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Alaska Blind Child Discovery

A cooperative, charitable research project to vision screen every preschool Alaskan

Value in Amblyopia


Value (AOS thesis)( Beauchamp G, Bane M, Stager D, Berry P, Wright W. A value analysis model applied to the management of amblyopia. Tr Am Ophth Soc 1999;97:349-372.)

Joish V, Malone DC, Miller JM. A cost-benefit analysis of vision screening methods for preschoolers and school -age children. J AAPOS 2003;7(4):283-290.INTRODUCTION: The purpose of this study was to determine costs and benefits of visual acuity screening (VAS) or photoscreening (PS) in children. METHODS: A societal-perspective, decision-analytic model compared VAS and PS conducted in three age groups: children 6 to 18 months, 3 to 4 years, and 7 to 8 years old. Literature estimates of sensitivity, specificity, and prevalence were used. Cost estimates and referral rates for surgical treatment were derived from a managed care database and the United States Social Security Administration. RESULTS: All the benefit-to-cost ratios exceeded 1.0, meaning that all screening programs studied had benefits that exceeded the cost of screening. The total net benefit was highest for PS in children of 3 to 4 years of age (19,412 US dollars) and the least for VAS in children 7 to 8 years of age (15,179 US dollars). The benefit-to-cost ratio was highest for the VAS in children 3 to 4 years of age (162 US dollars) and least for PS in infants 6 to 18 month old (140 US dollars). Sensitivity of the PS instrument and VAS charts were the most influential variables in determining the most cost-beneficial program. CONCLUSIONS: Based on the best available data, the net benefit of PS in 3 to 4 year old preschool children is greater than VAS in children 7 to 8 years of age, PS in toddlers, and VAS in children 3 to 4 years of age.

Arnold RW, Armitage MD, Gionet EG, Balinger A, Kovtoun TA, Machida CJ, et al. The cost and yield of photoscreening: Impact of photoscreening on overall pediatric ophthalmic costs. JPOS 2005;42(2):103-111.
Background: Approximately 5% of preschool children suffer from amblyopia.  Many of them have high or unequal hyperopia.  Amblyogenic risk factors can frequently be detected by photoscreening.
Method: MTI™ photoscreening was offered free-of-charge to a target group of children aged 1-4 from urban and rural screening hubs.  Their parents provided a brief family and health history before consenting to the flash photography.  Packets of screened images were mailed to the ABCD coordinating center for physician photoscreen interpretation, specifically seeking latent or anisometropic hyperopia.  Parents and screeners were then mailed results and information about amblyopia.  Follow-up exam data were then tallied.  A Cost-Consequence Analysis was developed for vision screening and eye care.
Result: In 1998 and 1999, 5166 screenings were performed with a “positive” interpretation rate of 4.5% in the 3046 urban children and 6.2% in the 2120 rural children.  The penetrance of screening was 13% in urban communities and 49% in rural communities.  The positive predictive value is estimated to be over 90%.  From this, the average cost to screen and inform an Alaskan preschooler is about $10.50.  The cost to detect by photoscreening an Alaskan with amblyogenic risk factors is about $225.  Compared to AAP 1995 guidelines, implementing photoscreening adds 9% while mandating complete pre-Kindergarten exam adds 49% to overall eye care.
Conclusion: In some of the least accessible parts of America, MTI™ photoscreening with experienced physician interpretation achieved high community penetrance and high positive predictive value for latent hyperopia and other amblyogenic factors.  The costs must be weighed against societal health goals.  When the follow-up costs are considered, adding photoscreening to current AAP guidelines may add $112 per child over ten years, but probably would also assist in the reduction of amblyopia.  We suspect that penetrance of urban photoscreening will remain low unless pediatric vision screening guidelines and reimbursement are revised.

Beauchamp C, Felius J, Beauchamp GR, Brown M, Brown G. The economic value added for care of amblyopia, strabismus, and asthma (abst). J AAPOS 2007;11(1):76.
Intro: Value analysis in health care calculats the economic value added (EVA) that results from improvements in health and health care.  Our purpose was to develop an EVA model and to apply the model to childhood helath conditions.
Results: Under the model assumptions, the annual net EVA is $27.9 billion for amblyopia, $15.2 billion for surgical strabismus, $11 billion for nonsurgical strabismus, and $190.8 billion for asthma.  The results reflect the maximum opportunity corresponding to the difference between no treatment and a perfect cure, and therefore, indicate an upper limit of what is feasible under current practice outcomes.
Discussion: Value-based medicine seeks to integrate costs with utility, but does not concretely inform resource allocations.  the EVA model demonstrates that there is no rationale for limiting the investment of resources applied to the cure of amblyopia, strabismus and asthma.

Donahue SP. How often are spectacles prescribed to "normal" preschool children? J AAPOS 2004;8(3):224-9.
INTRODUCTION: Legislation to require formal eye examination prior to school entry is being considered in several states and is supported by optical trade organizations. Pediatric ophthalmologists cite anecdotal cases that suggest children receive spectacles unnecessarily, but data to support this are lacking. METHODS: Eye examination results from children referred to local eye doctors following a statewide preschool photoscreening program were reviewed to determine how often glasses were prescribed for children who did not have amblyogenic factors (those with false-positive screenings). RESULTS: Of 102,508 preschool children screened, 890 children did not have amblyogenic factors (false-positive screenings). Nevertheless, spectacles were prescribed for 174 (19.5%) of these children. Only 5/272 children (1.8%) were prescribed glasses following examination by a pediatric ophthalmologist, while glasses were prescribed for 24/205 children (11.7%) examined by comprehensive ophthalmologists and 145/413 (35.1%) of children seen by optometrists (P < 0.001). Eighty children were prescribed glasses for refractive error ranging from -0.75 sph to +2.00 sph, 32 of whom had spherical equivalent of 1D or less. CONCLUSIONS: While some preschoolers without amblyogenic factors may require spectacle correction, a significant percentage of children are probably prescribed glasses unnecessarily. Extrapolation of these data to the United States population suggests that a single mandatory eye examination prior to school entry could cost over 200,000,000 US dollars yearly for unnecessary spectacles. Vision screening programs with high referral rates, and health policy proposals supporting comprehensive preschool eye exams, must consider these unnecessary costs.(6)

White A. Costs and Benefits of Comprehensive Eye Exams.  2004  [cited 2004 10/28/04]; Available from:
Comprehensive eye exams and vision screenings are two methods used to detect amblyopia and other visual disorders in children. Eye exams are performed by an ophthalmologist or optometrist and are used to diagnose vision problems. Vision screenings are conducted by non-medical volunteers, nurses and pediatricians and used to identify people at risk for vision problems.
The goal of the study was to estimate the impact and cost effectiveness of providing comprehensive eye exams to all preschool-age children. We compared the universal provision of eye exams to two interventions: (1) a system in which all preschool-age children receive a vision screening and (2) the eye care that would be provided to children even without the presence of a formal vision screening or eye exam program.
We assessed cost effectiveness using cost-utility analysis, a method of economic evaluation that analyzes the cost effectiveness of interventions based on the cost per Quality-Adjusted Life Year (QALY). For those with childhood amblyopia, lifetime utility is higher if the amblyopia is successfully treated, and the likelihood of successful treatment increases the earlier treatment begins. Successful treatment of amblyopia also reduces the likelihood of blindness later in life. This is an approach that has been used in many other studies to compare different interventions for the detection or treatment of given diseases.
To estimate model parameters, we conducted an extensive literature review and also consulted with the experts who are advising us on the study. While there is an extensive literature on amblyopia and other visual disorders, there are significant gaps in the literature that affect our ability to measure accurately several key model parameters and differences across relevant studies in their estimates of model parameters. We developed a flexible model that allowed the cost effectiveness of comprehensive eye exams to be evaluated under a range of alternative parameter values suggested by the literature.

[A web-published summary of Dr. White’s research noted that comprehensive pediatric eye exams would have a QALY of $12,985 when compared to “usual care,” and $18,390 compared to vision screening.  We asked Dr. White to perform the additional analysis for vision screening compared to no screening.  The QALY for vision screening versus “usual care” was $5680. Therefore, this additional analysis demonstrated that vision screening is an even better value than comprehensive eye examinations, and is one of the most cost effective interventions in ophthalmology.]


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