Vision Screening Among Children Aged <6 Years — Medical Expenditure Panel Survey, United States, 2009-2010

Alex R. Kemper, MD,1

John E. Crews, DPA2

Bonnie Strickland, PhD3

Jinan B. Saaddine, MD2

1Duke Clinical Research Institute and Department of Pediatrics, Duke University, Durham, North Carolina

2Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, CDC

3Division of Services for Children with Special Health Care Needs, Maternal and Child Health Bureau, Health Resources and Services Administration, Rockville, Maryland

Corresponding author: Alex R. Kemper, Duke Clinical Research Institute and Department of Pediatrics, Duke University. Telephone: 919-668-8038; E-mail: alex.kemper@duke.edu.

Introduction

Amblyopia or lazy eye is an important cause of monocular blindness (1–3) and is associated with a 2.6 fold increase in the risk for bilateral visual impairment in adults (4). However, amblyopia can usually be prevented through early detection and treatment. Treatment focuses on correcting the underlying cause of amblyopia (e.g., strabismus or unequal refractive error) and promoting the use of the amblyogenic eye (e.g., through patching of the other eye). Effectiveness of treatment decreases with age and is less successful after age 12 years (5,6). The overall prevalence of amblyopia among children aged 6 months to 6 years is 1% to 2%. In addition, the prevalence of amblyogenic risk factors among children in this age range is approximately 3% (7,8). Because amblyopia can usually be prevented with early intervention, preschool vision screening for the prevention of amblyopia is considered cost-effective (9).

Many children with or at risk for amblyopia have no symptoms. Therefore, the U.S. Preventive Services Task Force (USPSTF) recommends vision screening for all children at least once between ages 3 and 5 years to detect the presence of amblyopia or its risk factors. This is a USPSTF Grade B recommendation, which means USPSTF recommends the service. There is moderate certainty that vision screening for children aged 3–5 years has a moderate net benefit (10). As described in the USPSTF statement (10), many different vision screening tests are available, including those that evaluate vision directly (e.g., visual acuity or stereoacuity tests), automated and semiautomated devices that evaluate refraction and ocular alignment (e.g., autorefractors and photoscreeners), and tests that rely on physical examinations (e.g., cover-uncover test and the Hirschberg light reflex test). Although USPSTF does not recommend a specific test, the American Academy of Pediatrics (AAP) and other professional societies recommend either tests of visual acuity and stereoacuity or the use of an autorefractor or photoscreener (11). USPSTF did not find sufficient evidence to make a recommendation regarding vision screening for those aged <3 years.

The public health importance of vision loss prevention from amblyopia is underscored by the Healthy People 2020 objective of increasing from 40.1% to 44.1% the proportion of children aged ≤5 years and who receive vision screening (on the basis of data from the National Health Interview Survey, objective V-1 (12). A previous study using 2006–2007 Medical Expenditure Panel Survey (MEPS) data found that 64.9% of parents reported that their children aged 3–6 years ever had vision screening attempted (13). This proportion exceeds that used to set the Healthy People 2020 objective because it excluded children aged <3 years, for which no standard national recommendation exists for vision screening.

To highlight the importance of vision screening, the National Quality Forum (NQF) had established a specific quality measure (NQF #1412): the percentage of preschool-aged children who receive vision screening in the medical home (14). Preschool vision screening also is a component of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provided to those enrolled in Medicaid (15). The Bright Futures recommendations for preventive pediatric care, supported by the Health Resources and Services Administration (HRSA), include annual vision screening for children aged 3–6 years (16). To supplement the preschool vision screening services offered within primary care settings, screening is often provided in group settings (e.g., within preschools) by advocacy groups or by state public health departments.

The reports in this supplement provide the public and stakeholders responsible for infant, child, and adolescent health (including public health practitioners, parents or guardians, and their employers, health plans, health professionals, schools, child care facilities, community groups, and voluntary associations) with easily understood and transparent information about the use of selected clinical preventive services that can improve the health of infants, children, and adolescents. The topic in this report is one of 11 topics selected on the basis of existing evidence-based clinical practice recommendations or guidelines for the preventive services and availability of data system(s) for monitoring (17). This report analyzes 2009–2010 data from MEPS to determine the proportion of children who have received vision screening before age 6 years. Public health agencies can use these data to benchmark progress toward the goal of improving vision screening in this age group and reducing the prevalence of amblyopia.

Methods

To estimate the proportion of children who had received vision screening before age 6 years, CDC analyzed 2009–2010 data from the MEPS Child Preventive Health section of the Household component. MEPS is a set of nationally representative surveys of health and health-care delivery in the United States, and provides nationally representative estimates on health-care use, expenditures, sources of payment, and insurance coverage for the U.S. civilian noninstitutionalized population. Participants are selected from the previous year's National Health Interview Survey. The methods and sample source material are described in detail elsewhere (18).

The unit of analysis was the child. The study population consisted of children aged 60–71 months (i.e., aged 5 years) at the time of the survey. Receipt of vision screening was classified on the basis of response to the question: "Has a doctor or other health provider ever checked (PERSON)'s vision?" A person was considered to have received vision screening if the response was "Yes" or "Tried but (PERSON) was uncooperative." Attempts at vision screening were included because children might have been uncooperative because they had difficulty seeing. Children who are persistently noncooperative should be referred for a comprehensive eye examination. No information is provided in MEPS regarding the type of screening, where it was conducted, when it was conducted, who performed the screening, or the outcome of screening.

The relation between reported screening and several variables was evaluated; variables included sex, race/ethnicity, family income, insurance status at the time of the vision screening question, and whether the child had a special health-care need. Race/ethnicity was classified as non-Hispanic white, non-Hispanic black, Hispanic, and other. Family income was classified as <200% of the federal poverty level or ≥200% of the federal poverty level. Insurance coverage was classified as none (uninsured for entire year), any private (private coverage at any time during the year), and public only. Children with special health care needs were classified in MEPS using a standardized screener completed by parents. The basis for the screener is having a known limitation in activity, or either using or requiring more health-care services than other children.

CDC used statistical software for all analyses. All results, including means, proportions, and 95% confidence intervals (95% CIs), were adjusted for sampling design and by poststratification weights to reflect population level estimates. Chi-squared tests were used for bivariate comparisons of the categorical variables. Statistical significance was defined as p<0.05.

Results

A total of 1,141 children aged 5 years were included in the 2009–2010 MEPS. Overall, 77.9% of these children were reported as having ever had their vision checked by a doctor or other health-care provider. Of those who were reported to have had their vision checked, only four were reported to have been unsuccessful attempts.

The characteristics of subjects were stratified by age and the bivariate associations analyzed between the characteristics and proportion of children reported to have ever been vision screened (Table). Hispanic children were less likely than non-Hispanic children to have reported vision screening. Children whose families earned ≥200% above the federal poverty level were more likely to have reported vision screening than those whose families had lower incomes. Those with no insurance were less likely than those with public only or any private insurance to have reported screening. No statistically significant difference existed by sex or the presence of a special health-care need.

Discussion

By age 6 years, approximately 78% of children were estimated to have had their vision checked by a doctor or other health-care provider. This finding is substantially higher than the rate reported (40.1% of preschool children aged ≤5 that reported receiving vision screening in 2008) in Healthy People 2020 (objective V-1) because of a difference in the approach to analysis. In this evaluation, the focus was on the lifetime screening before age 6 years. However, this rate is still suboptimal; missed vision screening can contribute to preventable blindness in adults. In addition, differences were identified in screening rates by race/ethnicity, family income, and insurance status, which could lead to disparities in vision status.

Ongoing changes in the U.S. health-care system offer opportunities to improve the use of clinical preventive services among infants, children, and adolescents. The Patient Protection and Affordable Care Act of 2010 (as amended by the Health Care and Education Reconciliation Act of 2010 and referred to collectively as the Affordable Care Act [ACA]) expands insurance coverage, consumer protections, and access to care and places a greater emphasis on prevention (19). As of September 23, 2010, ACA § 1001 requires nongrandfathered private health plans to cover, with no cost-sharing, a collection of four types of clinical preventive services, including 1) recommended services of USPSTF graded A (strongly recommended) or B (recommended) (20); 2) vaccinations recommended by the Advisory Committee on Immunization Practices (21); 3) services adopted for infants, children, and adolescents under the Bright Futures guidelines supported by HRSA and AAP (22) and those developed by the Discretionary Advisory Committee on Heritable Disorders in Newborns and Children (23); and 4) women's preventive services as provided in comprehensive guidelines supported by HRSA (24). USPSTF recommends vision screening as a Grade B service for all children at least once between ages 3 and 5 years (10). The Bright Futures guidelines recommend vision screening for children at multiple points as the child ages (16). State Medicaid programs cover vision screening as part of EPSDT.

The Health Insurance Marketplace (or Health Insurance Exchange) began providing access to private health insurance for small employers and to persons and families interested in exploring their options for coverage, with policies taking effect as early as January 2014.* Federal tax credits are available on a sliding scale to assist those living at 100%–400% of the federal poverty level who purchase health insurance through the Marketplace (ACA § 1401). Insurance plans sold on the Marketplace must cover the four types of recommended clinical preventive services without cost-sharing, including vision screening.

MEPS is the only nationally representative survey that conducts ongoing surveillance to monitor vision screening rates in children. However, the vision screening question, "Has a doctor or other health provider ever checked (PERSON)'s vision?" does not assess the type of provider or location of the screening and does not focus on tests that could identify amblyopia. The question reflects any previous vision check that can occur from birth to the time of participation in MEPS, and respondents can vary in what they consider to qualify as checked vision, which could range from simple assessment of the red reflex to use of formal screening tests, including visual acuity assessment, tests of stereopsis, or autorefraction. Furthermore, no data are available regarding the results of the vision screening or the degree to which any necessary follow-up eye examinations or treatment occurred.

To address these gaps in surveillance and to improve the delivery of preschool vision services, HRSA's Maternal and Child Health Bureau funds a cooperative agreement with Prevent Blindness America to establish the National Center for Children's Vision and Eye Health (25). The Center is designed to support the public health role in ensuring a continuum of eye care for young children within the health-care delivery system and in the medical home (25). The activities of the Center are coordinated by Prevent Blindness America, a nonprofit organization, in partnership with CDC's National Center for Health Statistics, CDC's Vision Health Initiative, the Office of Head Start, the National Eye Institute, and Indian Health Service. These activities are guided by an expert panel that includes primary care providers, ophthalmologists, and optometrists. The Center is currently engaged in establishing evidence-based guidelines for vision screening and follow-up and in the development of state-based data systems for the monitoring and reporting of vision screening, follow-up eye care, and vision outcomes (25). In addition, the current National Survey of Children's Health, also supported by HRSA, in partnership with the National Center for Health Statistics, includes items that will provide more specific information on the age at vision screening, the type of test performed, and the location of the vision screening (26).

Limitations

The findings in this report are subject to at least five limitations. First, no information is provided about the timing (i.e., precise age of child at the time of screening). Second, no information exists regarding the quality of the screening (i.e., who performed the screen or the protocol employed). Third, no record exists of the outcome of the screening. Fourth, recall bias might affect the estimates. Finally, parents might not understand what is meant by screening (simple assessment to comprehensive eye examination), and therefore might believe other services (e.g., diagnostic care and treatment) are included. Each limitation has the potential to overestimate or underestimate the results of this analysis, and therefore, the results should be interpreted with caution.

Conclusion

Preschool vision screening is critical to improving long-term vision outcomes. Unfortunately, many children do not receive timely vision screening. Public health activities, including work by the National Center for Children's Vision and Eye Health to improve surveillance and the delivery of vision screening within primary care settings, and state and local efforts to provide screening within the community, are central to decreasing the long-term morbidity associated with amblyopia.

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