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Quality Improvement/Patient Safety: Primary & Subspecialty Outpatient Quality Improvement

QI 7: Primary & Subspecialty Outpatient QI Group 2

266 - Resident Quality Improvement Initiative to Decrease Disparities in Management of Lead Poisoning in Continuity Clinic

Monday, May 1, 2023

9:30 AM – 11:30 AM ET

Poster Number: 266
Publication Number: 266.453

Justine Hamilton, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Rebecca M. Jones, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Emily F. Gregory, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Colette R. Desrochers, Children's Hospital of Philadelphia, Philadelphia, PA, United States; George Dalembert, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Katie E. McPeak, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; Meera B. Siddharth, CHOP, Philadelphia, PA, United States; Elena Huang, Children's Hospital of Philadelphia, Philadelphia, PA, United States

Presenting Author(s)

Justine Hamilton, MD (she/her/hers)

PL1 Resident
Childrens Hospital of Philadelphia
Philadelphia, Pennsylvania, United States

Background: Follow-up of pediatric elevated blood lead levels (BLL) ensures that interventions can be initiated to reduce further lead exposure and limit negative consequences. The CDC recommends follow-up testing within 3 months for all children with BLL 3.5ug/dL or higher. Racial and socioeconomic inequities have been identified in many aspects of lead poisoning prevention and treatment.

Objective: Our aim is to increase follow-up BLLs among publicly insured patients in our continuity clinics by 10% from baseline by July 2023.

Design/Methods: We engaged residents and preceptors in equity-focused quality improvement (QI) methods to understand baseline follow-up rates for elevated BLLs and to generate feasible interventions to implement in PDSA cycles. From 7/2022 – 12/2022, residents and preceptors from 3 continuity sites affiliated with one residency program mapped processes and identified drivers for follow-up BLLs. Residents were introduced to electronic health record (EHR)-based population health reports to explore available data on patients at their clinic. Groups brainstormed and ranked interventions using impact-effort matrices. We collated and summarized matrices from 24 resident sessions (8 sessions at each of 3 clinic sites; Figure 1). We obtained baseline rates of follow-up testing within 3 months of elevated BLL for patients 9 to 72 months. The baseline period was 1/2021 – 6/2022. Data were visualized over time and stratified data by race/ethnicity, clinic site and payor type.

Results: >100 residents participated in at least 2 QI sessions. The baseline period captured 1054 BLLs. Baseline follow-up for all 3 sites was 41% (range 28-50%) with disparity noted across racial/ethnic groups (Figure 2) and between commercially (50%) and publicly insured patients (38%) (Figure 3). Feasible interventions proposed by clinic teams include targeted outreach to publicly insured patients with elevated BLLs, developing an evidence-based pathway for screening and management of lead and EHR clinical decision support to reduce missed opportunities to obtain screening or follow-up BLLs. In the first six months of our project, we have not seen a centerline shift in our data.

Conclusion(s):

Our project engaged a large number of residents in QI and use of EHR tools for practice improvement in primary care. Baseline data showed inequities in follow-up of BLL by payor type. In 2023, we will collaborate with one of our largest public payors to identify successful strategies to drive down elevated BLLs. Additional interventions will be presented to clinic medical directors, managers, and informatics leaders in early 2023.