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Nishimura M, Wong A, Maurer D. Continued care and provision of glasses are necessary to improve visual and academic outcomes in children: Experience from a cluster-randomized controlled trial of school-based vision screening. CANADIAN JOURNAL OF PUBLIC HEALTH = REVUE CANADIENNE DE SANTE PUBLIQUE 2024:10.17269/s41997-024-00884-8. [PMID: 38691337 DOI: 10.17269/s41997-024-00884-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 03/21/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVE To assess the effectiveness of a kindergarten vision screening program by randomly assigning schools to receive or not receive vision screening, then following up 1.5 years later. METHODS Fifty high-needs elementary schools were randomly assigned to participate or not in a vision screening program for children in senior kindergarten (SK; age 5‒6 years). When the children were in Grade 2 (age 6‒7 years), vision screening was conducted at all 50 schools. RESULTS Contrary to expectations, screened and non-screened schools did not differ in the prevalence of suspected amblyopia in Grade 2 (8.6% vs. 7.5%, p = 0.10), nor prevalence of other visual problems such as astigmatism (45.1% vs. 47.1%, p = 0.51). There was also no difference between screened and non-screened schools in academic outcomes such as the proportion of children below grade level in reading (33% vs. 29%) or math (44% vs. 38%) (p = 0.86). However, more children were wearing glasses in screened than in non-screened schools (10.2% vs. 7.8%, p = 0.05), and more children reported their glasses as missing or broken (8.3% vs. 4.7%, p = 0.01), suggesting that SK screening had identified successfully those in need of glasses. Examination of individual results revealed that 72% of children diagnosed and treated for amblyopia in SK no longer had amblyopia in Grade 2. CONCLUSION The prevalence of amblyopia and other visual problems was not reduced in Grade 2 by our SK vision screening program, perhaps because of poor treatment compliance and high attrition. The results suggest that a single screening intervention is insufficient to reduce visual problems among young children. However, the data from individuals with amblyopia suggest that continuing vision care and access to glasses benefits children, especially children from lower socioeconomic class.
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Affiliation(s)
- Mayu Nishimura
- Department of Psychology, Neuroscience & Behaviour, McMaster University, Hamilton, ON, Canada.
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, Toronto, ON, Canada.
| | - Agnes Wong
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Daphne Maurer
- Department of Psychology, Neuroscience & Behaviour, McMaster University, Hamilton, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Asare AO, Stagg BC, Sharareh N, Stipelman C, Del Fiol G, Smith JD. Vision Loss in Children from Immigrant and Nonimmigrant Households: Evidence from the National Survey of Children's Health 2018-2020. J Immigr Minor Health 2024:10.1007/s10903-024-01597-3. [PMID: 38581597 DOI: 10.1007/s10903-024-01597-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2024] [Indexed: 04/08/2024]
Abstract
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.
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Affiliation(s)
- Afua O Asare
- John A. Moran Eye Center, Department of Ophthalmology & Visual Sciences, Spencer Fox Eccles School of Medicine, University of Utah, 65 Mario Capecchi Drive, Salt Lake City, UT, 84132, USA.
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, 295 Chipeta Way, Williams Building, Room 1N410, Salt Lake City, UT, 84108, USA.
| | - Brian C Stagg
- John A. Moran Eye Center, Department of Ophthalmology & Visual Sciences, Spencer Fox Eccles School of Medicine, University of Utah, 65 Mario Capecchi Drive, Salt Lake City, UT, 84132, USA
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, 295 Chipeta Way, Williams Building, Room 1N410, Salt Lake City, UT, 84108, USA
| | - Nasser Sharareh
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, 295 Chipeta Way, Williams Building, Room 1N410, Salt Lake City, UT, 84108, USA
| | - Carole Stipelman
- Department of Pediatrics, Division of General Pediatrics, Spencer Fox Eccles School of Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, 421 Wakara Way, Ste 140, Salt Lake City, UT, 84108, USA
| | - Justin D Smith
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, 295 Chipeta Way, Williams Building, Room 1N410, Salt Lake City, UT, 84108, USA
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Heckenlaible NJ, Attzs MS, Kraus CL. Impact of social determinants of health on follow-up adherence, testing completion, and outcomes among pediatric glaucoma patients at a tertiary care center. J AAPOS 2024; 28:103856. [PMID: 38438075 DOI: 10.1016/j.jaapos.2024.103856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 12/17/2023] [Accepted: 12/28/2023] [Indexed: 03/06/2024]
Abstract
PURPOSE To identify patient characteristics associated with visit attendance, treatment outcomes, and optical coherence tomography (OCT) testing in pediatric glaucoma patients at an urban tertiary care center. METHODS The records of patients with childhood glaucoma seen from 2015 to 2021 were reviewed. Primary outcomes were the proportion of scheduled visits completed, visual acuity and intraocular pressure (IOP) at most recent follow-up, and rates of OCT testing. Social determinants of health evaluated included race and ethnicity, distance of residence from clinic, insurance carrier type and residence within Baltimore City County, the latter two serving as proxies for socioeconomic status. RESULTS A total of 99 patients met inclusion criteria: 61% were male; 47%, White (non-Hispanic); 25%, Black (non-Hispanic); 11%, Hispanic/Latino; and 7% Asian/Pacific Islander. Mean distance from clinic was 45.3 miles. Mean visit completion rate was 90.4%; there was no statistically significant variation in visit completion rates by patient characteristics. IOP outcomes did not vary across patient groups, but visual acuity outcomes in affected eyes were significantly worse among Baltimore City County residents compared with non-residents. Only 22% of the cohort received ≥1 OCT per year, and patients living 0-29.9 miles from clinic had significantly lower odds of reaching the threshold than more distant patients. Patients with state-based insurance had significantly lower odds of being ≥50th percentile for rate of OCTs received compared to patients with commercial insurance. CONCLUSIONS In children with glaucoma, residence within Baltimore City County was associated with significantly worse visual acuity outcomes, and close proximity to clinic was an independent predictor of lower rates of OCT testing, despite similar visit attendance rates and IOP outcomes across all groups.
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Affiliation(s)
| | | | - Courtney L Kraus
- Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, Maryland.
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Jamal O, Mallipatna A, Hwang SW, Dimaras H. Social Determinants of Health in Pediatric Ophthalmology Patients: Availability of Data in the Electronic Health Record and Association With Clinic Attendance. Transl Vis Sci Technol 2023; 12:36. [PMID: 38019501 PMCID: PMC10691384 DOI: 10.1167/tvst.12.11.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 10/30/2023] [Indexed: 11/30/2023] Open
Abstract
Purpose To characterize the availability of social determinants of health data in the electronic health record of pediatric ophthalmology patients and to examine the association of social determinants of health with attendance at scheduled operating room and clinic visits. Methods This was a retrospective cohort study of pediatric ophthalmology patients seen at The Hospital for Sick Children between June 1, 2018, and May 23, 2022. Data were collected on demographics, diagnosis, and management-plan. The χ2 tests and multivariable regression were used to examine associations between social determinants of health and attendance at scheduled operating room and clinic visits. Results The cohort consisted of 26,102 study subjects with 31,288 unique eye-related diagnoses representing 57 unique ICD-10 codes. Availability of data in the electronic health record ranged from 100% for sex, age and postal code to 0.1% for ethnic group. Female sex (P = 0.004) and urbanicity (P = 0.05) were associated with higher operating room visit cancellations. Female sex (P = 0.002), age group 0-13 (P ≤ 0.001), low-medium neighborhood income quintile (P ≤ 0.001), residence of Northern Ontario (P ≤ 0.001), and urbanicity (P ≤ 0.001) were associated with higher clinic visit cancellations and no-shows. Conclusions At a major tertiary-care hospital in Canada, key social determinant data such as ethnicity are not consistently available in the electronic health record of pediatric ophthalmology patients. Female sex, younger age, and living in a rural area or neighborhood with low-medium income quintile may be predictors of missed visits and require further study. Translational Relevance This study highlights a need for improved documentation of social determinants of health variables in electronic health records.
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Affiliation(s)
- Omer Jamal
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children and University of Toronto, Toronto, Canada
- University of Toronto, Institute of Medical Sciences, Toronto, Canada
| | - Ashwin Mallipatna
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children and University of Toronto, Toronto, Canada
| | - Stephen W. Hwang
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Canada
| | - Helen Dimaras
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children and University of Toronto, Toronto, Canada
- University of Toronto, Institute of Medical Sciences, Toronto, Canada
- Department of Ophthalmology & Vision Sciences, Faculty of Medicine & Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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Asare AO, Maurer D, Wong AMF, Saunders N, Ungar WJ. Cost-effectiveness of Universal School- and Community-Based Vision Testing Strategies to Detect Amblyopia in Children in Ontario, Canada. JAMA Netw Open 2023; 6:e2249384. [PMID: 36598785 PMCID: PMC9857467 DOI: 10.1001/jamanetworkopen.2022.49384] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
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.
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Affiliation(s)
- Afua Oteng Asare
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Program of Neurosciences and Mental Health, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- John Moran Eye Center, Department of Ophthalmology and Visual Sciences, University of Utah, Salt Lake City
| | - Daphne Maurer
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Psychology, Neuroscience and Behaviour, McMaster University, Hamilton, Ontario, Canada
| | - Agnes M. F. Wong
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Program of Neurosciences and Mental Health, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Natasha Saunders
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Program of Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Wendy J. Ungar
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Program of Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
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Muhammad M, Tumin D. Unmet needs for vision care among children with gaps in health insurance coverage. J AAPOS 2022; 26:63.e1-63.e4. [PMID: 35304321 DOI: 10.1016/j.jaapos.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 12/12/2021] [Accepted: 12/16/2021] [Indexed: 10/18/2022]
Abstract
BACKGROUND Access to vision care is essential for diagnosing and treating vision impairments. Gaps in health insurance coverage may prevent children from receiving vision care and lead to unmet needs for vision services. METHODS This study used deidentified data on children 3-17 years of age from the 2016-2019 National Survey of Children's Health. The primary outcome was caregiver-reported unmet needs for vision care in the previous 12 months. RESULTS Based on a sample of 106,876 children, 3.8% of US children had a recent gap in coverage, and 5.0% lacked insurance in the entire year leading up to the survey. The estimated population prevalence of caregiver-reported unmet needs for vision care was 0.7%. However, children with gaps in coverage had almost 19-fold higher odds of having caregiver-reported unmet vision care needs (OR = 18.7; 95% CI, 11.5-30.2; P < 0.001), and children with a complete lack of coverage also had a ninefold higher odds of caregiver-reported unmet vision care needs (OR = 9.5; 95% CI, 5.5-16.4; P < 0.001), compared to children with year-round private coverage. In the 2018-2019 data, results were similar when analyzing completion of routine vision testing within the past 12 months. CONCLUSIONS Children with gaps in coverage had the highest likelihood of caregiver-reported unmet vision care needs compared with children with year-round coverage or children with year-round lack of coverage.
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Affiliation(s)
- Mufida Muhammad
- Department of Pediatrics, Brody School of Medicine at East Carolina University, Greenville, North Carolina.
| | - Dmitry Tumin
- Department of Pediatrics, Brody School of Medicine at East Carolina University, Greenville, North Carolina
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