It has been estimated that 20% to 25% of school-aged children suffer from vision problems that can affect performance in school and life if left untreated.1,2 Some research suggests that such ocular challenges may be even more prevalent in low-income, urban areas, such as Philadelphia.3 Pennsylvania has mandated yearly vision screening for all students. When a child fails a vision screening, a note is sent home to the parents or guardians with the child, indicating the failure and suggesting a full eye examination. Every year, more than 22,000 Philadelphia public school students fail a school vision screening, but only approximately 23% of these students are taken by their parents to see an optometrist or ophthalmologist.4
To help address this gap, the National Football League Philadelphia Eagles Eye Mobile (EEM) was instituted to make comprehensive vision care more accessible by visiting schools where more than 80% of students fall below the Federal Poverty Line (household income < $19,090 for family of three or < $23,050 for family of four, http://aspe.hhs.gov/POVERTY/figures-fed-reg.shtml, accessed on December 15, 2012, which is applicable to the period of this study). The EEM provides children who fail the in-school vision screening with an examination by an optometrist and two pairs of prescription eyeglasses, if needed. If a child's best corrected visual acuity is below normal or the optometrist has any concerns about the child's ocular health, follow-up care from a pediatric ophthalmologist is arranged at one of three Philadelphia centers at no cost to the family. Subnormal vision is defined according to the Pennsylvania Department of Health guidelines as better than 20/40 in either eye prior to second grade, 20/30 or better starting in second grade, or a two-line difference between eyes for any grade. Once consent is obtained from the parent or guardian, the children are transported by bus to the closest location with a chaperone (or parent, if available) during school hours.
In the 2011–2012 school year, 2,979 students received care on the EEM, of whom 387 (13%) were referred to pediatric ophthalmology clinics. Despite the success of this program in delivering primary eye care, only 53% of patients referred from the EEM attended their scheduled pediatric ophthalmology appointment.
The Wills on Wheels (WOW) Mobile Eye Unit contains the same equipment as a standard pediatric ophthalmologist's office, along with telemedicine facilities and optical coherence tomography, and is staffed by ophthalmologists. We collaborated with the Philadelphia school system and the EEM to provide care at local schools to pediatric patients who were identified by the EEM optometrist as needing ophthalmologic consultation. This study investigates whether WOW could improve the rate of successful completion of the recommended ophthalmology consultation by bringing the ophthalmologist to the children rather than transporting the children to the ophthalmologist.
Patients and Methods
Patients who had been designated by the EEM optometrist as needing pediatric ophthalmic examination during the 2009 to 2012 school years, but who had not successfully completed the intended referral, were identified to be seen by WOW. The criteria for referral to WOW were identical to those that resulted in the initial failed referral to the pediatric ophthalmologist at Wills Eye Hospital. Therefore, a referral was indicated if a child's best corrected visual acuity was below normal or if the optometrist had any other concerns about the child's ocular health.
The students in this study, through information and consent forms sent home with the students to their parents or guardians, had been previously given the opportunity to take advantage of free school bus transportation with chaperones during school hours to attend a free pediatric ophthalmology appointment at Wills Eye Hospital, but failed to provide consent or be present for the program. This list of students was provided to the School District of Philadelphia, which gave each school nurse a list of students at their school who were still in need of ophthalmic care. The District was able to identify students who had transferred schools since the initial referral and redirect the notification to the school nurse at the child's current school. Students who had failed to follow up when they were screened in middle school but had since moved on to high school were excluded from the study due to limited program resources.
The parents or guardians of these pediatric patients were now offered the alternative option of having their child examined by an ophthalmologist on WOW at the child's school. School nurses obtained consent for treatment by sending consent forms home with the students and subsequently calling their parents or guardians, sometimes repeatedly. The District sent WOW to schools based on the number of referrals at that school with consent, physical ability of the school grounds to accept the WOW vehicle, and geographical proximity to Wills Eye Hospital. Most of the schools visited by WOW were located in south Philadelphia, where pediatric patients are usually referred to Wills Eye Hospital. WOW visited one school per day.
On the day of the WOW visit, students were excused from class by the school nurse for the eye examination. A record was kept of any numerical discrepancy between the number of patients scheduled and those who completed their examination. Follow-up calls were made to the school nurses by WOW personnel to identify reasons why students who were identified as needing ophthalmic consultation were unavailable when WOW visited the school. A Likert-style questionnaire was administered via telephone call to obtain the nurses' assessment of the WOW experience (Table 1). The number of successfully completed consultations through the WOW program was recorded, and this rate was compared to the historical rates for completion of consultation at Wills Eye Hospital after referral from EEM (Justason L, Rizwan RA, Tessier A, et al., unpublished data, 2016). Because this was a study conducted specifically to determine the impact of a mobile eye unit on completion of ophthalmology consultation, we did not collect data on the types of ocular pathology that were suspected before or discovered by ophthalmology consultation.
Phone Survey to School Nurses
The study was approved by the Wills Eye Institute Institutional Review Board and the Human Research Protection Office (HRPO) of the United States Army Medical Research and Material Command Office of Research Protections. The research adhered to the tenets of the Declaration of Helsinki.
One hundred thirty-two students at 21 schools were identified by school nurses as needing pediatric ophthalmology consultation. Consent forms for examination on WOW were sent home to the families of each child, of which 95 (72%) were returned correctly completed and thus included on the list of patients to be seen by WOW. Six students returned incorrect or incomplete consent forms and were excluded. There were 13 of 95 students who were not examined by the WOW due to absence on the day of the WOW visit (n = 7) or ophthalmic care delivered by an ophthalmologist or optometrist chosen by the family (6). Therefore, 82 of the 132 students (62%, confidence interval: 54% to 70%) were successfully examined by WOW. Compared to the previous rate of 53%, this was a statistically significant improvement in connecting children who have failed their school vision screenings with ophthalmic care (P = .036). The number of children seen at each school ranged from 2 to 8. In each instance, we were able to examine all present children who were scheduled to be seen. The numbers of children seen at each school were too small to allow for statistical comparison, but no obvious disparities were noted between schools with regard to consent rate or successful completion of consultation.
Of the 21 school nurses polled, 20 offered a response to the question: “Would you like to have WOW back at your school next year?” All 20 nurses answered in the affirmative. Of the 16 nurses who responded to the question: “Do you prefer escorting the students to hospitals for follow-up care through the free transport program or do you prefer Wills On Wheels coming to your school?,” 14 (88%) preferred WOW, 1 (6%) liked both equally, and 1 (6%) preferred going to the hospital. Of the 14 nurses who preferred WOW over the school district's free transport program, all cited convenience as a major reason. Four of these nurses indicated that WOW leads to a more effective use of the nurse's time, and 3 nurses noted that WOW helped minimize time away from the classroom. On a Likert scale of 1 to 5, the mean rating of satisfaction with services offered by WOW was 4.8 (range: 3 to 5).
This study evaluated the efficacy of the WOW mobile eye clinic in improving follow-up care for socioeconomically disadvantaged children who had been referred by an optometrist from an in-school vision care program for ophthalmology consultation. By bringing ophthalmic care to the schools, we found a significant increase in the rate of completion of the consultation compared to our past experience of having these children transported to our hospital. School nurses responded favorably to the program, citing improved convenience, simpler logistics, elimination of the need for escorts, more effective use of personnel time, increased patient comfort level, and maximization of instruction time.
Although transportation for students referred to our hospital had previously been provided free of charge, coordination of the transportation services including finding chaperones, obtaining buses for the schools on different days, and arranging for parking were all barriers to follow-up care. The Vision Van, a mobile outpatient ophthalmology clinic from Bascom Palmer Eye Institute in Florida, attended to disaster evacuees in the Miyagi and Iwate Prefectures in Japan after the Great East Japan Earthquake in 2011.5 Because there was limited transportation to hospitals after the disaster, the mobile ophthalmology clinic was able to provide immediate and valuable eye care to patients. Although this Vision Van serves as an extreme example of how bringing a mobile ophthalmology clinic to patients can improve the accessibility of eye care by reducing the need for transportation, it is consistent with our experience. We improved the connection to ophthalmologic care for underserved students by eliminating the barriers associated with transportation.
The main barrier to completion of a pediatric ophthalmologic consultation was difficulty in obtaining parental consent forms for examination. This sometimes occurred despite multiple reminders to the child and phone calls to the parents or guardians by the school nurses. This may be a result of a lack of parental understanding of the significance of their child failing a vision screening and the importance of follow-up care.1 Similar to our results, the Vision First program, which provides free eye examinations to pre-kindergarten through first grade students in Cleveland, Ohio, reported that only 50% of parents returned signed consent forms.6 The Baltimore Vision Screening Project, which combines identification through screening with on-site diagnostics and follow-up treatment through examination by off-site ophthalmologists for pediatric patients from inner-city elementary schools, also revealed a consent form return rate of 50%.7 Although we experienced a successful consent form completion rate of 72%, the process and return rate for obtaining consent for the prior transportation program was the same as that used for visits by WOW. Therefore, the success of WOW cannot be attributed to consent form collection. Additionally, one-third of children remained without eye care because of the failure to obtain consent. Difficulty in obtaining consent from families with low socioeconomic status is perhaps a universal obstacle in the quest to provide eye care to children in need.
Previous research has found that vision problems are disproportionately prevalent among school-aged urban minority youth, and follow-up for failed school vision screenings has been especially low in this population.3 Other reasons for vision health disparity in at-risk children include limited time and financial resources, lack of transportation to follow-up care, insurance coverage, and notification about outreach mechanisms in school districts.8 WOW worked mainly with schools where more than 80% of students fall below the federal poverty level to target this population and eliminate many of these barriers.
Time elapsed between the initial optometric examination performed by EEM and completion of ophthalmology follow-up by WOW was also a limiting factor. Because there is evidence that longer lag time between screening and follow-up lowers the follow-up rate,8 improving timelines for follow-up is important to improving the rate of completed consultations. In the previous bus transportation group, most chaperoned trips to the clinics were organized within a year of the optometric examination. Despite the fact that WOW examined patients who received their last optometric examination as far back as 3 years but had still not seen an ophthalmologist, the rate of successful ophthalmic consultation increased. By decreasing lag time with more frequent WOW school visits, perhaps the rate of successful consultation would be higher still.
Our study was limited in part by retrospective data collection. School truancy and family relocation rates, which affect follow-up rates in both the bus transportation program and WOW, were not obtained. The prevalence of specific ophthalmic pathologies and student demographics were not investigated or correlated with follow-up rates because the referral form data were de-identified prior to transfer for data analysis. It is possible that students with more ocular symptoms or disease would be more likely to attend. However, given that the patient population was the same (same schools and age group) for both the prior bus transportation program and the current WOW intervention, there is no reason to believe that the pathologies and subsequent motivation for follow-up would be significantly different between the two groups. We did not collect data on the follow-up rates for subsequent ophthalmic care when needed after the initial consultation. This is the subject of additional research. The location and layout of some schools was also a limiting factor and precluded some schools from participation because the size of WOW prevents it from visiting schools that can only be accessed by narrow streets or do not have adequate parking space. Other than one school, WOW visited each school only once. In the future, multiple visits to the same school may further increase successful consultation rates. We also did not analyze cost-effectiveness of the program. Finally, because the questionnaire to assess nurse satisfaction with the program was administered via telephone, each nurse could have felt obligated or coerced into giving positive feedback.
Vision is essential to the process of learning and development. Our findings underscore the potential impact of mobile eye clinics at schools in connecting children with ophthalmic care. Screening underserved pediatric populations in inner-city schools without adequate follow-up does not address the needs of pediatric patients requiring further examination. Therefore, by bringing ophthalmic consultation to schools through a program such as WOW, accomplishment of the recommended ophthalmic care may be more successful.
- Kemper AR, Cohn LM, Dombkowski KJ. Patterns of vision care among Medicaid-enrolled children. Pediatrics. 2004;113:190–196. doi:10.1542/peds.113.3.e190 [CrossRef]
- Zadnik K. The Glenn A. Fry Award Lecture: myopia development in childhood. Optom Vis Sci. 1997;74:603–608. doi:10.1097/00006324-199708000-00021 [CrossRef]
- Preslan MW, Novak A. A Baltimore Vision Screening Project. Phase 2. Ophthalmology. 1998;105:150–153. doi:10.1016/S0161-6420(98)91813-9 [CrossRef]
- Public Citizens for Children and Youth. A Problem We Don't See: The Status of Children's Vision Health in Philadelphia. Philadelphia: Public Citizens for Children and Youth; 2008:1–28.
- Yuki K, Nakazawa T, Kurosaka D, et al. Role of the Vision Van, a mobile ophthalmic outpatient clinic, in the Great East Japan Earthquake. Clin Ophthalmol. 2014;8:691–696. doi:10.2147/OPTH.S58887 [CrossRef]
- Traboulsi EI, Cimino H, Mash C, Wilson R, Crowe S, Lewis H. Vision First, a program to detect and treat eye diseases in young children: the first four years. Trans Am Ophthalmol Soc. 2008;106:179–186.
- Preslan MW, Novak A. Baltimore Vision Screening Project. Ophthalmology. 1996;103:105–109. doi:10.1016/S0161-6420(96)30753-7 [CrossRef]
- Poon B, Hertzman C, Holley P, et al. BC Early Childhood Vision Screening Program: Final Evaluation Report. Vancouver, British Columbia: Human Early Learning Partnership Screening Research and Evaluation Unit; 2012:1–137.
Phone Survey to School Nurses
How many children were supposed to be seen on the day of the WOW visit?
If any child was not seen, what was the reason?
Did you experience any problems getting completed consent forms back?
Compared to the program where children are escorted to an ophthalmologist's office, how do you feel about a mobile clinic coming to your school? Which program do you prefer? Please explain your reasoning.
On a scale of 1 to 5, with 5 being the most satisfied and 1 the least satisfied, please rate WOW's service.