ 33,555.20 a Based on 103 children with blood lead levels between 15-19 ug/dl. b An additional hour of case management services is provided for children with levels between 15-19 ug/dl for the purpose of conducting a home visit(s). c Based on 307 children with blood lead levels between 10-14 ug/dl. d Average cost per child (varies depending on blood lead level). Therefore, the annual cost savings which can be realized by providing comprehensive case management and ultimately preventing children's blood lead levels from rising above 19 ug/dl is $312,358.80 ($345,914.00 - $33,555.20.) Conclusion Many socioeconomic so·ci·o·ec·o·nom·ic adj. Of or involving both social and economic factors. socioeconomic Adjective of or involving economic and social factors Adj. 1. factors which can be influenced by elevated blood lead levels can be difficult to portray por·tray tr.v. por·trayed, por·tray·ing, por·trays 1. To depict or represent pictorially; make a picture of. 2. To depict or describe in words. 3. To represent dramatically, as on the stage. in monetary terms, such as education attainment, participation in the labor force, wage rates, lifetime earnings, etc. Other factors not considered as part of this model include: litigation An action brought in court to enforce a particular right. The act or process of bringing a lawsuit in and of itself; a judicial contest; any dispute. When a person begins a civil lawsuit, the person enters into a process called litigation. costs, court settlement costs, insurance fees, etc. For a more realistic estimate as to the cost lead poisoning places on society as a whole, all factors combined would need to be analyzed an·a·lyze tr.v. an·a·lyzed, an·a·lyz·ing, an·a·lyz·es 1. To examine methodically by separating into parts and studying their interrelations. 2. Chemistry To make a chemical analysis of. 3. . Since this report does not focus on the social costs of lead poisoning, the figures are considered conservative. Other researchers have prepared such cost estimates (2). The practice of providing comprehensive case management services is not solely for monetary purposes. Rather, case management has proven to be one of the most effective tools readily available to help decrease the incidence of childhood lead poisoning. The city of Manchester has experienced a decrease in the number of environmental inspections required (based on children's blood lead levels) by approximately 40% since case management services have been provided. Preliminary data also indicate that children experience a significant decrease in blood lead levels upon follow-up repeat testing while receiving case management services. During the first quarter of project year July 1994 to July 1995, of the 82 children in the city of Manchester who were receiving case management services (blood lead levels [greater than or equal to] 15 ug/dl) and who had at least one follow-up test, 50 experienced a decreased blood lead level. Equally significant is the percentage of children who never experience blood lead level increases once contact is made and case management services are provided. References 1. "Preventing Lead Poisoning in Young Children," Centers for Disease Control, Oct. 1991. 2. "Strategic Plan for Elimination of Childhood Lead Poisoning," Centers for Disease Control, 1991. 3. Yona, A, M.J. Brown, J. Graef, E. Cosgrove (1991), "Residential Deleading: Effects on the blood lead levels of lead-poisoned children," Pediatrics pediatrics (pēdēă`trĭks), branch of medicine dedicated to the attainment of the best physical, emotional, and social health for infants, children, and young people generally. , 88:893-897. Acknowledgements The City of Manchester Childhood Lead Poisoning Prevention Program is funded by the State of New Hampshire Childhood Lead Poisoning Prevention Program and the Center for Disease Control and Prevention Noun 1. Center for Disease Control and Prevention - a federal agency in the Department of Health and Human Services; located in Atlanta; investigates and diagnoses and tries to control or prevent diseases (especially new and unusual diseases) CDC . Christine Ballas, M.B.A., Public Health Specialist, City of Manchester Department of Health, 795 Elm St., Suite 302, Manchester, NH 03101. |
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