Defense Health Agency: Oversight needed to better ensure children are screened, tested and treated for lead exposure

What the GAO found

The Defense Health Agency (DHA)—the agency responsible for managing military medical treatment facilities—developed standardized guidelines for facility providers on pediatric lead processes. These include screening and testing children for elevated blood lead levels, treating children with elevated levels as indicated, and reporting any confirmed elevated levels to the appropriate authorities. The guidelines state that facility providers must follow the Centers for Disease Control and Prevention (CDC) recommendations regarding these pediatric lead processes. For example, the CDC recommends that children identified as having a high risk of lead exposure be tested for elevated blood lead levels. DHA and military service officials told GAO that they use email and other communication methods to disseminate information about pediatric lead processes to facility providers, including the new DHA guidelines.

Pediatric leadership processes include:

While the DHA has developed pediatric core guidelines and has stated that it expects facility providers to follow them, the DHA does not oversee facility providers’ adherence to these guidelines. DHA officials told GAO that they intend to conduct oversight of the screening, testing, treatment and reporting of elevated blood lead levels by developing a panel using data elements from DHA’s electronic health records system. However, DHA has not provided any documentation of these efforts or details such as a time frame for when this oversight will be implemented. The agency would be better positioned to ensure that the guidelines are consistently and systematically implemented in all facilities if DHA develops and implements a plan to oversee pediatric leadership processes.

In its 2021 report to Congress, DOD reported that 30,412 children were screened for lead exposure, 12,044 children were tested for elevated blood lead levels, and 83 children had elevated levels for the 8-month period covered. However, the data did not include pediatric lead screening and testing data from some facilities and complete information from others, likely representing an undercount. Further, DOD was unable to replicate the methodologies used to collect the data in the report. As a result, GAO cannot determine the extent to which the data in the report was complete or whether the data was accurate, and therefore reliable.

Why did the GAO do this study?

The Department of Defense (DOD) TRICARE program provides care to eligible pediatric beneficiaries through its military medical treatment facilities or civilian providers. The Fiscal Year 2020 National Defense Authorization Act (NDAA 2020) required DOD to (1) establish guidelines for its facility providers on the screening, testing, and reporting of blood lead levels in children; (2) distribute these instructions to its facilities providers; and (3) submit to Congress a report on the number of children screened for a high risk of lead exposure, tested for lead in their blood, and the number found to have a high level of lead in their blood.

The 2020 NDAA also included a provision for GAO to report on the effectiveness of DOD’s pediatric lead processes. This report (1) describes the guidelines established by DHA for facility providers for the screening, testing, treatment, and reporting of blood lead levels in children and how DOD disseminates them, (2) reviews DHA’s oversight of compliance with instructions from the facility provider, and (3) describes the reliability—accuracy and completeness—of the data in the DOD report to Congress.

GAO reviewed relevant DOD guidance; interviewed DHA and military service officials; and analyzed the credibility of the DOD report to Congress on pediatric lead.

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