Department of Psychology, University of Reading, Reading, UK.
Department of Public Health, Erasmus Medical Centre, Rotterdam, The Netherlands.
Strabismus. 2023 Sep;31(3):220-235. doi: 10.1080/09273972.2023.2268128. Epub 2023 Nov 6.
PURPOSE/BACKGROUND: Visual acuity (VA) screening in children primarily detects low VA and amblyopia between 3 and 6 years of age. Photoscreening is a low-cost, lower-expertise alternative which can be carried out on younger children and looks instead for refractive amblyopia risk factors so that early glasses may prevent or mitigate the conditions. The long-term benefits and costs of providing many children with glasses in an attempt to avoid development of amblyopia for some of them needs clarification. This paper presents a framework for modeling potential post-referral costs of different screening models once referred children reach specialist services.
The EUSCREEN Screening Cost-Effectiveness Model was used together with published literature to estimate referral rates and case mix of referrals from different screening modalities (photoscreening and VA screening at 2, 3-4 years and 4-5 years). UK 2019-20 published National Health Service (NHS) costings were used across all scenarios to model the comparative post-referral costs to the point of discharge from specialist services. Potential costs were compared between a) orthoptist, b) state funded ophthalmologist and c) private ophthalmologist care.
Earlier VA screening and photoscreening yield higher numbers of referrals because of lower sensitivity and specificity for disease, and a different case mix, compared to later VA screening. Photoscreening referrals are a mixture of reduced VA caused by amblyopia and refractive error, and children with amblyopia risk factors, most of which are treated with glasses. Costs relate mainly to the secondary care providers and the number of visits per child. Treatment by an ophthalmologist of a referral at 2 years of age can be more than x10 more expensive than an orthoptist service receiving referrals at 5 years, but outcomes can still be good from referrals aged 5.
All children should be screened for amblyopia and low vision before the age of 6. Very early detection of amblyopia refractive risk factors may prevent or mitigate amblyopia for some affected children, but population-level outcomes from a single high-quality VA screening at 4-5 years can also be very good. Total patient-journey costs incurred by earlier detection and treatment are much higher than if screening is carried out later because younger children need more professional input before discharge, so early screening is less cost-effective in the long term. Population coverage, local healthcare models, local case-mix, public health awareness, training, data monitoring and audit are critical factors to consider when planning, evaluating, or changing any screening programme.
目的/背景：儿童视力（VA）筛查主要用于检测 3 至 6 岁儿童的低 VA 和弱视。照片筛查是一种低成本、低技能的替代方法，可用于年龄较小的儿童，用于寻找屈光性弱视危险因素，以便早期配镜可以预防或减轻这些疾病。为避免一些儿童发生弱视而给许多儿童提供眼镜以长期受益和成本需要明确。本文提出了一种框架，用于建模不同筛查模式的潜在转介后成本，一旦转介儿童到达专科服务。
使用 EUSCREEN 筛查成本效益模型和已发表的文献来估计不同筛查模式（2 岁、3-4 岁和 4-5 岁时的照片筛查和 VA 筛查）的转诊率和转介病例组合。所有方案均使用英国 2019-20 年公布的国家卫生服务（NHS）成本来模拟从专科服务出院点的比较转介后成本。将潜在成本与以下三种情况进行了比较：a）视轴矫正专家，b）由国家资助的眼科医生，c）私人眼科医生。
由于疾病的敏感性和特异性较低，以及不同的病例组合，早期 VA 筛查和照片筛查的转介人数更多。照片筛查的转介患者既有弱视引起的视力下降，也有屈光不正，还有弱视危险因素的患者，其中大多数需要配镜治疗。成本主要与二级保健提供者和每个儿童的就诊次数有关。2 岁儿童由眼科医生治疗的转诊费用可能比 5 岁时接受转诊的视轴矫正专家服务高出 10 多倍，但 5 岁时的转诊仍可能有良好的结果。
所有儿童都应在 6 岁之前接受弱视和低视力筛查。非常早期发现弱视屈光危险因素可能会预防或减轻一些受影响儿童的弱视，但在 4-5 岁时进行单次高质量 VA 筛查也能获得非常好的人群结果。早期发现和治疗导致的总患者就诊成本远高于较晚筛查，因为在出院前，年幼的儿童需要更多的专业投入，因此从长期来看，早期筛查的成本效益较低。人口覆盖率、当地医疗保健模式、当地病例组合、公共卫生意识、培训、数据监测和审计是规划、评估或更改任何筛查计划时需要考虑的关键因素。
