May 2004
Volume 45, Issue 13
Free
ARVO Annual Meeting Abstract  |   May 2004
Cost–Effectiveness of Screening in the Pediatric Amblyopia Risk Investigation Study (PARIS)
Author Affiliations & Notes
  • K.D. Frick
    Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
  • H.I. Savage
    Dept. of Ophthalmology, George Washington University, Washington, DC
  • Footnotes
    Commercial Relationships  K.D. Frick, None; H.I. Savage, None.
  • Footnotes
    Support  Knights Templar Eye Foundation
Investigative Ophthalmology & Visual Science May 2004, Vol.45, 3492. doi:
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      K.D. Frick, H.I. Savage; Cost–Effectiveness of Screening in the Pediatric Amblyopia Risk Investigation Study (PARIS) . Invest. Ophthalmol. Vis. Sci. 2004;45(13):3492.

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Abstract

Abstract: : Purpose: To assess the cost of screening and diagnosis per case of amblyopia identified for children aged 3–6 screened by health extenders in a pediatrician’s office. All tests were compared to no screening. Methods: 200 children underwent timed amblyopia screening employing Lea visual acuity (LEA), Random Dot E (RDE), and noncycloplegic autorefraction with SureSight (NCAR). Then all subjects were encouraged to undergo a free complete ophthalmologic assessment. "Referral criteria" with NCAR include myopia >6 D, astigmatism >1.5 D, hyperopia > 3.5 D, anisometropia >2 D. To calculate costs of screening we analyzed costs of labor and equipment. Screening times were used to calculate labor costs for a nurse earning an average wage with average benefits. Equipment cost per screening was calculated as the total purchase price divided by 5000 exams, the expected lifetime of each device. Costs per amblyopia diagnosis include a hypothetical $90 "referral exam fee" for subjects who met referral criteria, multiplied by the fraction of patients who kept referral appointments (0.68). Results: The cost to administer all three tests including only time and materials was $3.79 per child (LEA $1.78, NCAR $1.35, and RDE $0.66/child). When adding the cost of referral exams, the cost per case of amblyopia detected for LEA ranged from a high of $540 (>20/32, sensitivity 1.0), to $348 (>20/40, sensitivity 0.73) to $314 (>20/50, sensitivity 0.36). Costs per amblyopia diagnosis for NCAR was $351 with sensitivity of 0.91. RDE was the least sensitive test for amblyopia ($582/case, sensitivity 0.08). Pairing screening tests increased amblyopia sensitivity and costs: NCAR/RDE ($364/case, sensitivity 1.0), LEA/NCAR ($450/case, sensitivity 1.0) and LEA/RDE ($387/case, sensitivity 0.73). Conclusions: Screening for amblyopia in the pediatrician’s office is inexpensive. Time for test administration and labor costs have as much impact on the cost of screening as the initial equipment costs. When including referral examination fees, the total cost of screening correlates with the rate of false positive tests. In this population, with primarily refractive and strabismic amblyopia, the paired strategy of NCAR/RDE had perfect sensitivity and among the lowest costs per case detected. Pairing NCAR and LEA (>20/40) also detected all children with amblyopia but cost 20% more per case. The optimal test strategy depends on the resources available, population specific rates of amblyopia risk factors, and tolerance for missed cases.

Keywords: screening for ambylopia and strabismus • amblyopia • strabismus: diagnosis and detection 
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