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Compliance with vision-screening guidelines among a national sample of pediatricians
Terry C Wall1, Wendy Marsh-Tootle, H Hughes Evans
1Division of General Pediatrics, Department of Pediatrics, University of Alabama at Birmingham, USA. twall@peds.uab.edu
Insights
Many pediatricians deviate from American Academy of Pediatrics (AAP) vision screening guidelines, particularly for young children. Compliance with recommended visual acuity testing and referral thresholds is suboptimal, impacting early detection of vision problems.
Area of Science:
- Pediatric ophthalmology
- Public health
- Clinical practice guidelines
Background:
- The American Academy of Pediatrics (AAP) provides guidelines for vision screening from birth through adolescence.
- Recommendations include visual acuity testing and binocular screening starting at age 3 years.
- Specific referral thresholds were established in 1996 for different age groups.
Purpose of the Study:
- To assess current vision screening and referral practices among primary care pediatricians in the US.
- To determine the extent of adherence to the 1996 AAP vision screening guidelines.
Main Methods:
- A national survey was mailed to a random sample of US pediatricians between May and October 1998.
- Follow-up surveys were sent to non-responders to maximize return rate.
- Descriptive statistics and regression analyses were used, focusing on primary care pediatricians and compliance with AAP recommendations.
Main Results:
- A 60% survey response rate was achieved, with 576 primary care pediatricians included in the analysis.
- Common screening methods included visual acuity testing (92%) and red reflex testing (95%).
- Routine visual acuity testing at age 3 was performed by only 37% of pediatricians, with significant variation in referral thresholds for younger children.
Conclusions:
- A substantial number of pediatricians do not adhere to AAP vision screening and referral guidelines, especially for younger children.
- Many pediatricians delay visual acuity testing beyond the recommended age of 3 years.
- Certain screening tests, such as cover tests and stereopsis testing, are underutilized by a significant portion of practitioners.
Objective:
The American Academy of Pediatrics (AAP) recommends vision screening from birth through adolescence, with visual acuity testing and binocular screening to begin at age 3 years. The 1996 AAP guidelines advised referral for visual acuity worse than 20/40 for children aged 3 to 5 years and worse than 20/30 for children aged 6 years and older. Our objective was to describe vision-screening and referral practices in a national sample of primary care pediatricians.
Methods:
We mailed a survey to a random sample of US pediatricians. Initial nonresponders were mailed up to 3 additional surveys. All mailings occurred between May and October 1998. Analyses focused on primary care pediatricians and consisted of descriptive statistics and regression analyses. The main outcome measure was compliance with 1996 AAP recommendations for vision screening.
Results:
Of the 1491 surveys mailed, 888 (60%) were returned, including 576 (65%) from primary care pediatricians. Vision-screening methods included visual acuity testing (92%), cover test (64%), red reflex test (95%), fundoscopic examinations (65%), and stereopsis testing (32%). Respondents routinely performed visual acuity testing at 3 years (37%), 4 years (79%), 5 years (91%), 6 years (80%), 7-12 years (82%), and 13-18 years (80%). Visual acuity thresholds for referring 3- and 4-year-olds were 20/40 (47%, 51%), 20/50 (36%, 32%), or worse than 20/50 (14%, 12%). The majority of pediatricians referred children aged 5 years and older at 20/40, although thresholds worse than 20/40 were reported commonly (18%-33%). Logistic regressions were done to identify factors associated with higher likelihood of performing specific screening tests. Although no factor was consistently associated with use of all screening tests, size of the practice was significant in several regression models.
Conclusions:
Many pediatricians do not follow AAP guidelines for vision screening and referral, especially in younger children. Two thirds of pediatricians do not begin visual acuity testing at age 3 years as recommended, and about one fifth do not test until age 5 years. In addition, one fourth do not perform cover tests or stereopsis testing at any age.