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, screening, visual impairment 

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Visual impairment affects between 5 and 10% of all children. (1) Both the American Academy of Pediatrics and the American Academy of Family Physicians 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. (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 practice-based research network 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 or ophthalmologist (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 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 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.

Methods

Study Population

The sample of pediatricians and family physicians was selected from the American Medical Association (AMA) Masterfile, the most complete national database of physicians available in the United States. 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 training and were younger than 65 years of age. The University of Michigan Institutional Review Board approved this study.

Survey

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. We defined urban practice as a practice site within a standard metropolitan statistical area, according to the 2000 U.S. census. (8)

Data Collection

Questionnaires were sent by first-class mail accompanied by a personalized cover letter signed by two of the investigators (ARK and JTB) in July 2001. Two follow-up surveys were mailed to nonrespondents at 4-week intervals.

Data Analysis

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] tests for categorical data. Pearson's [chi square] test was used to compare the median year of graduation from medical school. Stata 7.0 software (Stata Corp., College Station, TX) was used for all statistical analysis.

Results

Survey Response

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 and nonrespondents have similar demographic characteristics (Table 1).

Screening Practices

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).

Barriers

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.

Discussion

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 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 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 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

Key Points

* 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.

References

(1.) U.S. Preventive Services Task Force. Guide to Clinical Preventive Services. 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, Lighthouse 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 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 CA, Brotherton SE. Preschool vision screening in pediatric practice: A study from the Pediatric Research 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, 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, MI, and the Department of Pediatrics, University of Louisville, Louisville, KY.

Reprint 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, Ann Arbor, MI 48109-0456. Email: [e-mail]

Accepted July 9, 2002.

Copyright [c] 2003 by The Southern Medical Association

0038-4348/03/9609-0859

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--Malcolm Muggeridge