Vision Loss in Children from Immigrant and Nonimmigrant Households: Evidence from the National Survey of Children's Health 2018-2020.

The aim of this study was to determine whether immigrant generation is associated with caregiver-reported vision loss in children adjusting for sociodemographic characteristics. Nationally representative data from the National Survey of Children's Health (2018-2020) was used. The primary exposure was immigrant generation defined as: first (child and all reported parents were born outside the United States); second (child was born in the United States and at least one parent was born outside the United States); third or higher (all parents in the household were born in the United States). The main outcome was caregiver-reported vision loss in child. Adjusted odds ratios (aOR) and 95% confidence intervals were computed based on immigration generation. The study sample included 84,860 US children aged 3-17 years. First generation children had higher adjusted odds of caregiver-reported vision loss (aOR 2.30; 95% CI 1.21, 4.35) than third or higher generation children after adjusting for demographic characteristics and social determinants of health. For Hispanic families, first generation (aOR 2.99; 95% CI 1.34, 6.66), and second-generation children (aOR 1.70; 95% CI 1.06, 2.74) had a higher adjusted odds of vision loss compared with third or higher generation children. Even when adjusting for sociodemographic characteristics, first generation children had greater odds of vision loss, especially in Hispanic households, than third generation children. Immigration generation should be treated as an independent risk factor for vision loss for children and is a social determinant of eye health.

Association of Sociodemographic Characteristics with Pediatric Vision Screening and Eye Care: An Analysis of the 2021 National Survey of Children's Health.

PURPOSE: Vision screening and regular eye care can help detect and treat potentially irreversible vision impairment. This study aims to investigate the associations between sociodemographic and health characteristics and the receipt of eye care among children aged 17 years and younger in the United States. DESIGN: This cross-sectional study used data from the National Survey of Children's Health (NSCH), a nationally representative and population-based survey of randomly sampled households. PARTICIPANTS: Participants were children aged 0 to 17 years, residing in all 50 states and the District of Columbia, whose caregivers or parents answered an address-based survey by mail or online. METHODS: Weighted prevalence calculations were applied to analyze the data, and logistic regression was performed to explore associations between reported eye care and demographic, health, and parent-related variables. MAIN OUTCOME MEASURES: Caregiver-reported vision screenings, referral to an eye doctor after vision screening, eye doctor visits, and prescription of corrective lenses. RESULTS: Caregivers reported that 53.2% of children had a vision screening at least once (if child ≤ 5 years) or within the past 2 years (if child > 5 years). Of those screened, 26.9% were referred to an eye doctor. Overall, 38.6% of all children had a previous eye doctor visit, and among them, 55.4% were prescribed corrective lenses during the visit. Factors associated with decreased odds of vision screening included younger age, lack of health care visits, no insurance coverage, parent education high school or less, and lower household income. Non-White ethnicities, households with a non-English primary language, and lower incomes were more likely to be referred to an eye doctor after vision screening. Lower rates of eye doctor visits were associated with younger age, lack of insurance coverage, and primary household languages other than English. CONCLUSIONS: Children from disadvantaged backgrounds are less likely to receive vision screening and eye care. Targeted strategies are needed to increase vision screening and access to eye care services in these vulnerable groups. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Association Between Health Insurance and Primary Care Vision Testing Among Children and Adolescents.

This survey study assesses rates of vision testing by pediatrician or other primary care practitioners among insured and uninsured persons aged 3 to 17 years.

Systematic User-centered Design of a Prototype Clinical Decision Support System for Glaucoma.

Purpose: To rigorously develop a prototype clinical decision support (CDS) system to help clinicians determine the appropriate timing for follow-up visual field testing for patients with glaucoma and to identify themes regarding the context of use for glaucoma CDS systems, design requirements, and design solutions to meet these requirements. Design: Semistructured qualitative interviews and iterative design cycles. Participants: Clinicians who care for patients with glaucoma, purposefully sampled to ensure a representation of a range of clinical specialties (glaucoma specialist, general ophthalmologist, optometrist) and years in clinical practice. Methods: Using the established User-Centered Design Process framework, we conducted semistructured interviews with 5 clinicians that addressed the context of use and design requirements for a glaucoma CDS system. We analyzed the interviews using inductive thematic analysis and grounded theory to generate themes regarding the context of use and design requirements. We created design solutions to address these requirements and used iterative design cycles with the clinicians to refine the CDS prototype. Main Outcome Measures: Themes regarding decision support for determining the timing of visual field testing for patients with glaucoma, CDS design requirements, and CDS design features. Results: We identified 9 themes that addressed the context of use for the CDS system, 9 design requirements for the prototype CDS system, and 9 design features intended to address these design requirements. Key design requirements included the preservation of clinician autonomy, incorporation of currently used heuristics, compilation of data, and increasing and communicating the level of certainty regarding the decision. After completing 3 iterative design cycles using this preliminary CDS system design solution, the design was satisfactory to the clinicians and was accepted as our prototype glaucoma CDS system. Conclusions: We used a systematic design process based on the established User-Centered Design Process to rigorously develop a prototype glaucoma CDS system, which will be used as a starting point for a future, large-scale iterative refinement and implementation process. Clinicians who care for patients with glaucoma need CDS systems that preserve clinician autonomy, compile and present data, incorporate currently used heuristics, and increase and communicate the level of certainty regarding the decision. Financial Disclosures: Proprietary or commercial disclosure may be found after the references.

Cost-effectiveness of Universal School- and Community-Based Vision Testing Strategies to Detect Amblyopia in Children in Ontario, Canada.

Importance: Screening for amblyopia in primary care visits is recommended for young children, yet screening rates are poor. Although the prevalence of amblyopia is low (3%-5%) among young children, universal screening in schools and mandatory optometric examinations may improve vision care, but the cost-effectiveness of these vision testing strategies compared with the standard in primary care is unknown. Objective: To evaluate the relative cost-effectiveness of universal school screening and mandated optometric examinations compared with standard care vision screening in primary care visits in Toronto, Canada, with the aim of detecting and facilitating treatment of amblyopia and amblyopia risk factors from the Ontario government's perspective. Design, Setting, and Participants: An economic evaluation was conducted from July 2019 to May 2021 using a Markov model to compare 15-year costs and quality-adjusted life-years (QALYs) between school screening and optometric examination compared with primary care screening in Toronto, Canada. Parameters were derived from published literature, the Ontario Schedule of Benefits and Fees, and the Kindergarten Vision Testing Program. A hypothetical cohort of 25 000 children aged 3 to 5 years was simulated. It was assumed that children in the cohort had irreversible vision impairment if not diagnosed by an optometrist. In addition, incremental costs and outcomes of 0 were adjusted to favor the reference strategy. Vision testing programs were designed to detect amblyopia and amblyopia risk factors. Main Outcomes and Measures: For each strategy, the mean costs per child included the costs of screening, optometric examinations, and treatment. The mean health benefits (QALYs) gained were informed by the presence of vision impairment and the benefits of treatment. Incremental cost-effectiveness ratios were calculated for each alternative strategy relative to the standard primary care screening strategy as the additional cost required to achieve an additional QALY at a willingness-to-pay threshold of $50 000 Canadian dollars (CAD) ($37 690) per QALY gained. Results: School screening relative to primary care screening yielded cost savings of CAD $84.09 (95% CI, CAD $82.22-$85.95) (US $63.38 [95% CI, US $61.97-$64.78]) per child and an incremental gain of 0.0004 (95% CI, -0.0047 to 0.0055) QALYs per child. Optometric examinations relative to primary care screening yielded cost savings of CAD $74.47 (95% CI, CAD $72.90-$76.03) (US $56.13 [95% CI, $54.95-$57.30]) per child and an incremental gain of 0.0508 (95% CI, 0.0455-0.0561) QALYs per child. At a willingness-to-pay threshold of CAD $50 000 (US $37 690) per QALY gained, school screening and optometric examinations were cost-effective relative to primary care screening in only 20% and 29% of iterations, respectively. Conclusions and Relevance: In this study, because amblyopia prevalence is low among young children and most children in the hypothetical cohort had healthy vision, universal school screening and optometric examinations were not cost-effective relative to primary care screening for detecting amblyopia in young children in Toronto, Canada. The mean added health benefits of school screening and optometric examinations compared with primary care screening did not warrant the resources used.

Economic evaluations of vision screening to detect amblyopia and refractive errors in children: a systematic review.

OBJECTIVE: To synthesize and appraise economic evaluations of vision screening to detect vision impairment in children. METHODS: Literature searches were conducted on seven electronic databases, grey literature, and websites of agencies conducting health technology assessments. Studies were included if they (1) were full, comparative economic evaluations that used cost-utility, cost-benefit, cost-effectiveness, cost-consequence, or cost-analysis methods; (2) described screening services designed to detect amblyopia, strabismus, or uncorrected refractive errors in children under 6 years of age; and (3) published after 1994. High-quality studies were synthesized descriptively. Currencies were reported in 2019 Canadian dollars. Quality was assessed with the Pediatric Quality Appraisal Questionnaire (PQAQ). RESULTS: Vision screening services were conducted by paid staff, volunteers, or health care professionals in schools or clinics. Thirteen studies were published from five countries: China (n = 1), United States (n = 4), United Kingdom (n = 1), Canada (n = 1), and Germany (n = 6). Analytical techniques included cost-utility/cost-effectiveness combination (n = 2), cost-effectiveness analysis (n = 7), cost-utility analysis (n = 1), cost-benefit analysis (n = 1), cost-consequence analysis (n = 1), and cost analysis (n = 1). Incremental cost-effectiveness ratios ranged from C$1,056 to C$151,274 per additional case detected/prevented and from C$9,429 to C$30,254,703 per additional QALY gained, depending on the type of screening service and comparator. Six studies were determined to be of high quality. CONCLUSION: Vision screening to detect amblyopia for young children may be cost-effective compared with no screening if amblyopia reduced quality of life. Studies varied significantly in the type of screening services and comparators used. Methodological limitations were common. Future studies would be aided immensely by prospective studies on the impact of amblyopia on the health-related quality of life of young children and guidelines on the effective conduct of vision screening.

RéSUMé: OBJECTIF: Synthétiser et évaluer des évaluations économiques de dépistages visuels visant à détecter la déficience visuelle chez les enfants. MéTHODE: Nous avons interrogé sept bases de données électroniques, la littérature grise et les sites Web d'organismes effectuant des évaluations des technologies de la santé. Nous avons inclus les études correspondant aux critères suivants : (1) évaluations économiques comparatives exhaustives utilisant l'analyse coûts-utilité, coûts-bénéfices, coûts-efficacité ou coûts-conséquences ou l'analyse des coûts; (2) décrivant des services de dépistage visant à détecter l'amblyopie, le strabisme ou les anomalies de la réfraction non corrigées chez les enfants de moins de six ans; et (3) publiées après 1994. Nous avons fait la synthèse descriptive des études de haute qualité. Les devises ont été converties en dollars canadiens de 2019. Nous avons évalué la qualité des études à l'aide de l'outil PQAQ (Pediatric Quality Appraisal Questionnaire). RéSULTATS: Les services de dépistage visuel étaient offerts par du personnel rémunéré, des bénévoles ou des professionnels de santé dans des écoles ou des cliniques. Treize études ont été publiées dans cinq pays : Chine (n = 1), États-Unis (n = 4), Royaume-Uni (n = 1), Canada (n = 1) et Allemagne (n = 6). Les techniques d'analyse employées étaient la combinaison analyse coûts-utilité/analyse coûts-efficacité (n = 2), l'analyse coûts-efficacité (n = 7), l'analyse coûts-utilité (n = 1), l'analyse coûts-avantages (n = 1), l'analyse coûts-conséquences (n = 1) et l'analyse des coûts (n = 1). Les rapports coût-efficacité différentiels s'échelonnaient entre 1 056 $ CA et 151 274 $ CA par cas supplémentaire détecté/prévenu et entre 9 429 $ CA et 30 254 703 $ CA par année de vie pondérée par la qualité (AVPQ) supplémentaire gagnée, selon le type de service de dépistage et le comparateur. Six études ont été jugées être de haute qualité. CONCLUSION: Comparativement à l'absence de dépistage, les dépistages visuels pour détecter l'amblyopie chez les jeunes enfants peuvent être efficaces par rapport à leur coût lorsque l'amblyopie réduit la qualité de vie. Le type de services de dépistage et les comparateurs utilisés variaient considérablement d'une étude à l'autre. Les contraintes méthodologiques étaient courantes. Les études futures seraient grandement favorisées par des études prospectives des incidences de l'amblyopie sur la qualité de vie liée à la santé chez les jeunes enfants et par des lignes directrices sur l'exécution efficace des dépistages visuels.

Perceptions of Respect From Clinicians by Patients in Racial and Ethnic Minority Groups With Eye Disease.

IMPORTANCE: The perception of being treated with respect by clinicians may be a driver of disparities in individuals in racial and ethnic minoritie groups with eye diseases. Understanding these drivers may help identify potential interventions to reduce eye health disparities to prevent vision loss and blindness. OBJECTIVE: To evaluate the association between racial and ethnic minority status and the perception of being treated with respect by clinicians. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional analysis of a nationally representative cohort study using data from the National Health Interview Survey (NHIS) included participants in the 2017 survey with complete data on outcomes, associated factors, and covariates. Data analysis took place from January 2021 to February 2021. Using a population-based survey conducted in the US in 2017 by the US census bureau on behalf of the National Center for Health Statistics, NHIS study participants (age ≥18 years) who self-reported having an eye disease (macular degeneration, diabetic retinopathy [DR], glaucoma, cataracts) were included, and patients who self-reported as Black, Asian, other/multiple races, or Hispanic ethnicity were considered to be in racial and ethnic minority groups. MAIN OUTCOMES AND MEASURES: Multivariable logistic regression models were used to evaluate the association of minority status with self-reported "always" being treated with respect by clinicians and self-reported "always" being asked about opinions/beliefs about medical care. RESULTS: Participants in racial and ethnic minority groups had 23% lower odds of reporting being treated with respect compared with non-Hispanic White patients (adjusted odds ratio [AOR], 0.77; 95% CI, 0.61-0.97; P = .03). A minority of participants had 66% higher odds of reporting being asked about their beliefs (AOR, 1.66; 95% CI, 1.39-1.98; P < .001). For all patients, being asked about opinions/beliefs by their clinician was associated with a 5.8 times higher odds of reporting being treated with respect (AOR, 5.80; 95% CI, 4.35-7.74; P < .001). CONCLUSIONS AND RELEVANCE: In this nationally representative US population of patients with eye diseases, being a patient in a racial or ethnic minority group was associated with feeling less respected by health care professionals compared with non-Hispanic White patients. Asking about opinions and beliefs, regardless of race or ethnicity, is associated with patients feeling that they are treated with respect.

Socioeconomic Status and Vision Care Services in Ontario, Canada: A Population-Based Cohort Study.

OBJECTIVE: To test the association of material deprivation and the utilization of vision care services for young children. STUDY DESIGN: We conducted a population-based, repeated measures cohort study using linked health and administrative datasets. All children born in Ontario in 2010 eligible for provincial health insurance were followed from birth until their seventh birthday. The main exposure was neighborhood-level material deprivation quintile, a proxy for socioeconomic status. The primary outcome was receipt of a comprehensive eye examination (not to include a vision screening) by age 7 years from an eye care professional, or family physician. RESULTS: Of 128 091 children included, female children represented 48.7% of the cohort, 74.4% lived in major urban areas, and 16.2% lived in families receiving income assistance. Only 65% (n = 82 833) had at least 1 comprehensive eye examination, with the lowest uptake (56.9%; n = 31 911) in the most deprived and the highest uptake (70.5%; n =19 860) in the least deprived quintiles. After adjusting for clinical and demographic variables, children living in the least materially deprived quintile had a higher odds of receiving a comprehensive eye examination (aOR 1.43; 95% CI 1.36, 1.51) compared with children in the most materially deprived areas. CONCLUSIONS: Uptake of comprehensive eye examinations is poor, especially for children living in the most materially deprived neighborhoods. Strategies to improve uptake and reduce inequities are warranted.

Access to Vision Services by Vulnerable Populations in Canada: A Scoping Review.

Vision impairment has a significant impact on quality of life. Seventy percent of existing vision impairment in Canada is estimated to be correctable with prescription glasses. The sizeable proportion of correctable vision impairment appears related to the barriers to access to vision care in Canada. The objective of this scoping review is to determine gaps in the understanding of barriers to accessing vision care for vulnerable populations in Canada. The Arksey and O'Malley methodological framework was adopted. Studies published in English between 2005 and September 2017 on access to primary vision care by vulnerable populations in Canada were reviewed. Electronic databases used included Ovid MEDLINE, Ovid EMBASE, SCOPUS, ProQuest, and CINAHL. The Behavioural Model of Health Services Use was used to elucidate gaps in the literature. To develop relevant policies around vision care, efforts should be made to assess all dimensions of access for vulnerable populations across Canada.

Community vision screening in preschoolers: initial experience using the Plusoptix S12C automated photoscreening camera.

OBJECTIVE: Amblyopia is the leading cause of monocular vision impairment in children. Early intervention is critical to prevent permanent vision impairment. Preschool vision screening programs in Canada are limited. This study reports the initial results of a community-wide vision screening program for preschoolers using the Plusoptix S12C Photoscreener (Plusoptix Inc, Nuremburg, Germany). DESIGN: Cross-sectional. PARTICIPANTS: For this study, 1443 children aged 18-59 months were recruited and screened in various community settings in London, Ontario. METHODS: Participants were screened with the Plusoptix S12C device from September 2015 to May 2016. Data were analyzed for percentage of children referred for amblyogenic risk factors using the Arnold 2012 referral criteria. Referral, inconclusive results, follow-up rate, and positive predictive value were reported. RESULTS: Data from 1321 children were analyzed. Mean age of children meeting the inclusion criteria was 34.1 ± 9.6 (18-58) months. One hundred and nineteen children were referred to an optometrist for a comprehensive eye exam; 39 (3.0%) were inconclusive screens. The referral rate for children detected with amblyogenic risk factors was 6.1%. Forty (50.0%) children were documented as complying with the follow-up examination. The positive predictive value was 81.8%. CONCLUSIONS: Our community-wide vision screening program identified in a timely, manner, 80 preschoolers with amblyogenic risk factors previously unknown to be present. Results identified children with amblyogenic risk factors that may have gone undetected. This program could serve as a model for consideration by policy makers.