Vision Screening in Adults Across the Life Span.

OBJECTIVES: The goal of this study was to determine whether adults across the life span differ in responses to quick vision screening and how those responses relate to adults' use of specialized eye care. METHODS: Subjects were 363 community-dwelling ambulatory adults, 21 to 95 years old, who were tested while they wore their corrective lenses during routine visits to a tertiary care facility. No subjects had known neurological impairments, age-related macular degeneration, or other significant eye disease. A wall-mounted Early Treatment in Diabetic Retinopathy Study chart was used. RESULTS: Older adults 58 years old or older had significantly worse scores than younger adults. Scores did not differ between subjects who had been tested within or prior to the last 10 months. Older subjects had their vision tested significantly more recently than younger subjects. CONCLUSIONS: Vision screening is quick, inexpensive, and easily performed by ancillary staff, and it may provide the physician with useful additional information for treatment planning.

Sight-Threatening Ocular Diseases Remain Underdiagnosed Among Children Of Less Affluent Families.

Sight-threatening eye diseases such as strabismus (misaligned eyes) and amblyopia (lazy eye) develop during childhood. The earlier in life these diseases are diagnosed and effectively treated, the greater the chance of preventing irreversible long-term sight loss. Using 2001-14 claims data for nearly 900,000 US children with health insurance, we followed a cohort for up to fourteen years from birth, to assess whether household net worth affected rates of visits to ophthalmologists and optometrists or rates of diagnoses of strabismus and amblyopia. We found considerably lower use of eye care services among children in less affluent families than among those in more affluent ones, resulting in estimates of nearly 13,000 missed strabismus diagnoses and over 5,000 missed amblyopia diagnoses in a ten-year period. Despite ongoing efforts to improve screening rates for serious childhood ocular disorders, more attention should be directed to overcoming economic barriers that keep children from obtaining necessary eye care services.

[Vision Screening in Zurich]. / Sehscreening in der Stadt Zürich.

BACKGROUND: In the city of Zurich, vision screening is performed by school medical services as part of the legally compulsory preventive medical examinations. We retrospectively evaluated the results of the 2011-2012 school year. PATIENTS AND METHODS: Preventive medical examinations by the school medical services were performed in all kindergartens. The examinations were mandatory for first, second and eighth grade children, whilst those for the fourth grade were voluntary. The basic diagnostic testing consisted of monocular visual acuity (Snellen E chart) for all age groups and the stereopsis test (TNO test) in kindergartens. RESULTS: Vision screening was performed on 7499 children. 1471 first graders (55 %), 201 fourth graders (11 %) and 211 eighth graders (12.3 %) did not pass the examinations. In 33.7 % of the children who underwent the follow-up examination from an ophthalmologist, amblyogenic potential was found. CONCLUSIONS: Vision screening by the school medical services enrols most of the children from a single age group. The Snellen E charts used for the monocular distance acuity, together with the TNO stereo test, appear to constitute an effective testing combination. Ophthalmological follow-up examinations of the affected children revealed that one third were afflicted by amblyogenic factors.

The effect of health insurance coverage on medical care utilization and health outcomes: Evidence from Medicaid adult vision benefits.

Increasing the proportion of adults that have regular, comprehensive eye exams and reducing visual impairment due to uncorrected refractive error and other common eye health problems are federal health objectives. We examine the effect of vision insurance on eye care utilization and vision health outcomes by taking advantage of quasi-experimental variation in Medicaid coverage of adult vision care. Using a difference-in-difference-in-difference approach, we find that Medicaid beneficiaries with vision coverage are 4.4 percentage points (p<0.01) more likely to have seen an eye doctor in the past year, 5.3 percentage points (p<0.01) less likely to report needing but not purchasing eyeglasses or contacts due to cost, 2.0 percentage points (p<0.05) less likely to report difficulty seeing with usual vision correction, and 1.2 percentage points (p<0.01) less likely to have a functional limitation due to vision.

Diabetes Mellitus Care Provided by Nurse Practitioners vs Primary Care Physicians.

OBJECTIVES: To compare processes and cost of care of older adults with diabetes mellitus cared for by nurse practitioners (NPs) with processes and cost of those cared for by primary care physicians (PCPs). DESIGN: Retrospective cohort study. SETTING: Primary care in communities. PARTICIPANTS: Individuals with a diagnosis of diabetes mellitus in 2009 who received all their primary care from NPs or PCPs were selected from a national sample of Medicare beneficiaries (N = 64,354). MEASUREMENTS: Propensity score matching within each state was used to compare these two cohorts with regard to rate of eye examinations, low-density lipoprotein cholesterol (LDL-C) and glycosylated hemoglobin (HbA1C) testing, nephropathy monitoring, specialist consultation, and Medicare costs. The two groups were also compared regarding medication adherence and use of statins, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (for individuals with a diagnosis of hypertension), and potentially inappropriate medications (PIMs). RESULTS: Nurse practitioners and PCPs had similar rates of LDL-C testing (odds ratio (OR) = 1.01, 95% confidence interval (CI) = 0.94-1.09) and nephropathy monitoring (OR = 1.05, 95% CI = 0.98-1.03), but NPs had lower rates of eye examinations (OR = 0.89, 95% CI = 0.84-0.93) and HbA1C testing (OR = 0.88, 95% CI = 0.79-0.98). NPs were more likely to have consulted cardiologists (OR = 1.29, 95% CI = 1.21-1.37), endocrinologists (OR = 1.64, 95% CI = 1.48-1.82), and nephrologists (OR = 1.90, 95% CI = 1.67-2.17) and more likely to have prescribed PIMs (OR = 1.07, 95% CI = 1.01-1.12). There was no statistically significant difference in adjusted Medicare spending between the two groups (P = .56). CONCLUSION: Nurse practitioners were similar to PCPs or slightly lower in their rates of diabetes mellitus guideline-concordant care. NPs used specialist consultations more often but had similar overall costs of care to PCPs.

Vision Impairment Among Older Adults Residing in Subsidized Housing Communities.

PURPOSE OF THE STUDY: To examine the rate of vision impairment and the relationship between vision impairment, cognitive impairment, and chronic comorbid conditions in residents of federally subsidized senior housing facilities. DESIGN: Cross-sectional, observational study. METHODS: Vision screening events were held at 14 subsidized senior housing facilities in Jefferson County, Alabama for residents aged 60 years and older. Visual function (distance vision, near vision, and contrast sensitivity) measured with habitual correction if worn, cognitive status, and chronic comorbid conditions (hypertension, heart problems, circulation problems, and diabetes) were assessed. RESULTS: A total of 238 residents participated in the vision screenings. Most residents (75%) were African American. Vision impairment was common, with 40% of participants failing the distance acuity screening and 58% failing the near acuity screening; failure was defined as vision worse than 20/40 in either eye. Additionally, 65% failed the contrast sensitivity screening. A total of 30.6% of seniors had cognitive impairment. Regarding comorbid chronic conditions, 31% had circulation problems, 39% had diabetes, 41% had heart problems, and 76% had hypertension (59% had 2 or more of these). Visual acuity differed significantly between cognitive status groups and with the presence of heart and circulation problems. IMPLICATIONS: This study is among the first to provide information about vision impairment in this socioeconomically disadvantaged group of older adults. Vision impairment was common. Cognitive impairment and comorbid chronic conditions accounted for a small to moderate percentage of the variance in distance vision, near vision, and contrast sensitivity. Future studies should focus on strategies to facilitate access to eye care in this vulnerable population.

External validation of a risk assessment model to adjust the frequency of eye-screening visits in patients with diabetes mellitus.

AIMS: To validate a sight-threatening diabetic retinopathy (STDR) risk assessment model to adjust the frequency of eye-screening visits in patients with diabetes mellitus. METHODS: Retrospective follow-up study of patients with diabetes mellitus attending a diabetes center. Anonimyzed data on gender, type and duration of diabetes, HbA1c, blood pressure and the presence and grade of diabetic retinopathy were gathered to estimate risk for STDR for each individual's worse eye over time by means of a prediction model. Receiver operating characteristics (ROC) analysis was performed to determine the diagnostic ability of the model, and a calibration graph was done to see the model fit. RESULTS: 508 screening intervals were analyzed, median diabetes duration was 10years, 87% were type 2 diabetes mellitus, and 3.1% developed STDR before the next screening visit. The area under the ROC curve was 0.74, and the calibration graph showed that model had a good fit. The reduction in screening frequency was 40% compared with fixed annual screening. CONCLUSIONS: Current prediction model used to estimate the risk of developing STDR in patients with diabetes performed well. A personalized screening frequency for diabetic retinopathy could be implemented in practice.

Effect of a teleretinal screening program on eye care use and resources.

IMPORTANCE: Telemedicine is a useful clinical method to extend health care to patients with limited access. Minimal information exists on the subsequent effect of telemedicine activities on eye care resources. OBJECTIVE: To evaluate the effect of a community-based diabetic teleretinal screening program on eye care use and resources. DESIGN, SETTING, AND PARTICIPANTS: The current study was a retrospective medical record review of patients who underwent diabetic teleretinal screening in the community-based clinics of the Atlanta Veterans Affairs Medical Center from October 1, 2008, through March 31, 2009, and who were referred for an ophthalmic examination in the eye clinic. EXPOSURES: Clinical medical records were reviewed for a 2-year period after patients were referred from teleretinal screening. The following information was collected for analysis: patient demographics, referral and confirmatory diagnoses, ophthalmology clinic visits, diagnostic procedures, surgical procedures, medications, and spectacle prescriptions. MAIN OUTCOMES AND MEASURES: The accuracy between referring and final diagnoses and the eye care resources that were used in the care of referred patients. RESULTS: The most common referral diagnoses were nonmacular diabetic retinopathy (43.2%), nerve-related disease (30.8%), lens or media opacity (19.1%), age-related macular degeneration (12.9%), and diabetic macular edema (5.6%). The percentage of agreement among these 5 visually significant diagnoses was 90.4%, with a total sensitivity of 73.6%. Diabetic macular edema required the greatest number of ophthalmology clinic visits, diagnostic tests, and surgical procedures. Using Medicare cost data estimates, the mean cost incurred during a 2-year period per patient seen in the eye clinic was approximately $1000. CONCLUSIONS AND RELEVANCE: Although a teleretinal screening program can be accurate and sensitive for multiple visually significant diagnoses, measurable resource burdens should be anticipated to adequately prepare for the associated increase in clinical care.

Vision screening in preschoolers: the New South Wales Statewide Eyesight Preschooler Screening program.

OBJECTIVE: To evaluate screening and diagnostic outcomes of the New South Wales Statewide Eyesight Preschooler Screening (StEPS) program, a state-funded, universal vision screening program for 4-year-old children. DESIGN, SETTING AND PARTICIPANTS: A cross-sectional evaluation of the StEPS program, in which eligible 4-year-old children were offered a vision screen in local health districts in NSW, between 1 July 2010 and 30 June 2011. MAIN OUTCOME MEASURES: Number and proportion of eligible children who were offered screening; accepted screening; were screened and scored a pass or were referred (routinely or urgently) for further vision assessment; and were referred for further assessment and required intervention. RESULTS: Of 91 324 eligible 4-year-olds in NSW, 80 328 (88.0%) were offered screening, and 65 834 (72.1% of the eligible population) were screened. Of the children who were screened, 3867 (5.9%) scored less than 6/9-2 but better than 6/18 in one or both eyes and were referred to their general practitioner or eye health professional for further vision assessment. A further 1425 children (2.2%) scored 6/18 or less in one or both eyes and were referred for high-priority assessment. In the two local health districts with the most complete follow-up data, 704 of 779 children (90.4%) with routine referrals and 278 of 285 (97.5%) with high-priority referrals required treatment or review at a later date. CONCLUSIONS: The StEPS program has achieved a high screening participation rate in NSW. Many children have been diagnosed and received treatment for previously undetected serious vision disorders that may otherwise have been diagnosed too late for effective intervention.

Racial disparity of eye examinations among the U.S. working-age population with diabetes: 2002-2009.

OBJECTIVE: Diabetes care differs across racial and ethnic groups. This study aimed to assess the racial disparity of eye examinations among U.S. adults with diabetes. RESEARCH DESIGN AND METHODS: Working-age adults (age 18-64 years) with diabetes were studied using data from the Medical Expenditure Panel Survey Household Component (2002-2009) including the Diabetes Care Survey. Racial and ethnic groups were classified as non-Hispanic whites and minorities. People reporting one or more dilated eye examination were considered to have received an eye examination in a particular year. Eye examination rates were compared between racial/ethnic groups for each year, and were weighted to national estimates. Multivariate adjusted odds ratios (aORs) and 95% CIs for racial/ethnic difference were assessed annually using logistic regression models. Other influencing factors associated with eye examination were also explored. RESULTS: Whites had consistently higher unadjusted eye examination rates than minority populations across all 8 years. The unadjusted rates increased from 56% in 2002 to 59% in 2009 among whites, while the rates in minorities decreased from 56% in 2002 to 49% in 2009. The largest significant racial gap of 15% was observed in 2008, followed by 11%, 10%, and 7% in 2006, 2009, and 2005, respectively (P < 0.05). Minorities were less likely to receive eye examination (2006: aOR 0.75 [95% CI 0.57-0.99]; 2008: 0.61 [0.45-0.84]). CONCLUSIONS: The racial/ethnic differences in eye examinations for patients with diabetes have persisted over the last decade. National programs to improve screening and monitoring of diabetic retinopathy are needed to target minority populations.

A field report on self-screening visual acuity using a computerized vision screener.

BACKGROUND: Large-scale examinations are costly and time consuming. Costs could be reduced by asking patients to carry out tests by themselves. This study aimed to gain practical experience on how patients handle self-administered acuity tests. MATERIAL AND METHODS: We developed two computerized self-test acuity screening devices consisting out of a commercially available vision screener, an answering box and a PC. The answering box served to record the responses of the participants and to present verbal instructions to the participants. Participants took acuity tests for far (5 m, OS, OD, OU) and an acuity test for near (40 cm, OU) using the self-test screener. For the reason of privacy personal data like age, gender and habitual correction was entered on a separate PC. The devices were installed in two different locations and run without supervision. RESULTS: Personal data records of 2528 participants (4% women) were collected in both locations. The age in 45% of the participants ranged between 41 and 50 years. 31% of the participants declared to wear spectacles and 3% contact lenses. 66% of participants declared not to need a correction. A total of 1078 participants completed four acuity tests (OD far, OS far, OU far, OD near) using the self-test screening device. Depending on the acuity test and location, the average duration required to complete one acuity test ranged between 29.7 s to 39.1 s. The total duration for completing the four acuity tests was on average 133 ± 46 s. CONCLUSIONS: The duration for completing the acuity tests is considered as being short. Made experience speaks in favor of feasibility of self-tests in acuity screening.

Development of educational materials to improve rates of early eye care for Hispanic children.

The purpose of this study was to develop targeted materials to encourage Hispanic parents to seek eye care for their children. Hispanic children present with high rates of eye problems such as astigmatism, strabismus, and amblyopia. Related vision impairment can be prevented with timely detection and treatment. After failing a vision screening, a child must obtain professional eye care to take care of the suspected problem. We involved Hispanic community members and health care experts in Alabama to develop educational materials to encourage Hispanic parents to seek eye care for their children. There were six stages in the development of the educational materials: (a) focus groups with Hispanic parents, (b) development of preliminary materials (c) panel with Hispanic health experts (d) panel with members of the target population (e) final production of materials (f) pilot testing of materials. The parents and health experts suggested the information should be provided in the form of radio announcements, brochures, and newspaper advertisements. They also noted the content should stress the importance of seeking vision care for children even when there were no visible problems. Materials developed through this project included messages designed to overcome specific barriers identified by Hispanic parents and to educate them on the importance of comprehensive eye care for all children, regardless of the presence of visible symptoms.

Eye-care utilization among women aged > or =40 years with eye diseases--19 states, 2006-2008.

Diabetic retinopathy (DR), glaucoma, and age-related macular degeneration (ARMD) are major causes of vision loss and blindness. Women have been found to have a higher prevalence of vision loss than men. Early detection and timely treatment by eye-care providers are necessary to delay disease progression and prevent vision loss. To assess the use of professional eye care among women aged > or = 40 years, CDC analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) for 19 U.S. states for the period 2006-2008. This report summarizes the results of that analysis, which indicated that 21% of women with self-reported DR, 12% of women with self-reported glaucoma, and 8% of women with self-reported ARMD did not visit an eye-care provider in the recommended follow-up period. Women who did not have insurance coverage for eye care or who did not receive routine medical check-ups were more likely to report not having the recommended follow-up eye care. The two most commonly cited reasons for not having an eye-care visit were cost or not having insurance (range across diseases: 40%-46%) and having no reason to go for follow-up (range: 20%-29%). Compliance with obtaining eye examinations at recommended intervals among women aged > or = 40 years with eye diseases might be enhanced by improving access to health care and implementing and expanding existing educational programs to raise awareness regarding the importance of routine follow-up eye examinations.

Does opioid therapy affect quality of care for diabetes mellitus?

OBJECTIVE: To examine whether veterans who received chronic opioid therapy had worse diabetes performance measures than patients who did not receive opioids. STUDY DESIGN: Retrospective cohort study. METHODS: We identified all patients with diabetes mellitus receiving care in US Department of Veterans Affairs facilities during 2004. Cases received at least 6 prescriptions for chronic opioids during 2004, while controls were randomly selected from among patients with diabetes who received no opioids. We compared process measures (glycosylated hemoglobin and low-density lipoprotein cholesterol levels tested and an eye examination performed) and outcome measures (glycosylated hemoglobin level < or =9.0% and low-density lipoprotein cholesterol level < or =130 mg/dL) between groups. RESULTS: Cases (n = 47,756) had slightly worse diabetes performance measures than controls (n = 220,912) after adjustment for covariates. For example, 86.4% of cases and 89.0% of controls had a glycosylated hemoglobin test during fiscal year 2004 (adjusted odds ratio, 0.69; P <.001). Among cases, receipt of higher-dose opioids was associated with additional decrement in diabetes performance measures, with a dose-response relationship. CONCLUSIONS: Chronic opioid therapy among patients within the Veterans Affairs system is associated with slightly worse diabetes performance measures compared with patients who do not receive opioids. However, patients receiving higher dosages of opioids had additional decrements in diabetes performance measures; these patients may be appropriate targets for interventions to improve their care for pain and diabetes.

Quantitative pediatric vision screening in primary care settings in Alabama.

PURPOSE: Alabama Medicaid reimburses "objective" vision screening (VS), i.e., by acuity or similar quantitative method, and well child checks (WCCs) separately. We analyzed the frequency of each service obtained. METHODS: Claims for WCC and VS provided between October 1, 2002 and September 30, 2003 for children aged 3 to 18 years, and summary data for all enrolled children, were obtained from Alabama Medicaid. We used univariate analysis followed by logistic regression to explore the potential influence of factors (patient age, provider type, and provider's volume of WCCs) on the receipt of VS at pre-school ages. RESULTS: Children receiving WCCs were 55% black, 40% white, and 5% other. Percentages of children with WCC claims were highest at 4 years (57%) and thereafter declined to 30% at 6 to 14 years and to <10% at 18 years. Nearly all VS (>98% at each age) occurred the same day as the WCC. Pediatricians provided 68% of all WCCs. Multivariate analysis, after adjusting for nesting of pre-school patients within provider, showed the odds ratios (ORs) of VS were increased by patient age (5 years vs. 3 years, OR = 3.57, p < 0.0001), nonphysician provider type (nonphysician vs. pediatrician, OR = 1.80, p = 0.0004) and high WCC volume (at or above vs. below the median number (n = 8) of WCC per provider per year (OR = 7.11, p < 0.0001)). Because VS rates were high when attendance to WCC visits was low, few enrolled children received VS at any age (6% at the age of 3, 13% at the age of 4, and a maximum of 20% at the age of 5). CONCLUSIONS: National efforts to reduce preventable vision loss from amblyopia are hampered because children are not available for screening and because providers miss many opportunities to screen vision at pre-school age. Efforts to improve VS should target pediatrician-led practices, because these serve greater numbers of children.

Are there inequities in the utilisation of childhood eye-care services in relation to socio-economic status? Evidence from the ALSPAC cohort.

BACKGROUND: Equity of access to eye care in childhood remains poorly researched, and most studies report data on utilisation without any objective measure of clinical need. Participants/method: 8271 participants from the Avon Longitudinal Study of Parents and Children (ALSPAC), a longitudinal birth cohort, were seen at age 7, when they underwent a comprehensive eye examination and details of family history of eye conditions, vision problems and contact with eye-care services were obtained. RESULTS: 2931 (35.4%) children had been in contact with an eye-care specialist, and 1452 (17.6%) had received vision screening. Compared with social class I, the prevalence of eye conditions was higher in the lower groups (social class IIIM, IV, V) (OR 1.69, 95% CI 1.15 to 2.46). However, children from lower socio-economic status groups were less likely to see an eye-care specialist (OR 0.83, 95% CI 0.70 to 1.00) or to use screening services (OR 0.65, 95% CI 0.43 to 0.98). DISCUSSION/CONCLUSION: The differences in the trends between socio-economic groups in eye conditions and utilisation of services suggest inequitable access to services. These data highlight the limitations of community-based preschool vision screening, which fails to abolish this inequity. It is important that future research explores the reasons behind these patterns. Compulsory school-entry vision screening, as recommended by the National Screening Committee and the Hall Report may redress this differential uptake of services.

Factors that influence the receipt of eye care.

OBJECTIVES: To better understand what factors influence the receipt of eye care so that screening and education programs can be designed to promote early detection and treatment. METHODS: Twenty focus groups were conducted. Analyses entailed debriefing sessions, coding, and interpreting transcribed data. RESULTS: Attitudes about eyesight and eye exams influence the receipt of preventive eye care. Limited knowledge about certain eye diseases and conditions was reported. Participants stated that their primary care providers did not communicate information with them about eyesight nor did they conduct basic eye screenings. CONCLUSIONS: Improving provider-patient interactions and developing public health messages about eye diseases and preventive eye care can facilitate increased use of appropriate eye care services.