Choosing Wisely Through Children’s Eyes
“Of course this service is available for us, why shouldn’t we use it?”
This is the question Sean Donahue, MD, PhD, Coleman Professor of Ophthalmology, Neurology and Pediatrics at Vanderbilt University, often hears from parents about comprehensive eye exams for their children.
“That’s the struggle, because they probably don’t need it,” Dr. Donahue said. “There are unintended consequences of getting things you don’t need.”
For his work in improving care in pediatric ophthalmology, Dr. Donahue was recently recognized as a Choosing Wisely Champion by the American Association for Pediatric Ophthalmology and Strabismus (AAPOS). Announced earlier this year, the Champions program is an initiative of the ABIM Foundation to recognize clinicians who are leading efforts to reduce overuse and waste in health care. More than a dozen leading medical specialty societies have committed to participate in the program.
Dr. Donahue’s efforts include initiatives to ensure children don’t get glasses they don’t need. His work serves as the basis of the AAPOS Choosing Wisely® recommendation:
“Don’t put asymptomatic children in weak reading glasses.”
“We see so many kids who get an eye exam just because they can. It’s one thing to get an examination you don’t need, but when it leads to treatment, or screening or evaluations that you don’t need, it just goes out of control,” said Dr. Donahue.
Ensuring appropriate eye care for children has been a career-long endeavor for Dr. Donahue. In the early 1990s he and his colleagues began development of a screening tool to help reduce the number of children who receive unnecessary eye care.
“We thought, wouldn’t it be cool if we could use commercially available devices to screen kids for problems, and then set up a network of optometrists and ophthalmologists in their local communities who could see them and evaluate them? Then we could get the results back from those doctors and use them to help validate the instruments and make them better,” he said.
Dr. Donahue says the screening tools are particularly important as children are usually seen by clinicians who are not specialists in pediatric ophthalmology, which can lead to unnecessary care. His research found that overall about 20 percent of children were prescribed glasses they didn’t need after failing a vision screening. But there is wide variation in prescribing depending on the eye doctor’s training. Prescribing rates are as high as 40 percent when seen by an optometrist versus just 2 percent with a pediatric ophthalmologist.
“If you can create a vision screening program with an instrument in the pediatrician’s office where the pediatrician or nurse practitioner is providing the care, you end up only referring 10 to 12 percent of children who have a problem. So not only do you cut down the number of eye exams by 88 percent, but you also cut down the number of children who receive unnecessary spectacles because they can now be referred to a pediatric ophthalmologist,” he said.
Dr. Donahue is also a strong advocate for the AAPOS Choosing Wisely recommendation that states, “Annual comprehensive eye exams are unnecessary for children who pass routine vision screening assessments.” He estimates that if mandatory comprehensive eye exams were required by all states, more than $250 million would be spent on unnecessary glasses and another $500 million on the exams themselves.
In addition to the costs and time involved with unnecessary exams and prescribing, Dr. Donahue notes another downside – the struggle parents face in making sure their children actually wear their glasses.
“There’s this emotional burden the parents have that their child is going to have a lifetime of blindness if they don’t wear their glasses. So they force them to wear a pair of glasses that they don’t need. It becomes a fight the parents don’t need to be putting their energy into. They already have a lot of other things they need to worry about,” he said.
Dr. Donahue shares that efforts like Choosing Wisely are helping to change the prevailing mindset that more care is better.
“It is good that we have these guidelines to be able to talk about how to decrease unnecessary costs in health care,” he said. “Choosing Wisely really supports clinicians in having these conversations with their patients.”