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Study finds vision exams in children are cost effective
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While recently released study results support the effectiveness of preschool vision exams in significantly reducing vision loss caused by amblyopia, the American Academy of Ophthalmology (AAO) has urged health care professionals and public policy leaders to view the study with caution.
The study author stands by his results, but both he and the AAO call for more research on amblyopia and other visual disorders.
“Our report concludes that comprehensive exams almost certainly detect more cases of amblyopia than do vision screenings,” said economist Alan White, PhD, of Abt Associates in Cambridge, Mass., in an interview with Primary Care Optometry News. “Under a wide range of scenarios, comprehensive eye exams appear to be highly cost-effective relative to vision screening programs, given our existing standards of cost-effectiveness.”
Details of the study
The study, titled “Eye exams for children: their impact and cost-effectiveness,” which was prepared by Abt Associates for the Vision Council of America (VCA), was aimed at establishing whether the benefits of comprehensive vision exams counteracted their cost.
According to the study’s executive summary, cost-effectiveness was measured by a method called cost-utility analysis, which assesses the cost-effectiveness of interventions by comparing the benefits of a medical intervention (eye exams) to the costs of providing that intervention (eye exams and the resultant treatment expenses).
The cost-utility analysis was measured in quality-adjusted life years (QALYs). This unit conveys the additional costs required to generate a year of perfect health.
The economic model that was developed to compare these interventions dealt with amblyopia, which was the disorder for which there was the most medical data available in the literature.
The model took into account the following: the relative performance of comprehensive exams and vision screenings; the probability that treatment is successful; the costs of exams, screenings and treatment; the utility values associated with healthy vision, amblyopia and amblyopia-caused bilateral impairment; and patterns of treatment under usual eye care.
The study found that treating amblyopia is quite cost-effective, costing roughly $1,800 per QALY. Therefore, spending additional dollars on interventions that detect and lead to the treatment of large numbers of children with amblyopia would, in turn, be cost-effective.
Criticisms by ophthalmology
The study incurred criticism from various ophthalmologists, culminating in a press release disseminated by the AAO.
According to Dallas-based ophthalmologist George R. Beauchamp, MD, in the press release, the study makes “unproven assumptions” about the cost-effectiveness of eye exams.
“Providing eye exams alone does not treat or cure eye disease as the study’s executive summary states,” Dr. Beauchamp said. “The study also does not prove exams would be highly cost-effective and would produce a greater return on investment than many common health interventions, as it claims. If anything, I think this study provides an agenda calling for further research on the subject.”
VCA spokesman Joseph LaMountain said he is not surprised by ophthalmology’s response. “One well-known pediatric ophthalmologist wrote to me, minutes after receiving the 65-page report, and stated that ‘we are actively working against your organization and the propaganda that you are disseminating,’” Mr. LaMountain said. “No matter the facts, some will oppose exams for kids. It’s unfortunate.”
Dr. White told Primary Care Optometry News that he carefully examined the evidence at hand while conducting the study. “Given the cost-effectiveness of treatment for amblyopia, our report suggests that the higher costs associated with comprehensive exams are more than offset by the gains that result from additional children being successfully treated due to comprehensive exams,” he said. “From an economic perspective, it is this comparison of marginal benefits and costs, not a comparison of average costs per case diagnosed and treated, that is relevant for assessing the cost-effectiveness of comprehensive eye exams.”
Sean P. Donahue, MD, PhD, an ophthalmologist whose recent study concluded that spectacles are often unnecessarily prescribed for American children, leveled further criticism against the study.
In the AAO press release, Dr. Donahue maintained that the paper “mixes well-conducted clinical trials and weak, poorly conducted and non-controlled studies.” He claimed that the study doesn’t provide new information and is silent on the costs of an eye exam mandate.
While Dr. White agreed that some limitations on the study’s parameters existed, he added that he conducted an extensive literature review and also consulted with the panel of experts who had advised the researchers.
“In the report, we identified several parameters for which there is limited guidance in the literature,” he said. “These gaps do affect our ability to accurately measure key model parameters. This is a limitation that we acknowledge in the study. Indeed, we hope that the study may lead to additional research on the detection and treatment of amblyopia and other visual disorders.”
Mr. LaMountain said, “Dr. Donahue didn’t give one example of a poorly done study. In addition, his study focused only on the cost of eye exams. It ignored completely the costs associated with not doing exams. For example, Dr. Donahue admits that 50% of kids with vision problems are missed by his screeners. That’s far more costly than the 1% that may be overprescribed eye wear. His study was included in the Abt study and it made no difference in the final outcome.”
Also in the AAO press release, Dr. Beauchamp stressed that the results of the Abt study conflict with recent recommendations from the U.S. Preventive Services Task Force. Mr. LaMountain questions the interests of that group.
“The U.S. Preventive Services Task Force is made up of ophthalmologists and pediatricians, and they came out in support of vision screening,” he said. “Is that a surprise?”
For Your Information:
- Alan White, PhD, is an economist with Abt Associates. He can be reached at 55 Wheeler St., Cambridge, MA 02138-1168; (617) 492-7100; fax: (617) 492-5219.
- George R. Beauchamp, MD, is a pediatric ophthalmologist based in Dallas. He can be reached at 1643 Lancaster Dr., Ste. 201, Grapevine, TX 76051-3593; (214) 369-6434; fax: (214) 407-0616.
- Joseph LaMountain is a spokesperson for Vision Council of America. He can be reached at 1700 Diagonal Rd., Ste. 500, Alexandria, VA 22314; (703) 548-4560; fax: (703) 548-4580; e-mail: jlamountain@visionsite.org.
- Sean P. Donahue, MD, PhD, is associate professor of ophthalmology at Vanderbilt University. He can be reached at 8000 Medical Center East, Nashville, TN 37232-5100; (615) 343-7146; fax: (615) 343-4953.