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W. L. Marsh-Tootle, E. Funkhouser, T. C. Wall, M. G. Frazier; Knowledge, Attitudes, and Environment: What Do the Providers Say About Preschool Vision Screening in Primary Care Practices?. Invest. Ophthalmol. Vis. Sci. 2008;49(13):2580.
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To evaluate knowledge, attitudes and environment related to preschool vision screening (PVS) among primary care physicians enrolled in the intervention arm of a study to improve detection of amblyopia.
Alabama Medicaid providers who performed at least 8 well-child checks (WCCs) for preschoolers aged 3 or 4 years over a 12-month period were eligible. Physicians who enrolled (logged in to a web-site) were randomly assigned to an intervention (vision) or control (blood pressure) group. As they worked through interactive cases, participants responded to questions we developed to assess potential predictors of PVS.
Participants were pediatricians (48) family physicians (14) and nurse practitioners (3). While 64.5% correctly identified all risk factors for amblyopia, 93.5% underestimated their prevalence, and only 17% recognized that a high refractive error causes 30-50% of amblyopia. Most providers (79%) reported no referral barriers. Screening barriers were common: preschoolers take too much time (40.7%), cannot maintain cooperation (66.7%), and interrupt patient flow (33.3%); furthermore, reimbursement is too low (44.4%). The only test available to 39 providers (62.9%) was a Snellen chart. Only 1 provider responded they could successfully screen > 80% of 3- year olds. Providers perceived challenges for parents seeking eye exams [transportation and time off from work for eye exams (66.7%) and expense (35.2%)], yet, most providers (87%) expected parents to take the child if referred. Median scores were 5 correct of 7 (knowledge) +2 on a scale from -7 to 4 (attitudes) and -2 on a scale from -8 to 3 (environment). Knowledge scores had no association with either attitudes (r=0.00) or environment r=-0.07, p=0.6), but providers with higher attitude scores also scored higher on environment (r=0.32, p=0.02). Only 2 providers were in the upper quartile in all three categories.
Primary care providers underestimated the prevalence of risk factors, and did not recognize that many children have no outward signs of amblyopia. Many offices are not equipped with appropriate visual acuity tests; thus, few providers report successfully screening high percentages of their preschool patients. Improving PVS rates will require interventions at multiple levels, to improve knowledge, to integrate appropriate screening methods into the practice environment, and to address other environmental barriers including reimbursement.
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