Preschool vision screening in primary care after a legislative mandate for diagnostic eye examinations.Background: Kentucky legislation now requires that children entering public school receive a diagnostic eye examination.
Methods: Mail survey of randomly selected office-based primary care pediatricians (PDs, n = 221) and family physicians (FPs, n = 207) in Kentucky to assess the impact of the mandated eye examination.
Results: The response rate was 71% PDs and 51% FPs. Most offer preschool vision screening (PD 86%; FP 79%; P = 0.16), but many report they will be less likely to offer it in the future because of the mandated diagnostic eye examination (PD 61%; FP 50%; P = 0.09). Perceived barriers to the diagnostic eye examination include lack of parental knowledge about the requirement, belief by parents that they will need to pay, difficulty in getting an appointment, and lack of endorsement by primary care physicians.
Conclusion: Most primary care physicians in Kentucky offer preschool vision screening, but many now are likely to reduce their screening effort. Until more data are available regarding the impact of the required eye examination, primary care providers should not change their screening practices.
Key Words: health services research Health services research is the multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, , screening, visual impairment Visual Impairment Definition
Total blindness is the inability to tell light from dark, or the total inability to see. Visual impairment or low vision is a severe reduction in vision that cannot be corrected with standard glasses or contact lenses and
Visual impairment affects between 5 and 10% of all children. (1) Both the American Academy of Pediatrics The American Academy of Pediatrics ("AAP") is an organization of pediatricians, physicians trained to deal with the medical care of infants, children, and adolescents. Its motto is: "Dedicated to the Health of All Children. and the American Academy of Family Physicians American Academy of Family Physicians,
n.pr a national medical organization established in 1947 to promote the practice of family medicine. endorse routine vision screening, beginning in early childhood. (2) Preschool vision screening is especially important because it allows for the early detection and treatment of amblyopia Amblyopia Definition
Amblyopia is an uncorrectable decrease in vision in one or both eyes with no apparent structural abnormality seen to explain it. . (1)
Vision screening is challenging, however, especially when it involves evaluating young children who may not understand or be able to cooperate with the screening. Furthermore, little is known about the accuracy of the commonly used office-based vision screening tests. (3) The rate of preschool vision screening by primary care physicians has been reported as low as 15 to 30%. (4,5) However, the rate of vision screening increases with the age of the child. A study of a large pediatric pediatric /pe·di·at·ric/ (pe?de-at´rik) pertaining to the health of children.
Of or relating to pediatrics. practice-based research network A practice-based research network (PBRN) is a group of health care providers or medical clinics that are typically practicing in non-university based community environments that are networked for the purpose of examining and evauluating the health care processes that occur in real found that by 5 years of age the rate of vision screening
was 81%. (6) Even still, 1 in 5 children may not be screened by school entry.
The Commonwealth of Kentucky has passed legislation (HB 706) leading to the creation of a new public agency, the Early Childhood Development Authority whose mission is to ensure that all children meet their developmental potential. Among the initiatives in this legislation is the mandate that all children entering preschool, Head Start, or public school for the first time have a diagnostic eye examination, as opposed to vision screening, by an optometrist optometrist /op·tom·e·trist/ (op-tom´e-trist) a specialist in optometry.
A medical professional who examines and tests the eyes for disease and treats visual disorders by prescribing corrective or ophthalmologist ophthalmologist /oph·thal·mol·o·gist/ (of?thal-mol´ah-jist) a physician who specializes in ophthalmology.
A physician who specializes in ophthalmology. (HB 706, Part 3, Section 8(1)g). (7) This requirement, which took effect in July 2000, is unique in the country.
Enforcement of the requirement occurs within local school districts. Children who do not receive the required diagnostic examination cannot be barred from attending school. Instead, local school districts are responsible for helping families obtain the eye examination for their children. For example, families who cannot afford to pay for the eye examination may be encouraged to apply for public insurance. Children who are ineligible in·el·i·gi·ble
1. Disqualified by law, rule, or provision: ineligible to run for office; ineligible for health benefits.
2. for public insurance are eligible for funds set aside from the Tobacco Settlement to cover the cost of the eye examination. In addition, other organizations, such as the Lions Club and the Kentucky Optometric Association, provide assistance. To help families access resources and navigate (1) "Surfing the Web." To move from page to page on the Web.
(2) To move through the menu structure in a software application. the healthcare system, the state Family Resource and Youth Services Centers, housed within public schools, can help coordinate assistance and arrange referrals.
Unlike the diagnostic examination, state funds for treatment of visual impairment are provided only as part of public insurance (Medicaid or CHIP). No additional state funds have been set aside for such treatment. However, the Family Resource and Youth Services Centers may help families gain assistance and coordinate care.
No information is available regarding the impact of the legislation requiring the diagnostic eye examination on the delivery of vision care services. To understand the effectiveness of the program, important data would include the number of children who have received a diagnostic examination and the number who received treatment based on the results of the diagnostic examination. There is no state requirement for systematically collecting and reporting this information and we are unaware of any plan for such analysis.
It is critical to understand how this legislation affects the care children receive, especially since other states may look to this legislation as a model. Because pediatricians and family physicians have contact with most families of young children as part of routine healthcare, they may have important insight into the barriers of receiving the mandated eye examination. Furthermore, primary care physician support is likely to impact the success of the requirement. To begin to understand the impact of the requirement for a diagnostic eye examination, we surveyed primary care physicians in Kentucky.
The sample of pediatricians and family physicians was selected from the American Medical Association American Medical Association (AMA), professional physicians' organization (founded 1847). Its goals are to protect the interests of American physicians, advance public health, and support the growth of medical science. (AMA (Automatic Message Accounting) The recording and reporting of telephone calls within a telephone system. It includes the calling and called parties and start and stop times of the call. ) Masterfile, the most complete national database of physicians available in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. . The AMA Masterfile includes both members and nonmembers of the AMA. Using a computer algorithm, we randomly selected actively practicing office-based primary care pediatricians (n = 221) and family physicians (n = 207) in Kentucky who had completed residency A duration of stay required by state and local laws that entitles a person to the legal protection and benefits provided by applicable statutes.
States have required state residency for a variety of rights, including the right to vote, the right to run for public office, the training and were younger than 65 years of age. The University of Michigan (body, education) University of Michigan - A large cosmopolitan university in the Midwest USA. Over 50000 students are enrolled at the University of Michigan's three campuses. The students come from 50 states and over 100 foreign countries. Institutional Review Board approved this study.
The survey instrument was a 1-page questionnaire consisting of 10 questions, which took 5 minutes to complete. Items queried included their office-based screening practices for preschool-aged children, activities performed in support of the state requirement for the diagnostic eye examination, perceived barriers to delivery of the eye examination, and practice characteristics. The survey was pretested on a group of community pediatricians to ensure ease of completion and understandability. Outcome measures included office-based screening practices, recommendations provided to families regarding the mandated diagnostic eye examination, and their perceived barriers to delivery of the diagnostic examination. Dependent variables included practice and physician demographics The attributes of people in a particular geographic area. Used for marketing purposes, population, ethnic origins, religion, spoken language, income and age range are examples of demographic data. . We defined urban practice as a practice site within a standard metropolitan statistical area, according to according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. the 2000 U.S. census. (8)
Questionnaires were sent by first-class mail accompanied by a personalized per·son·al·ize
tr.v. per·son·al·ized, per·son·al·iz·ing, per·son·al·iz·es
1. To take (a general remark or characterization) in a personal manner.
2. To attribute human or personal qualities to; personify. cover letter signed by two of the investigators (ARK ark, in the Bible.
1 Boat of Noah, which he built at God's command to preserve his family and certain creatures from the Deluge.
2 Ark of the Covenant, the sacred wooden chest of the Hebrews, representative of God or identified with Him. and JTB JTB - jump trace buffer ) in July 2001. Two follow-up surveys were mailed to nonrespondents at 4-week intervals.
Initially, general frequency responses to all survey items were determined. After this, the survey responses from pediatricians and family physicians were compared by two-sided [chi square chi square (kī),
n a nonparametric statistic used with discrete data in the form of frequency count (nominal data) or percentages or proportions that can be reduced to frequencies. ] tests for categorical data categorical data
data relating to category such as qualitative data, e.g. dog, cat, female. It may be nominal when a name is used, e.g. location, breed, or ordinal when a range of categories is used, e.g. calf, yearling, cow. . Pearson's [chi square] test was used to compare the median year of graduation Graduation is the action of receiving or conferring an academic degree or the associated ceremony. The date of event is often called degree day. The event itself is also called commencement, convocation or invocation. from medical school. Stata Stata (Statistics/Data Analysis) is a statistical program created in 1985 by Statacorp that is used by many businesses and academic institutions around the world. Most of its users work in research, especially in the fields of economics, sociology, political science, and 7.0 software (Stata Corp., College Station, TX) was used for all statistical analysis.
Among those surveyed, 7 of the pediatricians and 40 of the family physicians were found to be ineligible because they do not provide direct clinical care for young children, have retired, or no longer practice in the state of Kentucky. Of the remaining and presumed eligible sample, we received completed surveys from 151 of 214 pediatricians (71% response rate) and 86 of 167 family physicians (51% response rate). For both pediatricians and family physicians, the survey respondents In the context of marketing research, a representative sample drawn from a larger population of people from whom information is collected and used to develop or confirm marketing strategy. and nonrespondents have similar demographic characteristics (Table 1).
Routine preschool vision screening is offered for children 5-years old and younger by 86% of the pediatricians and 79% of the family physicians (P = 0.16). Table 2 lists the reported vision screening practices by age of the child. However, 61% of pediatricians and 50% of family physicians report that they are now less likely to screen for visual impairment (P = 0.09) because of the requirement for a diagnostic eye examination before public school entry.
Support of Mandatory Eye Examination
As mandated by the law, a diagnostic eye examination performed by an eye care specialist is routinely recommended by 79% of pediatricians and 63% of family physicians (P < 0.01). However, 11% of pediatricians and 6% of family physicians report never recommending the diagnostic examination for their patients (P < 0.01).
Most pediatricians and family physicians identified barriers to the implementation of the mandatory school-entry diagnostic eye examination (92% each, P = 0.99). The key barriers, listed in Table 3, are divided into a primary care physician factor, parent factors, and eye care specialist factors. The most commonly reported barriers were parental lack of knowledge about the requirement and belief that they would need to pay for the diagnostic examination.
The Commonwealth of Kentucky has developed a novel approach to the detection of visual impairment in children. By mandating a diagnostic examination before school entry, the legislation may enhance the detection of visual impairment by augmenting screening through expanding available services. However, this legislation may bypass vision screening in the primary care practice setting and remove responsibility for detection of visual impairment from the medical home. No data are available regarding the impact that this legislation has on the delivery of care for children.
We found that most, but not all, primary care physicians provide vision screening in their office for children by five years of age. However, as a result of the requirement for diagnostic eye examinations, more than half of primary care physicians will be less likely in the future to offer vision screening in their offices. Because no data are available on the number of children who do not receive the mandated diagnostic eye examination, the impact of the decrease in primary care vision screening is unclear. There is a potential that the legislation may lead to fragmentation (1) Storing data in non-contiguous areas on disk. As files are updated, new data are stored in available free space, which may not be contiguous. Fragmented files cause extra head movement, slowing disk accesses. A defragger program is used to rewrite and reorder all the files. of care, allowing children with visual impairment to go undetected. Since there is no formal record sharing process, primary care physicians may not be aware of those children in their practice that do not receive the diagnostic eye examination. A decrease in vision screening by primary care physicians would especially affect those children whose families face particular barriers to the diagnostic eye examination, such as their knowledge about the requirement or availability of funds to pay for the examination.
An important role of the primary care physician is coordination of care. By removing the responsibility for the detection of visual impairment from the medical home, the responsibility for coordinating care for those children who are found to have visual impairment by the mandated diagnostic examination is also removed. Families would need to navigate the financial and clinical aspects of the health care system to ensure their children receive the appropriate treatment. This may decrease the number of children with visual impairment who receive optimal care.
The mandated diagnostic examination may be important for the detection of visual impairment for children who have had a false negative screening test, who have primary care providers that do not routinely screen, or who do not have a medical home. Providing complementary services, vision screening and diagnostic eye examinations, may minimize the number of young children with uncorrected visual impairment. However, providing diagnostic eye examinations for all children is significantly more expensive than screening. Also, there may be important induced induced /in·duced/ (in-dldbomacst´)
1. produced artificially.
2. produced by induction.
adj artificially caused to occur.
induction. costs, such as when parents miss work to take their child for the examination. No data are available regarding the cost-effectiveness of the requirement of a diagnostic eye examination compared with usual care.
This analysis has two limitations. First, screening practices are based on self-report and not chart audit. Secondly, we assessed the barriers to the diagnostic examination by physician survey and not by surveying families directly. However, physician attitudes about the barriers are important in assessing their support for the diagnostic eye examination.
Future research should quantify Quantify - A performance analysis tool from Pure Software. the impact of the requirement for a mandated eye examination. Specifically, such work should determine the rate of compliance with the requirement, the number of children who have visual impairment identified, and the rate at which children with confirmed visual impairment receive recommended therapy. Until such data are available, primary care physicians should not stop offering routine preschool vision screening. Before adopting similar legislation, other states should weigh the potential benefit of expanding services to ensure early detection against the costs of implementing mandatory diagnostic examinations and the potential of screening in other settings to decrease.
Table 1. Characteristics of respondents versus nonrespondents Pediatricians Respondents Nonrespondents P Characteristic (n = 151) (n = 65) value Male sex 63% 65% 0.84 Year of medical school 1981 1982 0.81 graduation (median) Urban practice 62% 61% 0.89 Family Physicians Respondents Nonrespondents P Characteristic (n = 86) (n = 81) value Male sex 80% 88% 0.19 Year of medical school 1981 1981 0.93 graduation (median) Urban practice 52% 47% 0.48 Table 2. Proportion of primary care physicians in Kentucky who offer routine vision screening for young children Age of P child Pediatricians Family physicians value 3 years 25% 22% 0.10 4 years 63% 45% 0.01 5 years 79% 80% 0.93 Table 3. Key barriers identified by primary care physicians to children undergoing the mandated diagnostic eye examination Family P Barrier Pediatricians physicians value Primary care physician factor Lack of endorsement by 20% 10% 0.05 primary care physicians Parent factors Lack of knowledge about 58% 78% <0.01 the requirement Lack of knowledge about 31% 49% <0.01 the benefit of early intervention Belief they need to pay for 58% 64% 0.38 the diagnostic examination Eye care specialist factors Lack of availability 9% 12% 0.48 Difficulty in getting an 31% 20% 0.06 appointment
* Most primary care physicians routinely recommend a diagnostic eye examination to their patients.
* Vision screening efforts by primary care physicians has decreased due to the requirement for a diagnostic vision examination.
* The compliance rate with the requirement for a diagnostic eye examination is not known. According to primary care physicians, the most common barriers to receipt of the diagnostic eye examination are parental lack of knowledge about the requirement and the belief that they would need to pay for the diagnostic eye examination.
(1.) U.S. Preventive Services the duty performed by the armed police in guarding the coast against smuggling.
See also: Preventive Task Force. Guide to Clinical Preventive Services clinical preventive service Managed care A health care service delivered in clinical settings for the purpose of preventing the onset or progression of a health condition or illness . Alexandria, VA, International Medical Publishing, 1996, ed 2.
(2.) Schmidt P. Current screening programs, in Hartmann EE (ed): Vision Screening in the Preschool Child. New York New York, state, United States
New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of , Lighthouse lighthouse, towerlike structure erected to give guidance and warning to ships and aircraft by either visible or radioelectrical means. Lighthouses were long built to conform in structure to their geographical location. Until the beginning of the 19th cent. International, 1998, pp 129-164.
(3.) Kemper AR, Margolis PA, Downs SM, et al. A systematic review of vision screening tests for the detection of amblyopia. Pediatrics pediatrics (pēdēă`trĭks), branch of medicine dedicated to the attainment of the best physical, emotional, and social health for infants, children, and young people generally. 1999; 104:1220-1222.
(4.) Stange KC, Flocke SA, Goodwin MA, el al. Direct observation of rates of preventive service delivery in community family practice. Prey Med 2000; 31:167-176.
(5.) Marcinak JF, Yount SC. Evaluation of vision screening practices of Illinois pediatricians, Clin Pediatr (Phila) 1995;34:353-357.
(6.) Wasserman RC, Croft CROFT, obsolete. A little close adjoining to a dwelling-house, and enclosed for pasture or arable, or any particular use. Jacob's Law Dict. CA, Brotherton SE. Preschool vision screening in pediatric practice: A study from the Pediatric Research Pediatric Research is one of the most respected peer-reviewed medical journals within the field of pediatrics in the world.
It is the official publication of the American Pediatric Society, the European Society for Paediatric Research, and the Society for Pediatric in Office Settings (PROS) Network--American Academy of Pediatrics. Pediatrics 1992;89: 834-838.
(7.) Commonwealth of Kentucky. KIDS Now: Kentucky Invests in Developing Success--H.B. 706. Available at: http://gov.state.ky.us/ecd/ New_page_1.htm. Accessed July 11, 2003.
(8.) U.S. Bureau of the Census Noun 1. Bureau of the Census - the bureau of the Commerce Department responsible for taking the census; provides demographic information and analyses about the population of the United States
Census Bureau , U.S. Department of Commerce. Metropolitan and Micropolitan Statistical Area Definitions. Available at: http://www. census.gov/population/www/estimates/metrodef.html. Accessed July 11, 2003.
From the Child Health Evaluation and Research Unit, Division of General Pediatrics, University of Michigan, Ann Arbor Ann Arbor, city (1990 pop. 109,592), seat of Washtenaw co., S Mich., on the Huron River; inc. 1851. It is a research and educational center, with a large number of government and industrial research and development firms, many in high-technology fields such as , MI, and the Department of Pediatrics, University of Louisville See also
1. ^ 
2. ^  URL accessed on June 8 2006
3. , Louisville, KY.
Reprint reprint An individually bound copy of an article in a journal or science communication requests to Alex R. Kemper, MD, MPH, MS, Child Health Evaluation and Research Unit, Division of General Pediatrics, University of Michigan, 6C19 300 N. Ingalls Building The Ingalls Building, built in 1903 in Cincinnati, Ohio, was the world's first reinforced concrete skyscraper. The 16 story building was designed by the Cincinnati architectural firm Elzner & Anderson and was named for its primary financial investor, Melville Ingalls. , Ann Arbor, MI 48109-0456. Email: email@example.com
Accepted July 9, 2002.
Copyright [c] 2003 by The Southern Medical Association
There is no such thing as darkness; only a failure to see.