MANAGEMENT OF CHILDHOOD LEAD-POISONING - CLINICAL IMPACT AND COST-EFFECTIVENESS

Objectives. No consensus exists regarding the preferred treatment of c hildhood lead poisoning. The authors used decision analysis to compare the clinical impacts and cost-effectiveness of four management strate gies for childhood lead poisoning, and to investigate how effective ch elation therapy must be in reducing neurophyschologic sequelae to warr ant is use. Methods. The model was based on a 2-year-old child with mo derate lead poisoning [blood lead level 1.21 to 1.88 mumol/L (25 to 39 mug/dL)]. The following strategies were compared: 1) no treatment; 2) EDTA provocation testing, followed by chelation if testing is positiv e (PROV); 3) penicillamine chelation with crossover to EDTA provocatio n testing if toxicity occurs (PCA); 4) EDTA provocation testing with c rossover to penicillamine chelation if testing is negative (EDTA). Res ults. The EDTA and PCA strategies prevented 22.5% of the cases of read ing disability and resulted in an increase of 1.02 quality-adjusted li fe years compared with no treatment. When the costs of outpatient EDTA testing and chelation are considered, the EDTA strategy is more cost- effective than the PCA strategy; when impatient costs are considered, the PCA strategy becomes more cost-effective. When costs of remedial e ducation are considered, all strategies are cost-saving compared with no treatment if chelation reduces the risk of lead-induced reading dis ability by more than 20%. Conclusions. Treatment strategies for childh ood lead poisoning vary in clinical impact, cost, and cost-effectivene ss. Chelation of the 1.4% of United States preschoolers whose blood le ad levels are 1.21 mumol/L (25 mug/dL) or higher could prevent more th an 45,000 cases of reading disability, and save more than $900 million per year in overall costs when the costs of remedial education are co nsidered.