Photoscreener access improves vision screening rates in toddlers, but disparities remain
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Key takeaways:
- The vision screening rate increased from 5.7% in 2015 to 72.1% in 2022 across all racial and ethnic groups.
- Black, Asian or Hispanic patients were less likely to be screened for amblyopia than white patients.
Increased availability of photoscreeners led to higher rates of overall vision screening for children aged 3 years in one large health care system, according to a study published in JAMA Ophthalmology.
However, additional targeted efforts beyond mass photoscreening are needed to address existing care disparities in children with amblyopia, the researchers wrote.
Amblyopia can result in permanent vision loss without proper treatment before the child is aged 7 years. The U.S. Preventive Services Task Force recommended in 2017 that all children aged 3 to 5 years receive at least one vision screening to check for amblyopia. Still, the current screening rate among children aged 3 years is approximately 40%, which leaves “substantial room for improvement,” Cheryl D. Stults, PhD, a senior scientist and research sociologist at Palo Alto Medical Foundation Research Institute and the Center for Health Systems Research, and colleagues wrote.
Methods, results
In this retrospective cohort study, the researchers aimed to understand the factors and trends associated with amblyopia vision screening, pediatric ophthalmology referral, and diagnosis before and after the USPSTF recommendation and the subsequent photoscreening expansion across the Palo Alto Medical Foundation (PAMF), a large health care system in Northern California.
Using electronic health record data, researchers identified 23,246 patients (48.2% girls; 32.9% Asian; 25% white; 10.5% Hispanic; 0.6% Black; 11.2% other; 19.9% unknown) aged 2.75 years to 3.25 years who attended a well-child care visit at PAMF between 2015 and 2017, or the preimplementation period, as well as 34,281 children (48.2% girls; 33.6% Asian; 22.8% white; 10.6% Hispanic; 0.6% Black; 12.2% other; 20.3% unknown) of the same age who had a well-child care visit after the expansion, from 2018 to 2022.
Results showed the vision screening rate increased from 5.7% in 2015 to 72.1% in 2022, increasing consistently across all racial and ethnic groups.
Further, the referral rate increased from 17% in 2015 to 23.6% in 2018. Notably, the referral rate then decreased to 15.7% in 2022.
The diagnosis rate of amblyopia varied, ranging between 2.7% and 3.1% in the preimplementation period, peaking in 2018 at 3.4% and decreasing to 1.4% in 2022.
The researchers also examined how ethnicity and race affected amblyopia screening, referral and diagnosis rates, focusing on the period after expansion.
Overall, screening rates appeared higher among Asian (70.9%) and white (70.8%) patients compared with those who were Black (65.9%) or Hispanic (67.7%; P .001). Multivariate regression analyses showed that patients who were Asian (adjusted OR = 0.8), Black (aOR = 0.71) or Hispanic (aOR = 0.88) were less likely to be screened than white patients.
However, patients who were Asian or Hispanic were more likely to be referred (Asian: aOR = 1.49; Hispanic: aOR = 1.32) and diagnosed (Asian: aOR = 1.29; Hispanic: aOR = 1.67) compared with white patients, and Black patients had comparable likelihoods of referral and diagnosis as white patients, according to the researchers.
Racial, ethnic disparities remain
The researchers noted the study has limitations, including that it may have limited generalizability due to the relatively high-income levels of the patients included in the analysis. They also noted that the age range they used in this study may have missed some children who attended delayed well-child visits during the pandemic.
Overall, although photoscreening rates increased significantly after the 2017 USPSTF recommendation, disparities in amblyopia screening, referral and diagnosis were still evident in this population, according to the researchers.
“It may be that some screening differences are due to factors regarding all photoscreening devices, which could potentially harbor bias,” Stults and colleagues wrote, adding that evidence has suggested the software algorithms used in these devices have mostly been derived from predominantly white populations.
It was “surprising” that referral and diagnosis rates decreased while screening rates increased, the researchers wrote.
“One potential explanation is that if there are access problems due to a lack of [pediatric] ophthalmologists, clinicians might ‘not want multiple false or borderline referrals’ when services are ‘stretched and scarce,’ possibly leading them to not refer as often,” they wrote.
Ultimately, additional efforts must be made beyond mass photoscreening to address these disparities, the researchers wrote. For instance, the American Academy of Ophthalmology recommends increasing diversity among ophthalmologists and referring primary care physicians or using these findings to create a predictive model for amblyopia risk factor diagnosis in young children.
Perspective
Back to Top
This study investigates the impact of widespread implementation of photoscreening devices for detecting amblyopia in a large health care system. The data were reviewed over a span of 8 years, and the researchers found a significant increase in vision screening rates — from 5.7% in 2015 to 72.1% in 2022, following the implementation of photoscreeners in 2018.
However, referral and diagnosis rates decreased during the same period. The study found persistent disparities in screening rates among different racial and socioeconomic groups, with Black and Hispanic children receiving less screening compared with Asian and white children.
The results emphasize the importance of integrating user-friendly vision screening devices to enhance early detection of amblyopia. The increase in screening rates following the implementation of photoscreening devices suggests that these tools can effectively address time constraints in pediatric care settings, potentially improving patient outcomes.
The study has limitations, including its retrospective design and reliance on electronic health records, which may introduce biases. Additionally, the study’s focus on a specific health care system may limit the generalizability of the findings.
Future research should explore the reasons behind persistent disparities and examine the effectiveness of photoscreening devices in diverse populations to ensure equitable access to vision care.
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