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Original Investigation |

Cost-effectiveness of School-Based Eye Examinations in Preschoolers Referred for Follow-up From Visual Screening

Eugene A. Lowry, MD1; Alejandra G. de Alba Campomanes, MD, MPH1
[+] Author Affiliations
1Department of Ophthalmology, University of California, San Francisco
JAMA Ophthalmol. 2016;134(6):658-664. doi:10.1001/jamaophthalmol.2016.0619.
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Published online

Importance  Many preschool visual screening programs incorporate school-based comprehensive examinations, but the follow-up rates and cost-effectiveness of this approach are not well studied.

Objective  To determine the follow-up rates and cost-effectiveness of referral to community-based eye care professionals vs to a mobile eye examination unit (mobile follow-up) among preschool children with failed visual screening results.

Design, Setting, and Participants  This retrospective cohort cost-effectiveness study with decision analytic modeling and probabilistic sensitivity analysis included 3429 children in 37 public preschools in San Francisco, California, who underwent visual chart screening during the 2009-2012 academic years and 1524 children in the same schools who underwent autorefraction screening during the 2012-2013 academic year. One hundred seventy-five children who underwent visual chart screening were referred for community-based comprehensive eye examinations; 204 who underwent autorefractive screening were referred for preschool-based mobile follow-up. Data were collected from October 1, 2009, to May 29, 2013, and analyzed from June 30, 2013, to January 16, 2016.

Main Outcomes and Measures  Cost-effectiveness of community-based vs mobile follow-up standardized for referral method.

Results  Of the 175 children referred for community-based follow-up (91 boys [52.0%]; 84 girls [48.0%]; mean [SD] age, 3.8 [0.7] years), 104 attended (59.4%). Of 204 children referred for mobile follow-up (89 boys [43.6%]; 115 girls [56.4%]; mean [SD] age, 4.1 [0.6] years), 112 attended (54.9%). Costs per case detected were $664 and $776, respectively. In univariate analysis, mobile follow-up was equally cost-effective if it increased the follow-up rate to 73% or if its costs were reduced by at least 27%. In multivariate analysis with Monte Carlo simulation, community-based follow-up was more cost-effective than mobile follow-up in 88% of simulated cases and had typical savings of $112 (95% CI, −$77 to $368) per case detected.

Conclusions and Relevance  Community-based eye care professionals may provide more cost-effective care than a mobile eye examination unit visiting the preschool among children with failed preschool-based visual screening.

Figures in this Article


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Figure 1.
Decision Model for Cost-effectiveness Analysis

We compared data from the 2009-2012 academic years using visual chart screening and community-based follow-up (A) with data from the 2012-2013 academic year using autorefraction screening and preschool-based follow-up with mobile examinations (mobile follow-up [B]) and modeled autorefraction screening and community-based follow-up (C).

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Figure 2.
Threshold Analysis of Preschool-Based Follow-up

Cost per case with preschool-based follow-up using a mobile examination unit (mobile follow-up) across a range of follow-up rates is compared with the baseline cost per case of community-based follow-up at a rate of 59% shown. Mobile follow-up became equally cost-effective at a 73% follow-up rate.

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Figure 3.
Cost per Case of Amblyopia Detected

Central values represent baseline cost per case detected. Each variable is ranged to the lower and upper limit of a sensitivity range (described in the Methods section; values are given in the Table). Cost-effectiveness preference may change based on follow-up costs, but is not sensitive to expected variations in follow-up rate.

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