Share this article on:

Vision and Eye Health in Children 36 to <72 Months: Proposed Data Definitions

Marsh-Tootle, Wendy L.*; Russ, Shirley A.; Repka, Michael X.

doi: 10.1097/OPX.0000000000000444
Original Articles
Press Release

Purpose To recommend a standardized approach for measuring progress toward national goals to improve preschool children’s eye health.

Methods A multidisciplinary panel of experts reviewed existing measures and national vision-related goals during a series of face-to-face meetings and conference calls. The panel used a consensus process, informed by existing data related to delivery of eye and non-eye services to preschool children.

Results Currently, providers of vision screening and eye examinations lack a system to provide national- or state-level estimates of the proportion of children who receive either a vision screening or an eye examination. The panel developed numerator and denominator definitions to measure rates of children “who completed a vision screening in a medical or community setting using a recommended method, or received an eye examination by an optometrist or ophthalmologist at least once between the ages of 36 to <72 months.” A separate measure for children with neurodevelopmental disorders and measures for eye examination and follow-up were also developed. The panel recommended that these measures be implemented at national, state, and local levels.

Conclusions Standardized performance measures that include all eye services received by a child are needed at state and national levels to measure progress toward improving preschool children’s eye health.

Supplemental digital content is available in the text.

*OD, MS

MD, MPH

MD, MBA

University of Alabama at Birmingham, School of Optometry, Birmingham, Alabama (WM-T); University of California, Los Angeles - Center for Healthier Children, Families and Communities, Los Angeles, California (SAR); and Zanvyl Krieger Children’s Eye Center and Adult Strabismus Service, Wilmer Eye Institute and the Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland (MXR).

Wendy L. Marsh-Tootle University of Alabama at Birmingham School of Optometry 1716 University Blvd Birmingham, AL 35294 e-mail: wmarsht@uab.edu

aA full list of the members of the National Expert Panel to the National Center for Children’s Vision and Eye Health is provided in the Acknowledgments.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.optvissci.com).

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

The Maternal and Child Health Bureau (MCHB) established the National Center for Children’s Vision and Eye Health (NCCVEH) to recommend systems to increase rates of vision screening and necessary eye examinations in children aged 36 to younger than 72 months. The NCCVEH facilitated an independent expert panel of professionals in eye care, pediatrics, and related fields to establish guidelines for vision screening (see Cotter et al. in this issueChildren’s Vision and Eye Health. Vision screening for children 36 to <72 months: recommended practices. Optom Vis Sci 2014; 92: 6–16.','400');" onMouseOut="javascript:ImageWrapperControl_ImageMouseOut();">1), recommendations for data collection (see Hartmann et al. in this issueChildren’s Vision and Eye Health. Vision and eye health in children 36 to <72 months: proposed data system. Optom Vis Sci 2014; 92: 24–30.','400');" onMouseOut="javascript:ImageWrapperControl_ImageMouseOut();">2), and performance measures to track progress toward national goals related to children’s visual health. The rationale and process used to develop the recommendations are fully described in the Appendix (available at http://links.lww.com/OPX/A188).

Increasing the proportion of preschool-aged children who receive either a valid vision screening (in a community setting or in the medical home) or an eye examination by an ophthalmologist or optometrist is a national public health priority. Healthy People 2020 specifically included the goal of increasing vision screening rates in children aged 5 years and younger, with a target of 44%.3 In addition, the United States Preventive Services Task Force endorsed preschool vision screening for children aged 3 to 5 years,4 and the American Academy of Pediatrics’ Bright Futures Guidelines5 recommended vision screening for preschool children to detect amblyopia or risk factors for the development of amblyopia. Early diagnosis of amblyopia is particularly important as there is evidence that treatment before age 5 years leads to better long-term outcomes, whereas delaying treatment until age 7 or older reduces treatment outcomes.6,7

Existing data provide widely varying estimates of US preschool vision screening rates ranging from 2 to 64% (Table 1) depending on the definition of screening, the population studied, ages of children included, and the sources of data.3,8–13 Some studies report only numbers of children screened and not the size of the population from which those children are drawn; hence, the proportion of children screened is unknown. The absence of a standardized approach to the determination of vision screening rates means that the United States lacks reliable data to track national progress toward vision screening goals or to compare rates of vision screening across states and regions.

TABLE 1

TABLE 1

For our vision care system to improve, it is necessary to measure each step in the continuum of care, including screening, eye examinations, diagnosis of significant conditions, and provision of necessary treatment and follow-up care. One multiclinic study has shown that only 48% of children aged 3 to 5 years who failed vision screening in the medical home were documented to be referred for diagnostic evaluation.14 To accomplish goals of improved vision care, it is important to monitor the quality of preventive child health services, to evaluate the performance of the system of vision screening for young children, and to respond to requirements for program accountability (required by the Title V Maternal and Child Health Services Block Grant Program [MCHB],15,16 the Children’s Health Insurance Program Reauthorization Act [CHIPRA],17 and/or the Patient Protection and Affordable Care Act18).

Optometrists and ophthalmologists have long been interested in measuring vision screening performance. Both disciplines have a close working knowledge of the process of screening and follow-up, extensive experience with the eye health care delivery system, and an understanding of measures that would best reflect vision care quality. Development and implementation of performance measures for vision screening of preschool-aged children should include ophthalmologists and optometrists in leadership positions.

Back to Top | Article Outline

RECOMMENDATION DEVELOPMENT

The NCCVEH expert panel undertook a consensus process incorporating review of the published literature (through February 2014) including research, reviews, and policy statements, as well as consultation with programs that are developing vision screening infrastructure and with national and state agencies actively involved in performance measure development. The panel considered whether any existing measures could be adopted more widely. The National Quality Forum has endorsed a performance measure (#1412; “Preschool Vision Screening in the Medical Home”) to document the proportion of “children under 5 years old who receive visual acuity or photo-screening” among “all children under 5 years old attending preventive care visits.”19 Although this measure is useful to evaluate primary care performance, it is not useful as a population-based measure. Excluded from this measure are children who miss well-child visits,20 receive a vision screening in community-based settings such as Head Start or preschool, or have been examined directly by an optometrist or ophthalmologist.

The expert panel also reviewed the methodology used in existing regional vision screening performance estimates, to determine whether any could be “scaled up” to provide a population-based estimate. However, each of the methods had flaws, including reliance on family’s memory of a screening event, study of a nonrepresentative population sample, or lack of a valid screening assessment.

The expert panel determined that a new approach was needed, one that included all sources of vision screening and eye care using a unique child identifier. The former requirement allowed inclusion of all sites of care, so that rates are not underestimated. The latter requirement allows elimination of duplicate services so that screening rates are not overestimated.

The expert panel recognized that the data collection infrastructure supporting vision screening and follow-up in the United States is underdeveloped. Rather than consider only those measures that could be estimated from the existing highly fragmented system, the panel chose instead to make recommendations for more comprehensive measures, recognizing that accepted, well-designed performance measures can help to drive development of appropriate national, state, and local data systems and inform policy direction.

Back to Top | Article Outline

Recommendations from the National Expert Panel to the NCCVEH for Preschool-Aged Child Vision Care Performance Measures

The expert panel adopted general principles of measure development including the need to define both the numerator and the denominator for each measure (simple tallies of episodes of care would be insufficient), the need to define the age range of children included in the measure, and the recommendation to report performance by birth cohort, that is, the child’s birth year. The panel also determined that more than one measure would be needed to monitor the full continuum of vision care. The panel recognizes that the following recommendations are the first step in a methodical process that is necessary to ensure that valid, standardized measures are obtained across settings.

Back to Top | Article Outline

Recommendation 1: Performance Measures for Vision Care

The expert panel recommends a child-based performance measure for vision care for children aged 36 to younger than 72 months, defined as:

  • Numerator: Number of children from the denominator who completed a valid vision screening in a medical or community setting or received an eye examination by an optometrist or ophthalmologist at least once between the ages of 36 and younger than 72 months. (For all performance measures, “valid vision screening” is defined as vision screening attempted using a recommended quantitative method [see Cotter et al. in this issueChildren’s Vision and Eye Health. Vision screening for children 36 to <72 months: recommended practices. Optom Vis Sci 2014; 92: 6–16.','400');" onMouseOut="javascript:ImageWrapperControl_ImageMouseOut();">1] with an outcome of “pass” OR another outcome [fail or untestable] AND evidence that the child was referred or rescreened as specified in Table 2. Thus, a nonpassing result without evidence of a referral or rescreen is considered an invalid screening and is not counted in the numerator. Acceptable evidence of referral would be the date of the appointment, and name of consulting ophthalmologist or optometrist reported by the screening agency.)
  • Denominator: All children who turn 72 months of age by December 31st of the reporting year in the entire population, or a representative sample.
TABLE 2

TABLE 2

As the minimum standard of care stipulates at least one vision screening (or eye examination) between the ages of 36 and younger than 72 months, the panel recommends that this measure be reported retrospectively by birth cohort when the youngest child in each birth year has reached the age of 72 months (i.e., on December 31st of that year; those children who turn 72 months of age between January 1 and December 31 of the reporting year). For example, children born in 2010 would have this measure determined at the end of 2016 including screenings from 2013, 2014, 2015, and 2016.

Entities establishing this performance measure are encouraged to identify their baseline performance and to set annual targets increasing toward their specific goal. Provider-based data collected can be used to determine an “achievable benchmark of care” (ABC).21 For example, using the ABC method, rates of quantitative vision screening by “best” pediatric primary care providers in Alabama were 68.3% of 3-year-olds, 79.4% of 4-year-olds, and 93.2% of 5-year-olds.22 Entities that require a population-based goal (such as the Healthy People 2020 goal of 44% of children screened by 2020) will need to be equipped to report all community-based and office-based screening. Lower population-based targets may be appropriate owing to children not attending office- or community-based screening, or because reporting is not accurate.

Age-specific reporting, for purposes of identifying settings that successfully test younger children, could be a secondary goal, because identified gaps in care could be corrected before the ideal age to correct vision problems has passed. Reporting age-specific screening rates would require adjustments to the numerator and denominator to reflect the cohort being addressed. For example, the denominator could be restricted to “All children who turn 48 months of age by December 31st of the reporting year in the state, or a representative sample” and the numerator could specify “Number of children from the denominator who completed a valid vision screening in a medical or community setting, or received an eye examination by an ophthalmologist or optometrist at least once between the ages of 36 to <48 months.”

Back to Top | Article Outline

Recommendation 2: Performance Measures for Children with Diagnosed Neurodevelopmental Disorders

The panel recommends a separate performance measure for children diagnosed as having neurodevelopmental disorders (e.g., hearing impairment, motor abnormalities such as cerebral palsy, Down syndrome, cognitive impairment, autism spectrum disorders, and speech/language delay) who should be referred directly (Table 2). This measure addresses eye examination rates for these children. Implementation will require integration of vision and developmental diagnostic data.

  • Numerator: Number of children from the denominator who completed an eye examination by an ophthalmologist or optometrist within 6 months of diagnosis of the neurodevelopmental disorder.
  • Denominator: All children who turn 72 months of age by December 31st of the reporting year in the state, or a representative sample, diagnosed as having a neurodevelopmental disorder.

The expert panel further recommends the setting of baselines and target goals for each of these measures, with annual monitoring and progress reports.

Back to Top | Article Outline

Recommendation 3: Performance Measures for Follow-Up and Treatment

Children who do not pass quantitative screening or rescreening in primary care or community settings should obtain follow-up care and any required treatment. The panel recommends a performance measure addressing the proportion of children receiving follow-up eye examinations after a screening referral (Table 2), defined as:

  • Numerator: Number of children from the denominator who completed an eye examination by an optometrist or ophthalmologist within 6 months of a referral from quantitative vision screening.
  • Denominator: All children who turn 72 months of age by December 31st of the reporting year in the state, a region, or a representative sample, who were referred after quantitative screening (Table 2) in a medical or community setting between the ages of 36 and younger than 72 months.

In case of multiple services, data should reference the earliest examination by an optometrist or ophthalmologist, which was preceded by a referral from a screening (this performance measure does not include eye examinations not preceded by a referral, or triggered by another reason such as positive family history, neurodevelopmental disorder, or observation of an abnormality). This measure should be calculated 6 months after the end of the reporting year, to account for those children who failed a vision screening between the ages of 67 and younger than 72 months who required time to receive a follow-up eye examination.

The following treatment measure addresses the proportion of children with an eye examination found to have a visually significant eye condition, who receive treatment or additional visits to an ophthalmologist or optometrist.

  • Numerator: Number of children from the denominator who obtained glasses and/or attended at least one follow-up appointment with an optometrist or ophthalmologist within 6 months of an eye examination. (This numerator would be reported by the prescribing ophthalmologist or optometrist.)
  • Denominator: All children who turn 72 months of age by December 31st of the reporting year in the population, or a representative sample, who were prescribed treatment including glasses and/or instructed by an optometrist or ophthalmologist to return within 6 months (e.g., for treatment of amblyopia, strabismus, or amblyogenic refractive error23).

This measure would provide surveillance of treatment adherence in children diagnosed as having vision conditions or amblyogenic refractive error. In children with multiple services, the earliest relevant visits would be counted. This measure requires that children with amblyopia, strabismus, or amblyogenic refractive error be seen within 6 months of the initial diagnosis or glasses prescription.

Back to Top | Article Outline

Recommendations for Implementation of Preschool Vision Care Performance Measures

  • Each state, region, locality, and program will need to determine how to implement these measures. Organizations already use a variety of systems to report required measures such as immunizations and well-child examinations. Using existing data infrastructure, while working toward a more interchangeable data system that will readily support the implementation and reporting of valid measures, is recommended. The panel further recognizes that states and organizations are in differing stages of developing integrated, or even linked data systems, and of adoption of electronic health records. Despite the fluidity of the data landscape, we urge implementation of performance measures into emerging data systems to assure the necessary infrastructure and data elements to allow reporting of the vision measures.
  • The feasibility of implementing these vision performance measures can be enhanced by “lessons learned” during implementation of the 18 national performance measures currently required for pediatric health care.24 Like past efforts, implementation of the vision performance measures will require technical assistance and integration with other data collection and performance measure initiatives. Implementation may involve development of “Use Cases”25 in which the process and steps for vision performance measures are developed. A technical manual, developed with input from experts in epidemiology, performance measurement, statistics, information technology, and vision, should be adopted so that basic measures are standardized, and the estimates are valid, reliable, and comparable to other locations. This process should be informed by previous efforts to develop other pediatric performance measures, for example, the core CHIPRA measures.26 Measures may be applied to the whole population or to a representative sample of children aged 36 to younger than 72 months.
  • Linkage of child-based measures with child demographic information will enable monitoring of possible disparities in health care provision,27,28 for example, racial/ethnic differences in screening and/or follow-up rates, which are especially important for children.
  • Recognizing that most states do not currently have Web-based integrated reporting systems to track vision care, we support the use of national parent survey data, for example, the National Survey of Children’s Health, as an interim step to allow states to estimate their performance on our recommended measures. Because survey methods are subject to the potential inaccuracies and recall bias inherent in the use of parent-report data, Web-based data systems should supersede the survey approach as quickly as possible.
  • Rather than separate efforts by agencies such as the National Council on Quality Assurance, the National Quality Forum, the American Academy of Pediatrics, the Agency for Healthcare Research and Quality, and the MCHB to develop performance measures, each of these agencies should continue to collaborate so that efforts are streamlined and coordinated.
  • Vision care performance measure results should be publicly available. Such data can be used to determine progress toward goals and drive quality improvement efforts. Addition of future performance measures should be driven in part by consumer priorities, for example, measuring and reporting on the quality of life for children diagnosed as having and treated for significant vision disorders including amblyopia.

Improvements in vision screening and eye examination rates can also be enhanced by concurrent public health and health behavior campaigns aimed at parents and providers. The literature addressing efforts to understand and improve providers’ and parents’ behaviors related to vision care is small but has revealed that providers with high levels of knowledge and positive attitudes toward vision screening are more likely to report compliance with preschool vision screening recommendations29 and that failing to realize that children without signs or symptoms can still have serious eye problems is a barrier to screening and seeking eye examinations.29,30 Attempts to improve provider behavior, including office-based11,14,31,32 and Internet-based33 interventions have shown some success in improving rates of screening and knowledge about amblyopia. More research and effort in this area are urgently needed.

Back to Top | Article Outline

CONCLUSIONS

Increasing requirements for quality and accountability at national, state, local, and provider levels are driving the development of vision care performance measures. Monitoring the vision care system for preschool-aged children requires regular reporting of measures of vision screening, eye examinations, and treatment. These expert panel recommendations represent the first step toward creating a comprehensive data collection and reporting system. Eye care professionals including optometrists and ophthalmologists should be in leadership positions, driving their evolution and implementation.

Wendy L. Marsh-Tootle

University of Alabama at Birmingham

School of Optometry

1716 University Blvd

Birmingham, AL 35294

e-mail: wmarsht@uab.edu

Back to Top | Article Outline

ACKNOWLEDGMENTS

Members of the National Expert Panel to the National Center for Children’s Vision and Eye Health

Shirley A. Russ, MD, MPH (Panel Chair), University of California, Los Angeles-Center for Healthier Children, Families and Communities, Los Angeles, CA; Sandra S. Block, OD, MEd, FAAO (Panel Cochair), Illinois College of Optometry, Chicago, IL; Joseph M. Miller, MD, MPH (Panel Cochair), The Clara and Murray Walker Professor and Chair of Ophthalmology and Vision Science, The University of Arizona College of Medicine, Tucson, AZ; Martha Dewey Bergren, DNS, RN, University of Illinois-Chicago, College of Nursing, Chicago, IL; Richard T. Bunner, MA, Ohio Department of Health (Retired), Columbus, OH; Susan A. Cotter, OD, MS, FAAO, Southern California College of Optometry at Marshall B. Ketchum University, Fullerton, CA; Lynn A. Cyert, PhD, OD, FAAO, Northeastern State University, Oklahoma College of Optometry, Tahlequah, OK; Holly A. Grason, MA, Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; E. Eugenie Hartmann, PhD, University of Alabama at Birmingham, School of Optometry, Birmingham, AL; Karen F. Hughes, MPH, Chief, Division of Family and Community Health Services, Ohio Department of Health, Columbus, OH; Amy K. Hutchinson, MD, Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA; Alex R. Kemper, MD, MPH, Department of Pediatrics and Duke Evidence-based Practice Center, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Sandra Leonard, RN, MS, FNP, Division of Adolescent and School Health, Centers for Disease Control and Prevention, Atlanta, GA; Stacy Ayn Lyons, OD, FAAO, Chair, Department of Specialty and Advanced Care, New England College of Optometry, Boston, MA; Wendy L. Marsh-Tootle, OD, MS, FAAO, University of Alabama at Birmingham, School of Optometry, Birmingham, AL; Renee Mika, OD, FAAO, Cherry Street Health Services-Heart of the City Health Center, The Grand Rapids Lion’s Club Vision Clinic, Grand Rapids, MI; Bruce D. Moore, OD, FAAO, Marcus Professor of Pediatric Studies, New England College of Optometry, Boston, MA; Nicole Pratt, New Jersey Statewide Parent Advocacy Network, Newark, NJ; Graham E. Quinn, MD, MSCE, Division of Pediatric Ophthalmology, The Children’s Hospital of Philadelphia and Scheie Eye Institute, University of Pennsylvania Health System, Philadelphia, PA; Jean E. Ramsey, MD, MPH, Associate Professor for Ophthalmology and Pediatrics, Boston University School of Medicine, Boston, MA; Michael X. Repka, MD, Zanvyl Krieger Children’s Eye Center and Adult Strabismus Service, Wilmer Eye Institute and the Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD; David K. Wallace, MD, MPH, Department of Ophthalmology, Duke University Eye Center and Department of Pediatrics, Duke University School of Medicine, Durham, NC.

Development of these recommendations was produced, in part, through a cooperative agreement (H7MMC15141) and grant (H7MMC24738) from the Maternal and Child Health Bureau of the Health Resources and Services Administration, United States Department of Health and Human Services. The views expressed in the publication are solely the opinions of the authors and do not necessarily reflect the official policies of the United States Department of Health and Human Services or the Health Resources and Services Administration, nor does mention of the department or agency names imply endorsement by the United States Government. The recommendations represent the consensus of the National Expert Panel to the National Center for Children(tm)s Vision and Eye Health. They do not necessarily reflect the views of any individual member of the panel, or of any of the professional organizations to which the panel members belong.

Received October 31, 2013; accepted October 3, 2014.

Back to Top | Article Outline

APPENDIX

The Appendix, which describes the process used to develop the National Expert Panel recommendations, is available at http://links.lww.com/OPX/A188.

Back to Top | Article Outline

REFERENCES

1. Cotter SA, Cyert LA, Miller JM, Quinn GE; for the National Expert Panel to the National Center for Children’s Vision and Eye Health. Vision screening for children 36 to <72 months: recommended practices. Optom Vis Sci 2014; 92: 6–16.
2. Hartmann EE, Block SS, Wallace DK; for the National Expert Panel to the National Center for Children’s Vision and Eye Health. Vision and eye health in children 36 to <72 months: proposed data system. Optom Vis Sci 2014; 92: 24–30.
3. Healthy People 2020. Objective Retained as Is from Healthy People 2010, V HP2020. Washington, DC: US Department of Health and Human Services. Available at: http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=42. Accessed Feb 4, 2013.
4. United States Preventive Services Task Force. Vision screening for children 1 to 5 years of age: US Preventive Services Task Force Recommendation statement. Pediatrics 2011; 127: 340–6.
5. Bright Futures guidelines for health supervision of infants, children, and adolescents. Rationale and evidence. American Academy of Pediatrics. Available at: http://brightfutures.aap.org/pdfs/Guidelines_PDF/13-Rationale_and_Evidence.pdf. Accessed May 1, 2013.
6. Repka MX, Kraker RT, Holmes JM, Summers AI, Glaser SR, Barnhardt CN, Tien DR. Pediatric Eye Disease Investigator Group. Atropine vs patching for treatment of moderate amblyopia follow-up at 15 years of age of a randomized clinical trial. JAMA Ophthalmol 2014; 132: 799–805.
7. Scheiman MM, Hertle RW, Beck RW, Edwards AR, Birch E, Cotter SA, Crouch ER Jr., Cruz OA, Davitt BV, Donahue S, Holmes JM, Lyon DW, Repka MX, Sala NA, Silbert DI, Suh DW, Tamkins SM. Randomized trial of treatment of amblyopia in children aged 7 to 17 years. Pediatric Eye Disease Investigator Group. Arch Ophthalmol 2005; 123: 437–47.
8. Levinson DR. Most Medicaid Children in Nine States Are Not Receiving All Required Preventive Screening Services, OEI-05-08-00520. Washington, DC: United States Department of Health and Human Services, Office of Inspector General; 2010. 2, 4. Available at: https://oig.hhs.gov/oei/reports/oei-05-08-00520.pdf. Last accessed May 2, 2013.
9. Kemper AR, Wallace DK, Patel N, Crews JE. Preschool vision testing by health providers in the United States: findings from the 2006-2007 Medical Expenditure Panel Survey. J AAPOS 2011; 15: 480–3.
10. Hambidge SJ, Emsermann CB, Federico S, Steiner JF. Disparities in pediatric preventive care in the United States, 1993-2002. Arch Pediatr Adolesc Med 2007; 161: 30–6.
11. Shaw JS, Wasserman RC, Barry S, Delaney T, Duncan P, Davis W, Berry P. Statewide quality improvement outreach improves preventive services for young children. Pediatrics 2006; 118: 1039–47.
12. Stange KC, Flocke SA, Goodwin MA, Kelly RB, Zyzanski SJ. Direct observation of rates of preventive service delivery in community family practice. Prev Med 2000; 31: 167–76.
13. Marsh-Tootle WL, Wall TC, Tootle JS, Person SD, Kristofco RE. Quantitative pediatric vision screening in primary care settings in Alabama. Optom Vis Sci 2008; 85: 849–56.
14. Kemper AR, Helfrich A, Talbot J, Patel N, Crews JE. Improving the rate of preschool vision screening: an interrupted time-series analysis. Pediatrics 2011; 128: 1279–84.
15. Social Security Act of 1965 §501, 42 United States C. §701-710 (2010).
16. Title V. Maternal and Child Health Services Block Grant Program. U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA). Available at: http://mchb.hrsa.gov/programs/titlevgrants. Accessed May 2, 2013.
17. Dougherty D, Schiff J, Mangione-Smith R. The Children’s Health Insurance Program Reauthorization Act quality measures initiatives: moving forward to improve measurement, care, and child and adolescent outcomes. Acad Pediatr 2011; 11: S1–10.
18. Goldstein MM, Rosenbaum S. From EPSDT to EHBs: the future of pediatric coverage design under government financed health insurance. Pediatrics 2013; 131: S142–8.
19. NQF Releases Updated Child Quality Health Measures. Washington, D.C.: National Quality Forum. Available at: http://www.qualityforumorg/News_And_Resources/Press_Releases/2011/NQF_Releases_Updated_Child_Quality_Health_Measures.aspx. Accessed May 2, 2013.
20. The Department of Health and Human Services Children’s Health Insurance Program Reauthorization Act 2011 Annual Report on the Quality of Care for Children in Medicaid and CHIP. Washington, D.C.: Health and Human Services Secretary, U.S. Department of Health and Human Services; 2011. Available at: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Downloads/2011_StateReporttoCongress.pdf. Accessed Mar 4, 2014.
21. Weissman NW, Allison JJ, Kiefe CI, Farmer RM, Weaver MT, Williams OD, Child IG, Pemberton JH, Brown KC, Baker CS. Achievable benchmarks of care: the ABCs of benchmarking. J Eval Clin Pract 1999; 5: 269–81.
22. Marsh-Tootle WL, McGwin G, Tootle JS, Wall TC. Preschool vision screening in primary care settings: typical and achievable rates during three annual periods. Invest Ophthalmol Vis Sci 2012; 53:E-Abstract 3879.
23. Donahue SP, Arthur B, Neely DE, Arnold RW, Silbert D, Ruben JB. Guidelines for automated preschool vision screening: a 10-year, evidence-based update. J AAPOS 2013; 17: 4–8.
    24. Title V Information System. Washington, D.C.: U.S. Department of Health and Human Services, Health Resources and Services Administration. Available at: https://mchdata.hrsa.gov/tvisreports/MeasurementData/StandardNationalMeasureIndicatorSearch.aspx?MeasureType=Performance&YearType=MostRecent. Accessed May 20, 2014.
    25. Bittner K, Spence I. Use Case Modeling. Boston: Addison-Wesley Longman Publishing Co., Inc.; 2002.
    26. CHIPRA Initial Core Set of Children’s Health Care Quality Measures. Baltimore, MD: Centers for Medicare & Medicaid Services. Available at: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/CHIPRA-Initial-Core-Set-of-Childrens-Health-Care-Quality-Measures.html. Accessed Mar 4, 2014.
    27. Flores G. Technical report—racial and ethnic disparities in the health and health care of children. Committee on Pediatric Research. Pediatrics 2010; 125: 979–1020.
    28. Berdahl T, Owens PL, Dougherty D, McCormick MC, Pylypchuk Y, Simpson LA. Annual report on health care for children and youth in the United States: racial/ethnic and socioeconomic disparities in children’s health care quality. Acad Pediatr 2010; 10: 95–118.
    29. Marsh-Tootle WL, Funkhouser E, Frazier MG, Crenshaw K, Wall TC. Knowledge, attitudes and environment: what primary care providers say about preschool vision screening. Optom Vis Sci 2010; 87: 104–11.
    30. Frazier M, Garces I, Scarinci I, Marsh-Tootle W. Seeking eye care for children: perceptions among Hispanic immigrant parents. J Immigr Minor Health 2009; 11: 215–21.
    31. Hered RW, Rothstein M. Preschool vision screening frequency after an office-based training session for primary care staff. Pediatrics 2003; 112: 17–21.
    32. Clausen MM, Armitage MD, Arnold RW. Overcoming barriers to pediatric visual acuity screening through education plus provision of materials. J AAPOS 2009; 13: 151–4.
    33. Marsh-Tootle WL, McGwin G, Kohler CL, Kristofco RE, Datla RV, Wall TC. Efficacy of a web-based intervention to improve and sustain knowledge and screening for amblyopia in primary care settings. Invest Ophthalmol Vis Sci 2011; 52: 7160–7.
    Keywords:

    children; vision; vision screening; performance measure; data analysis

    Supplemental Digital Content

    Back to Top | Article Outline
    © 2015 American Academy of Optometry