Costs and effectiveness of two models of school-entry visual acuity screening in the UK

Abstract

Cost effectiveness of different visual screening modalities cannot be calculated without long-term outcome data. This paper reports detailed outcomes from a gold-standard UK recommended orthoptist-delivered screening (ODS) at 4-5 years in school, compared to a neighboring schoolnurse delivered screening (SNDS), both feeding into the same treatment pathway. The target condition was reduced visual acuity (VA) of worse than logMAR 0.2 in either eye.Available records from screening databases and hospital records were analyzed, comparing the two services wherever possible.More screening data was available from the ODS. ODS: 5706 screened, 3.5% referred. False positives 6.5%, PPV 91.4%, sensitivity 97.9%, and specificity 99.8% for reduced VA. Cost per child with reduced vision detected £195.22, and per amblyope detected £683.28. The mean treatment cost per child with reduced VA was £331.68 and for amblyopia treatment was £458.65.SNDS: 5630 screened and 3.8% referred (plus some referrals to local optometrists lost to follow up). False positives 34%, PPV 53.2%, sensitivity and specificity estimated as 89.3% and 98.67%. Costs to secondary services of false positives were seven times greater. The cost per child with confirmed reduced vision seen at the hospital was 46% more; and per amblyope detected was 39% more.Outcomes for treatment post referral in both groups were similar and excellent. 86% of genuine referrals improved to within normal limits with glasses alone. Of 221 genuine referrals with final outcome data, all now have better than 0.2logMAR acuity in the better eye and only two (0.9%) have residual amblyopia in one eye worse than 0.4logMAR. About 14-18% of children with reduced VA would have passed AAPOS photoscreening referral criteria.An orthoptist-delivered single VA screen at 4-5 years is highly cost effective with good outcomes. The main contributing factors to success appear to be training and experience in accurate VA testing, the opportunity to rescreen equivocal results, and monitoring, audit, and feedback of outcomes.

A Comprehensive Overview of Vision Screening Programmes across 46 Countries

“…Vision screening using a VA or orthoptic tests, and even photoscreening, only look for markers for significant refractive error which still needs to be confirmed. A subsequent consideration is how much difference does the correction of refractive error in early childhood make to a child’s life if their VA is adequate (but perhaps not perfect) ( Horwood et al, 2021 ). Secondly, referral criteria (i.e., pass/fail criteria) should be clearly defined for the target condition(s), with consideration of age-appropriate normative data.…”

The cost-effectiveness of different visual acuity screening strategies in three European countries: A microsimulation study

“…Since the screeners in England and Wales are orthoptists or trained by orthoptists, we assumed a 10% higher test sensitivity compared to the screening by youth healthcare nurses in the Netherlands. The percentage repeated screens (3.5%) ( Horwood et al, 2021 ) and referral (13%) ( Yau et al, 2020 ) are known for ages 4 to 5 years. The assumptions for diagnostic activity and treatment were the same as for the Netherlands.…”

Worsening vision at age 4–5 in England post‐COVID: Evidence from a large database of vision screening data

“…More recently, a study noted that the UK is an outlier in only screening children's vision once, at 4-5 years of age, but found this to be cost-effective. 39 A systematic review from this time argued that the UK screening programme was preferable for detecting amblyopia when compared with autorefraction or photorefraction at a younger age. 40 A systematic review of clinical practice guidelines to support the World Health Organization's (WHO) package of eye care interventions found four guidelines on child vision screening; three in the USA and one in the UK.…”

“…More recently, a study noted that the UK is an outlier in only screening children's vision once, at 4–5 years of age, but found this to be cost‐effective 39 . A systematic review from this time argued that the UK screening programme was preferable for detecting amblyopia when compared with autorefraction or photorefraction at a younger age 40 …”