Vision and Eye Health in Children 36 to <72 Months: Proposed Performance Measures
Currently, providers of vision screening and eye examinations lack a system to provide national or state level estimates of the proportion of children who receive either a vision screening or an eye examination. Recommendations have been developed by the National Expert Panel to the National Center for Children’s Vision and Eye Health at Prevent Blindness and funded by the Maternal and Child Health Bureau of the Health Resources and Services Administration, U.S. Department of Health and Human Services to establish performance measures for children’s vision health. The panel developed numerator and denominator definitions to measure rates of children “who completed a vision screening in a medical or community setting using a recommended method, or received an eye examination by an optometrist or ophthalmologist at least once between the ages of 36 to <72 months.” Separate measures for vision care provided to children with neurodevelopmental disorders, measures for receipt of an eye examination, and receipt of follow-up care were also developed. The panel recommends that these measures be implemented at national, state and local levels.
This webpage provides a synopsis of the article content. Read the complete journal article.
The expert panel recommends a child-based performance measure for vision care of children aged 36 to <72 months, defined as:
Numerator: Number of children from the denominator who completed a valid* vision screening in a medical or community setting, or received an eye examination by an optometrist or ophthalmologist at least once between the ages of 36 to <72 months.
Denominator: All children who turn 72 months of age by December 31st of the reporting year in the entire population, or a representative sample.
*For all performance measures, “valid vision screening” is defined as: vision screening attempted using a recommended quantitative method (See Vision Screening Recommendations) with an outcome of “pass” OR another outcome (fail or untestable) AND evidence that the child was referred or re-screened. Thus, a non-passing result without evidence of a referral or rescreen is considered an invalid screening and is not counted in the numerator. Acceptable evidence of referral would be the date of the appointment, and name of consulting ophthalmologist or optometrist reported by the screening agency.
- Entities establishing this performance measure are encouraged to identify their baseline performance and to set annual targets increasing towards their specific goal.
- Entities that require a population based goal, (such as the Healthy People 2020 goal of 44% of children screened by 2020), will need to be equipped to report all community-based and office-based screening.
- Age-specific reporting, for purposes of identifying settings that successfully test younger children, could be a secondary goal.
- Reporting age specific screening rates would require adjustments to the numerator and denominator to reflect the cohort being addressed.
The panel recommends a separate performance measure for children with diagnosed neurodevelopmental disorders (e.g., hearing impairment, motor abnormalities such as cerebral palsy, Down syndrome, cognitive impairment, autism spectrum disorders and speech / language delay), who should be referred directly.
Implementation will require integration of vision and developmental diagnostic data.
Numerator: Number of children from the denominator who completed an eye examination by an ophthalmologist or optometrist within 6 months of diagnosis of the neurodevelopmental disorder.
Denominator: All children who turn 72 months of age by December 31st of the reporting year in the state, or a representative sample, diagnosed with a neurodevelopmental disorder.
The panel recommends a performance measure addressing the proportion of children receiving follow-up eye examinations after a screening referral defined as:
Numerator: Number of children from the denominator who completed an eye examination by an optometrist or ophthalmologist within 6 months of a referral from quantitative vision screening.
Denominator: All children who turn 72 months of age by December 31st of the reporting year in the state, a region, or a representative sample, who were referred after quantitative screening (see Table 2) in a medical or community setting between the ages of 36 to <72 months.
In case of multiple services, data should reference the earliest examination by an optometrist or ophthalmologist, which was preceded by a referral from a screening (this performance measure does not include eye examinations not preceded by a referral, or triggered by another reason such as positive family history, neurodevelopmental disorder, or observation of an abnormality).
This measure should be calculated 6 months after the end of the reporting year, in order to account for those children that failed a vision screening between the ages of 67 to <72 months who required time to receive a follow up eye examination.
The following treatment measure addresses the proportion of children with an eye examination found to have visually-significant eye conditions, who receive treatment or additional visits to an ophthalmologist or optometrist.
Numerator: Number of children from the denominator who obtained glasses and/or attended at least one follow-up appointment with an optometrist or ophthalmologist* within 6 months of an eye examination.
Denominator: All children who turn 72 months of age by December 31st of the reporting year in the population, or a representative sample, who were prescribed treatment including glasses and/or instructed by an optometrist or ophthalmologist to return within six months (e.g. for treatment of amblyopia, strabismus, or amblyogenic refractive error21).
* This numerator would be reported by the prescribing ophthalmologist or optometrist.
This measure would provide surveillance of treatment adherence in children with diagnosed vision conditions or amblyogenic refractive error.
- Utilizing existing data infrastructure, while working towards a more interchangeable data system that will readily support the implementation and reporting of valid measures, is recommended.
- The panel urges implementation of performance measures into emerging data systems to assure the necessary infrastructure and data elements to allow reporting of the vision measures.
- Implementation of the vision performance measures will require technical assistance, and integration with other data collection and performance measure initiatives.
- A technical manual, developed with input from experts in epidemiology, performance measurement, statistics, information technology, and vision, should be adopted so that basic measures are standardized, and the estimates are valid, reliable and comparable to other locations.
- Linkage of child-based measures with child demographic information will enable monitoring of possible disparities in health care provision (27,28) e.g. racial/ethnic differences in screening and/or follow-up rates, which are especially important for children.
- The panel supports the use of national parent survey data, e.g. the National Survey of Children’s Health (NSCH), as an interim step to allow states to estimate their performance on the recommended measures, however a web-based data system should supersede the survey approach as quickly as possible.
- Vision care performance measure results should be publicly available. Such data can be used to determine progress toward goals and drive quality improvement efforts.
- Improvements in vision screening and eye examination rates can also be enhanced by concurrent public health and health behavior campaigns aimed at parents and providers.
Marsh-Tootle, WL, Russ SA, Repka MX for the National Expert Panel to the National Center for Children’s Vision and Eye Health. Vision Screening for Children 36 to <72 Months: Proposed Performance Measures. Optom Vis Sci 2015;92(1):17-23.
Wendy L. Marsh-Tootle, OD, MS
University of Alabama at Birmingham
School of Optometry
1716 University Blvd.
Birmingham, AL, 35294
1. Cotter SA, Cyert LA, Miller JM, Quinn GE. Vision screening for children 36 to <72 months: Recommended practices. Optom Vis Sci January 2015 [ePub ahead of print].
2. Hartmann EE, Block SS, Wallace DK. Vision and eye health in children 36 to <72 months: Proposed data system. Optom Vis Sci January 2015 [ePub ahead of print].
3. US Department of Health and Human Services. Healthy People 2020. Objective Retained As Is From Healthy People 2010, V HP2020–1. (http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=42). Last accessed Feb 4, 2013.
4. US Preventive Services Task Force. Vision screening for children 1 to 5 years of age: US Preventive Services Task Force Recommendation statement. Pediatrics, 2011, 127(2): 340-6.
5. American Academy of Pediatrics. Bright Futures guidelines for health supervision of infants, children, and adolescents. Last accessed May 1, 2013.
6. Repka MX, Kraker RT, Holmes JM, Summers AI, Glaser SR, Barnhardt CN, Tien DR; for the Pediatric Eye Disease Investigator Group. Atropine vs Patching for Treatment of Moderate Amblyopia: Follow-up at 15 Years of Age of a Randomized Clinical Trial. JAMA Ophthalmol. 2014 May 1. doi: 10.1001/jamaophthalmol.2014.392. [Epub ahead of print]
7. Scheiman MM, Hertle RW, Beck RW, Edwards AR, Birch E, Cotter SA, Crouch ER Jr, Cruz OA, Davitt BV, Donahue S, Holmes JM, Lyon DW, Repka MX, Sala NA, Silbert DI, Suh DW, Tamkins SM; Pediatric Eye Disease Investigator Group. Randomized trial of treatment of amblyopia in children aged 7 to 17 years. Arch Ophthalmol 2005 Apr; 123(4):437-47.
8. Levinson DR. Most Medicaid Children in Nine States Are Not Receiving All Required Preventive Screening Services, OEI-05-08-00520. Washington, DC: United States Department of Health and Human Services, Office of Inspector General, May 2010. 2, 4. (https://oig.hhs.gov/oei/reports/oei-05-08-00520.pdf). Last accessed May 2, 2013.
9. Kemper AR, Wallace DK, Patel N, Crews JE. Preschool vision testing by health providers in the United States: findings from the 2006-2007 Medical Expenditure Panel Survey. J AAPOS. 2011 Oct; 15(5): 480-3.
10. Hambidge SJ, Emsermann CB, Federico S and Steiner JF. Disparities in pediatric preventive care in the United States, 1993-2002. Arch Pediatr Adolesc Med. 2007;161:30-6.
11. Shaw JS, Wasserman RC, Barry S, Delaney T, Duncan P, Davis W, Berry P. Statewide quality improvement outreach improves preventive services for young children. Pediatrics. 2006; 118(4): e1039-47.
12. Stange KC, Flocke SA, Goodwin MA, Kelly RB, Zyzanski SJ. Direct observation of rates of preventive service delivery in community family practice. Prev Med. 2000; 31(2 Pt 1): 167-76.
13. Marsh-Tootle WL, Wall TC, Tootle JS, Person SD, Kristofco RE. Quantitative pediatric vision screening in primary care settings in Alabama. Optometry and Vision Science. 2008; 85(9): 849-56.
14. Kemper AR, Heifrich A, Talbot J, Patel N, Crews JE, Improving the rate of preschool vision screening: an interrupted time-series analysis. Pediatrics, 2011; 128 (5): e1279-84.
15. Social Security Act of 1965 §501, 42 United States C. §701-710 (2010).
16. US Department of Health and Human Services Health Resources and Services Administration (HRSA) Maternal and Child Health Title V Maternal and Child Health Services Block Grant Program (http://mchb.hrsa.gov/programs/titlevgrants). Last accessed May 2, 2013.
17. Dougherty D, Schiff J, Mangione-Smith R. The Children’s Health Insurance Program Reauthorization Act quality measures initiatives: moving forward to improve measurement, care, and child and adolescent outcomes. Acad Pediatr. 2011, 11(3 Suppl): S1-S10.
18. Goldstein MM, Rosenbaum S. From EPSDT to EHBs: the future of pediatric coverage design under government financed health insurance. Pediatrics, 2013; 131 Suppl 2:S142-8.
19. NQF Releases Updated Child Quality Health Measures. (http://www.qualityforum.org/News_And_Resources/Press_Releases/2011/NQF_Releases_Updated_Child_Quality_Health_Measures.aspx). Last accessed May 2, 2013.
20. Health and Human Services Secretary. Annual Report on the Quality of Care for Children in Medicaid and CHIP. Washington, DC: US Department of Health and Human Services; September 2011. (http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Downloads/2011_StateReporttoCongress.pdf). Last accessed Mar 4, 2014.
21. Weisman NW, Allison JJ, Keife CI, Farmer RM, Weaver MT, Williams OD, Child IG, Pemberton JH, Brown KC, Baker CS. Achievable benchmarks of care: the ABCs of benchmarking. J Eval Clin Pract. 1999 Aug; 5(3):269-81. Review.
22. Marsh-Tootle WL, McGwin G, Tootle JS, and Wall TC. Preschool vision screening in primary care settings: Typical and achievable rates during three annual periods. ARVO abstract 3879/D703:2012.
23. Donahue SP, Arthur BA, Neely DE, Arnold RW, Silbert D, Ruben JB. On behalf of the AAPOS Vision Screening Committee. Guidelines for automated preschool vision screening: A 10-year, evidence-based update. ; JAAPOS 2013;174-8..
24. US Department of Health and Human Services Health Resources and Services Administration (HRSA) 435 Maternal and Child Health Title V Maternal and Child Health Services Block Grant Program (Access 436 verified May 20, 2014)
25. Bittner K and Spence I. Use Case Modeling. Boston: Addison-Wesley Longman Publishing Co., Inc.; ©2002
26. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/CHIPRA-Initial-Core-Set-of-Childrens-Health-Care-Quality-Measures.htm Last accessed Mar 4, 2014
27. Flores G; Committee on Pediatric Research. Technical report–racial and ethnic disparities in the health and health care of children. Pediatrics. 2010; 125(4): e979-1020.
28. Berdahl T, Owens PL, Dougherty D, McCormick MC, Pylypchuk Y, Simpson LA. Annual report on health care for children and youth in the United States: racial/ethnic and socioeconomic disparities in children’s health care quality. Acad Pediatr. 2010; 10(2): 95-118.
29. Marsh-Tootle, WL. Funkhouser E, Frazier MG, Crenshaw K Wall TC. Knowledge, Attitudes and Environment: What Primary Care Providers Say about Preschool Vision Screening. Optom Vis Sci. 2010 Feb;87(2):104-11
30. Frazier M, Garces I, Scarinci I, Marsh-Tootle W.Seeking Eye Care for Children: Perceptions among Hispanic Immigrant Parents. J Immigr Minor Health. 2009, 11:215-21. EPub 2008 Jun 13.
31. Hered RW1, Rothstein M. Preschool vision screening frequency after an office-based training session for primary care staff. Pediatrics. 2003 Jul;112(1 Pt 1):e17-21.
32. Clausen MM1, Armitage MD, Arnold RW. Overcoming barriers to pediatric visual acuity screening through education plus provision of materials. J AAPOS. 2009 Apr;13(2):151-4. doi: 10.1016/j.jaapos.2008.10.018.
33. Marsh-Tootle WL, McGwin G, Kohler CL, Kristofco RE, Datla, RV, Wall, TC. Efficacy of a web based intervention to improve and sustain knowledge about screening for amblyopia in primary care settings. Invest Ophthalmol Vis Sci. 2011 Sep 9;52(10):7160-7.doi: 10.1167/iovs.10-6566.