A population-level post-screening treatment cost framework to help inform vision screening choices for children under the age of seven

PURPOSE/BACKGROUND

Visual acuity (VA) screening in children primarily detects low VA and amblyopia between 3 and 6 years of age. Photoscreening is a low-cost, lower-expertise alternative which can be carried out on younger children and looks instead for refractive amblyopia risk factors so that early glasses may prevent or mitigate the conditions. The long-term benefits and costs of providing many children with glasses in an attempt to avoid development of amblyopia for some of them needs clarification. This paper presents a framework for modeling potential post-referral costs of different screening models once referred children reach specialist services.

METHODS

The EUSCREEN Screening Cost-Effectiveness Model was used together with published literature to estimate referral rates and case mix of referrals from different screening modalities (photoscreening and VA screening at 2, 3-4 years and 4-5 years). UK 2019-20 published National Health Service (NHS) costings were used across all scenarios to model the comparative post-referral costs to the point of discharge from specialist services. Potential costs were compared between a) orthoptist, b) state funded ophthalmologist and c) private ophthalmologist care.

RESULTS

Earlier VA screening and photoscreening yield higher numbers of referrals because of lower sensitivity and specificity for disease, and a different case mix, compared to later VA screening. Photoscreening referrals are a mixture of reduced VA caused by amblyopia and refractive error, and children with amblyopia risk factors, most of which are treated with glasses. Costs relate mainly to the secondary care providers and the number of visits per child. Treatment by an ophthalmologist of a referral at 2 years of age can be more than x10 more expensive than an orthoptist service receiving referrals at 5 years, but outcomes can still be good from referrals aged 5.

CONCLUSIONS

All children should be screened for amblyopia and low vision before the age of 6. Very early detection of amblyopia refractive risk factors may prevent or mitigate amblyopia for some affected children, but population-level outcomes from a single high-quality VA screening at 4-5 years can also be very good. Total patient-journey costs incurred by earlier detection and treatment are much higher than if screening is carried out later because younger children need more professional input before discharge, so early screening is less cost-effective in the long term. Population coverage, local healthcare models, local case-mix, public health awareness, training, data monitoring and audit are critical factors to consider when planning, evaluating, or changing any screening programme.

The influence of health systems on breast, cervical and colorectal cancer screening: an overview of systematic reviews using health systems and implementation research frameworks

Objectives

Screening for breast, cervical and colorectal cancer in an average-risk population is widely recommended in national and international guidelines although their implementation varies. Using a conceptual framework that draws on implementation and health systems research, we provide an overview of systematic literature reviews that address health system and service barriers or facilitators to effective cancer screening.

Methods

Using a systematic approach, we searched Cochrane Database of Systematic Reviews, Ovid Medline, Ovid Embase, Web of Science, PsychInfo and other internet sources. We included systematic reviews of screening interventions (i.e. targeting people at average risk) for breast, cervical and colorectal cancer. The analysis included 90 systematic reviews.

Results

This review identified a multitude of barriers and facilitators affecting the health system, the capabilities of individuals in the system and their intentions. A large proportion of the available evidence focused on uptake. The reviews demonstrated that health system factors influenced participation, as well as quality and effectiveness of the service provided. The barriers with the biggest impact were knowledge/education, mainly of clients but also providers (capability barriers) and beliefs and values (intention barriers) of the eligible population. These findings complement the usual focus on psychological and social barriers to informed participation by individuals that dominate the screening literature. The facilitators with the most supporting evidence were educational interventions (overcoming capability and intention barriers), invitation letters, reminders and appointments. These were mainly directed at eligible individuals and, to a lesser extent, to providers and healthcare professionals. Only a small number of reviews, mainly from Europe, specified organized, rather than opportunistic, screening programmes. In those, low participation was the most frequently cited barrier and invitation letters (including physician endorsement, phone calls and reminders to non-responders and healthcare professionals) were the most prevalent facilitators.

Conclusion

Despite evidence of barriers and facilitators to screening participation and opportunistic screening, further health systems research covering the entire screening system for organized programmes is required.