And while state-sponsored, school-based eye exams appear to spot vision problems effectively, the follow-up for children who can't see clearly varies.
These conclusions, from a study published in the March issue of the journal Pediatrics, and from three other studies published recently in major journals, come from a team of pediatric researchers at the University of Michigan Health System. Noting the lack of solid data on children's eye care, they decided to take a long, hard look at the way kids' vision problems are detected and corrected.
Using state and national databases, interviews with parents and public health providers, and information about the location of optometrists and opthalmologists, the researchers for the first time are bringing into focus some major underlying disparities in children's eye care.
"Our findings suggest that roughly one in five children has a vision problem," says Alex Kemper, M.D., MPH, MS, the lead author on all four papers and an assistant professor of pediatrics at the U-M Medical School. "These studies show major differences between children in different racial, income and insurance groups in whether they receive eye care."
For instance, in the new Pediatrics study, non-Hispanic white Michigan children enrolled in Medicaid were 37 percent more likely than Hispanic or non-white children to visit an eye specialist or be prescribed corrective lenses in a one-year period.
In a study published in the January issue of Optometry and Vision Sciences, uninsured black and Hispanic children had far lower odds of having eyeglasses or contact lenses than other children, regardless of insurance status – and black children without insurance were least likely of all to receive vision correction.
A major source of this disparity appears to be the amount of cash that parents have to spend to take care of their kids' eyes, according to Kemper and his colleagues in the Child Health Evaluation and Research Unit of the U-M Division of General Pediatrics.
"Routine vision care is largely an out-of-pocket expense in this country, except for children enrolled in Medicaid, and it can be expensive. Even when insurance covers some expenses, parents find themselves paying for glasses that their children like better than the covered ones, or for replacements when glasses break or contact lenses get lost," he explains. "At the same time, there's no clear definition of which kids need glasses, nor standard guidelines for optometrists and ophthalmologists to follow, so there can be major differences in diagnosis and treatment from provider to provider."
Some states, such as Michigan, have school-based vision screening programs to identify children with vision problems who have never seen an eye doctor. Although such programs have been in place for decades, little data about their worth has ever been produced.
Kemper and his colleagues published the results of their exhaustive examination of Michigan's vision screening program in the February American Journal of Preventive Medicine. They talked to 842 parents randomly selected from those whose children had an abnormal vision screening exam in 11 public health districts representing the rural, suburban and urban areas of Michigan. They also talked with the public health staff who conduct or oversee screening in those districts.
Regardless of race, income or insurance status, three-quarters of the parents said they had sought follow-up care for their children after receiving notice of a possible vision problem, and three-quarters of those said the follow-up resulted in treatment such as a prescription for eyeglasses.
"Vision screening programs are important for finding those children with vision problems who have not otherwise been identified in other ways, such as screening by their pediatrician or family physician, or by complaints about their ability to see," says Kemper. "These programs may be important for overcoming disparities in care."
The new Pediatrics study of Michigan children enrolled in Medicaid shows differences in the receipt of care, even among children in families with similar economic backgrounds and presumably similar access to eye care. Rural children were more likely to receive eye care than those in urban areas. Within urban areas, non-Hispanic white children were more likely to receive eye care than Hispanic or non-white children. However, within rural areas there were no differences by race or ethnicity.
Beyond the Michigan studies of Medicaid recipients and screening tests, Kemper and his co-authors used two national databases to look at factors influencing vision care across the country. Their article in the January issue of Optometry and Vision Sciences used the 1998 Medical Expenditure Panel Survey, a federal database with information on 22,953 individuals selected to represent the national population, with oversampling of racial and ethnic minorities to allow for better statistical power.
In this population, almost 24 percent of children between the ages of 5 and 18 had corrective lenses, which correlates to 25 percent of the general population when adjusted statistically.
Children whose families earned less than twice the federal poverty level were far less likely than other children to have corrective lenses, and children with no insurance or with public insurance such as Medicaid were less likely than those with private health insurance to have glasses or contact lenses.
When race was added to the mix, uninsured non-black/non-Hispanic children were just as likely to have corrective lenses as children of any race who had insurance. But black and Hispanic children without insurance fared far worse: The odds that they would have glasses or contact lenses were 129 percent lower than the odds for their uninsured counterparts of other races and ethnicities.
The fact that insured black and Hispanic children had about the same rate of corrective lens use as other insured children means that the major disparities seen between uninsured children of different races and ethnicities has to do with use of services, not prevalence of eye problems, Kemper says.
These same differences between racial and ethnic groups, between the insured and the uninsured, and between the very poor and the better-off, were also evident in another national U-M study looking at whether children had seen an eye specialist in the previous year.
The U-M team published its results of an analysis of data from the National Health Interview Study, representing 13,376 children between the ages of 5 years and 17 years, in the September/October issue of Ambulatory Pediatrics.
Just as in the study of corrective lens use, this analysis of optometrist and ophthalmologist visits showed that Hispanic and non-Hispanic black children were less likely to have received eye care than non-Hispanic/non-black children. The same was true for children whose families earned less than 200 percent of the federal poverty level, for children without health insurance, and for children who had not had a well-child doctor visit in the last year.
Overall, Kemper says, the evidence points to a wide variety of economic and social factors affecting children's chance of receiving eye care. There may be over-utilization of eye services by children in certain groups, he adds, as well as under-utilization among others.
"All in all, these data show us for the first time what eye care for American children really looks like," he says. "Now, the challenge is to dive deeper into the issue, and to find ways to standardize screening, diagnostic criteria and care so that every child who needs help can see clearly."
Funding for the four studies came from the National Eye Institute of the National Institutes of Health, the Michigan Department of Community Health, and Kemper's previous support as a Pfizer Scholar.
References:
Pediatrics, March 1, 2004, Vol. 113 No. 3
Optometry and Visual Sciences, January 2004, Vol. 81 No. 1, pp. 7-10
American Journal of Preventive Medicine, February 2004, Vol. 26, No. 2, pp. 141-146
Ambulatory Pediatrics, September-October 2003, Vol. 2, No. 5, pp. 270-274.
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PEDIATRICS