What To Know About “Low-Value” Care And The High Value of Eye Examination

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Low-value care is wasteful and challenging to health.  Services with little or no clinical benefit, or when the risk of harm outweighs the benefit of the service, are known as “low-value”.  An ongoing focus in health care involves attempts at reducing costs due to the complexities of “low-value care”.  In 2013, the IOM estimated the US had $765 billion in wasted health care expenditures on low-value care, otherwise known as a given health care service, test, or treatment that provides a low level of clinical benefit, is associated with medical errors, and/or has pricing failures associated with care.  Low-value care can harm patients directly (risk from unnecessary procedure) or indirectly (leading to additional unnecessary or non-beneficial services, or directing away from high-value care).  A recent Health Affairs study reported more than $500 million was spent in 2014 on 44 low-value health services in one U.S. state.

While initiatives like Choosing Wisely aim to reduce low-value care, there are acknowledged limitations on where consensus exists among professionals and stakeholders.  Shared decision making (SDM)  – the process in which clinicians and patients work together to make treatment decisions and care plans based on clinical evidence that balances risks and expected outcomes with patient preferences – is another strategy that continues to be hailed as a well-regarded approach:

Administrators deferred to clinicians, and clinicians generally agreed that shared decision making, done well, which included cost conversations, can address many of these grey areas and reduce low-value care sufficiently and appropriately.

I just returned from speaking at Kansas Optometric Association’s Fall Eyecare Conference where I focused one of my presentations on shared decision making and SDM benefits.  I included highlighted ‘clinician lists’ of low-value care developed by our colleagues at American Academy of Family Physicians, American College of Physicians, American Academy of Pediatrics, and American Academy of Ophthalmology:

A national task force on low-value care recently identified five services that “should not be purchased at any price“. The list includes:  pre-surgical diagnostic testing & imaging for low risk patients; vitamin D screening; PSA screening in men 75 yrs +; imaging for low-back pain; and use of ‘expensive branded drugs’ when identical ingredient generics are available.  These items outline a “call to action” for U.S. health care purchasers, where more than $25 billion annually is spent on these top five services alone.

Five more recommendations in eye care.  In addition to the aforementioned important purchaser and primary health care low-value items, here are a five low-value “don’ts” from the AAO list above of specific interest to eye care and the eye doctor’s integrated care team:

  • Don’t conduct preoperative tests for eye surgery without indication
  • Don’t order routine imaging without signs of eye disease
  • Don’t prescribe antibiotics for adenoviral conjunctivitis (‘pink eye’)
  • Don’t prescribe antibiotics pre- or post- intravitreal injection
  • Don’t prescribe punctal plugs for ‘mild dry eye’ as first line treatment

All of these item ‘hit lists’ provide low-value care examples relative to the concept of “de-implementation”, or the approach of stopping practices that are not evidence-based and known to be ineffective.  (Note:  The field of dissemination and implementation science, or D&I, continues to develop over the past decade with more evolving research that will further assist us in recognizing unproven, ineffective and harmful practices. And, while there are many other recommendations out there [i.e., ‘patient lists’], these current ‘clinician lists’ are linked individually to the specialty societies who created them with their own chosen methodologies.)

There is one more, and it’s an important one.  Based on all current evidence, there exists another ongoing low-value approach relative to the nation’s eye and vision care that I argue deserves attention and de-implementation:  the case for ‘vision screening‘.  Here’s why:

  1. From the national perspective, in 2017 there is a lack of U.S. Preventive Services Task Force (USPSTF) recommendations for population-based ‘vision screening’.
    • The USPSTF concluded there is insufficient evidence for ‘vision screening’ in children 3 years & younger, and insufficient in older adults.
    • The only USPSTF recommendation made for what USPSTF identifies as beneficial ‘vision-related screening’ narrowly targets children 3-5 years of age for the sole visual condition of amblyopia.  While it remains important to diagnose and treat amblyopia as early as possible, this age group represents a small percentage of the total U.S. population.
      • Important to note is that while the USPSTF concluded with moderate certainty amblyopia ‘screening’ in children 3-5 years old has moderate net-benefit compared with no screening, they did not compare ‘screening’ to the benefits of eye examination.
  2. Limitations exist relative to the case for eye/vision-related ‘screening’:
    • There is an overall lack of strength of screening evidence in the areas of standardization, targeting, reliability, and specificity.  These factors support evidence-based screening recommendations for effective population-based implementation, and are absent en masse for a global ‘vision screening’ approach that properly targets undiagnosed populations.
      • It must accurately represent targeted health outcomes of group of individuals, and properly assess the distribution of outcomes within targeted group.
      • Without clear metrics, opportunity is limited for results to objectively identify a targeted health problem/condition for intervention (and thus missing what is required for a recommended health screening process).
    • There remains no universally accepted definition of ‘vision screening amongst clinicians, researchers, health care professionals, states, school districts, service organizations, and even among those that aim to ‘screen’:
      • This historical and persistent lack of clarity in “defining what you mean when you say eye/vision screen” has resulted in subsequent gaps and lack of evidence to support its value or benefit vs. risks.
      • Important population health questions on ‘eye/vision screening’ remain:  What is it? What is the health objective? What does it refer to/measure/target? How is it defined?  How does clinical and population health research view/define ‘vision’ as a health variable/factor? How does ‘screening’ compare to what we know as comprehensive eye examination?  What is being compared to what?
    • Avoid conflating eye examination with ill-defined ‘vision screening’.  Most doctors-in-training are taught processes of direct patient care (for eye doctors, how to examine the patient’s eyes and visual system) in settings commonly referred to as ‘screenings’.  This educational approach allows the student, under supervision of the attending doctor, to practice clinical processes of care in their field as they learn. Unfortunately, persistent use of terminology that frames eye examination as ‘screening’ misrepresents the care sequences being provided, and diminishes how the value of eye care is ultimately perceived.  It’s critical for eye care professionals to clarify for the public and the greater health care community any misperceptions of eye examination framed as ‘vision screening’ to minimize confusion, and avoid using the term ‘screening’ for doctor-based eye examination & care.
  3. When eye doctor-administered ‘vision screening techniques’ were evaluated for “four important eye conditions” as part of the Vision in Preschoolers (VIP) study, the findings revealed sensitivity of 11 screening techniques used for detecting clinically significant vision problems in children 3-5 years of age varied from 16 to 64%, with specificities ranging from 62 to 98%; in addition, when tests were compared again with a specificity of 94%, the sensitivity dropped further:
    • VIP reported that “screening tests”- even when administered by licensed and trained eye doctors – “vary widely in performance…with 90% specificity, the best tests detected only two thirds of children having > or =1 targeted conditions.”
    • This highlights the critical population health issues of screening specificity and targeting – for example, are certain undiagnosed eye & systemic conditions more important than others?  Who determines this heirarchy? For which populations? What risks are ‘acceptable’?  And what other opportunities for improved health outcomes are people currently willing to sacrifice when ‘screening for vision’?
  4. Evidence supports that eye care is readily available and accessible in the U.S. Included in the 2016 report from the National Academies of Science, Engineering, and Medicine (NASEM) is key information supporting the population health benefits of eye examination for people of all ages:
    • The NASEM report recognizes that eye examination is “the gold standard in clinical vision care to most accurately identify and diagnose eye and vision problems.”
    • The NASEM report also highlights the existing lack of evidence for screening, and a need for research and development efforts that may result in effective future screening protocols.
    • Unlike in other countries where geographical and health care provider limitations truly exist, the U.S. eye doctor workforce – and especially doctors of optometry who provide the bulk of primary eye/vision care – remains available but under-utilized across the country.
  5.  Emerging evidence continues to support eye examination as high-value care, defined by the ACP as health care that balances clinical benefit with costs and harms with the goal of improving patient outcomes.  There is also a wealth of evidence in the literature as well as in the AOA Clinical Practice Guidelines that supports the following population health facts, whose underlying problems are effectively diagnosed and marked for treatment through comprehensive eye examination:
    • An estimated one in five preschool children has vision problems, and undiagnosed eye and vision disorders lead to additional problems in children’s development, school performance, and social interactions.
    • Diabetes, neurological disease, and many other systemic and chronic conditions are more often first detected by doctors of optometry.
    • Vision impairment is associated with more chronic health conditions & doctor visits, and more medications, deaths, falls/injuries, and depression in order adults.
    • The impacts of untreated vision impairment complicate management of health, amplify the negative effects of other conditions, and reduce independence.
  6. There is no existing ‘vision screen’ that matches the demonstrated value of an eye examination in the U.S.  Best practices for eye examination by an eye doctor includes a series of clinical procedures, examinations, tests, and assessments based on patient presentation and individual patient needs that utilizes the clinical decision making and diagnostic skills of the eye doctor and includes shared decision making with the patient, to best determine individualized patient treatment, prognosis, and management, and includes eye/vision as well as systemic health considerations.
  7. The following sample of organizations are aligned in stated support of the high value of eye examination by eye doctors:
    • U.S. Dept. of Health and Human Services:  eye examination (and prescribed treatment including glasses) is an essential health benefit (EHB) for children across the nation.
    • National Eye Institute:  eye examination is a foundation for good health.
    • Centers for Disease Control & Prevention: eye examinations are essential for timely diagnosis and treatment of eye disease and to maintain good vision.
    • American Academy of Ophthalmology: comprehensive eye examination recommended for children with family history of disease, disorders associated with eye problems, and whose caretakers are suspicious of vision problems.
    • National Association of School Nurses:  recommends eye examinations for children because of a medical or developmental risk for a vision problem, and lists other reasons for a child going directly to an eye doctor.
  8. Lastly, here’s a helpful visual example that tells the story of the complexities facing primary care providers (PCP) and primary eye care providers (PCEP), shared parallels regarding ‘screening’ challenges and potential health outcomes, and related primary care and population health considerations…note the extensive list of multiple systems for the PCP to review, including the list of multiple eye-related processes (in smaller red circle) that physicians recognize as fundamental to the primary care ‘screening physical examination’:

phys screen

Just as there remains no single screen that can rule in or out a healthy person, there’s no single screen that can rule in or out a healthy visual system.  Until the evidence base for ‘vision screening’ is shown to meet the high value of a comprehensive eye examination in addressing the myriad of population health objectives, ‘vision screening’ will remain a low-value approach to improving health.

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