Costs and effectiveness of two models of school-entry visual acuity screening in the UK.

Cost effectiveness of different visual screening modalities cannot be calculated without long-term outcome data. This paper reports detailed outcomes from a gold-standard UK recommended orthoptist-delivered screening (ODS) at 4-5 years in school, compared to a neighboring school-nurse delivered screening (SNDS), both feeding into the same treatment pathway. The target condition was reduced visual acuity (VA) of worse than logMAR 0.2 in either eye.Available records from screening databases and hospital records were analyzed, comparing the two services wherever possible.More screening data was available from the ODS. ODS: 5706 screened, 3.5% referred. False positives 6.5%, PPV 91.4%, sensitivity 97.9%, and specificity 99.8% for reduced VA. Cost per child with reduced vision detected £195.22, and per amblyope detected £683.28. The mean treatment cost per child with reduced VA was £331.68 and for amblyopia treatment was £458.65.SNDS: 5630 screened and 3.8% referred (plus some referrals to local optometrists lost to follow up). False positives 34%, PPV 53.2%, sensitivity and specificity estimated as 89.3% and 98.67%. Costs to secondary services of false positives were seven times greater. The cost per child with confirmed reduced vision seen at the hospital was 46% more; and per amblyope detected was 39% more.Outcomes for treatment post referral in both groups were similar and excellent. 86% of genuine referrals improved to within normal limits with glasses alone. Of 221 genuine referrals with final outcome data, all now have better than 0.2logMAR acuity in the better eye and only two (0.9%) have residual amblyopia in one eye worse than 0.4logMAR.About 14-18% of children with reduced VA would have passed AAPOS photoscreening referral criteria.An orthoptist-delivered single VA screen at 4-5 years is highly cost effective with good outcomes. The main contributing factors to success appear to be training and experience in accurate VA testing, the opportunity to rescreen equivocal results, and monitoring, audit, and feedback of outcomes.

Lung transplant or bust: patients' recommendations for ideal lung transplant education.

CONTEXT: Effective lung transplant education helps ensure informed decision making by patients and better transplant outcomes. OBJECTIVE: To understand the educational needs and experiences of lung transplant patients. DESIGN: Mixed-method study employing focus groups and patient surveys. SETTING: Barnes-Jewish Hospital in St Louis, Missouri. PATIENTS: 50 adult lung transplant patients: 23 pretransplant and 27 posttransplant. MAIN OUTCOME MEASURES: Patients' interest in receiving specific transplant information, the stage in the transplant process during which they wanted to receive the education, and the preferred format for presenting the information. RESULTS: Patients most wanted information about how to sustain their transplant (72%), when to contact their coordinator immediately (56%), transplant benefits (56%), immunosuppressants (54%), and possible out-of-pocket expenses (52%). Patients also wanted comprehensive information early in the transplant process and a review of a subset of topics immediately before transplant (time between getting the call that a potential donor has been found and getting the transplant). Patients reported that they would use Internet resources (74%) and converse with transplant professionals (68%) and recipients (62%) most often. DISCUSSION: Lung transplant patients are focused on learning how to get a transplant and ensuring its success afterwards. A comprehensive overview of the evaluation, surgery, and recovery process at evaluation onset with a review of content about medications, pain management, and transplant recovery repeated immediately before surgery is ideal.

Balance control in glaucoma.

PURPOSE: To examine postural stability in glaucoma patients and subjects with no ocular disease. METHODS: Twenty-four glaucoma (G) and 24 control (C) subjects participated (mean age [SD] G: 65.9 [5.5] years; C: 68.3 [5.2] years). Postural stability was measured using a force-balance platform under four conditions: eyes open/closed standing on a firm surface and eyes open/closed on a foam surface. Average magnitude of center of foot pressure displacement (root mean square [RMS]) was calculated in the anteroposterior (AP) direction. The Romberg Quotient (RQ) was used to evaluate the visual contribution to balance. The difference in sway between firm and foam standing evaluated the relative somatosensory contribution to balance. The binocular mean deviation (BinMD) score was calculated from Humphrey 24-2 SITA strategy tests. RESULTS: Glaucoma patients had a lower visual contribution to sway (AP RQ, G = 1.65 [0.44]; AP RQ, C = 2.25 [0.53], P = 0.0001), and higher relative somatosensory contribution to sway (change in AP RMS EYES open firm to foam standing: G = 4.12 [1.85] mm, C = 2.22 [2.04] mm, P = 0.002). BinMD was a significant predictor of balance (AP RQ versus BinMD ß-coefficient = 0.58, P = 0.0001; change in AP RMS [eyes open "firm" to "foam"] versus BinMD ß-coefficient = -0.35, P = 0.02). CONCLUSIONS: Glaucoma patients display differences in their visual and somatosensory contributions to quiet standing balance compared with control subjects, associated with the degree of binocular visual field loss. This suggests that balance control may be compromised in this patient group.

Tier 4 Child and Adolescent Mental Health Services (CAMHS) - Inpatient Care, Day Services and Alternatives: An Overview of Tier 4 CAMHS Provision in the UK.

This paper addresses Tier 4 services for children and young people whose needs require highly specialised services, and describes the range of provision which is currently available for this group. Although the evidence base is in its infancy, what is known about clinical outcomes, cost effectiveness and the views of users is summarised. The current shortfalls in tier 4 provision are highlighted, the drivers for change are identified and recommendations are made for future service improvements.