683 - Improving Visual Acuity Screening in 12-60 month-olds by Integrating Instrument-based Testing: A Resident Quality Improvement Initiative

Visual acuity testing is the gold standard for vision screening to identify visual abnormalities, but instrument screening devices allow testing for eye conditions or risk factors that can cause decreased vision or amblyopia without active participation from the patient. The American Academy of Pediatrics recommends visual acuity screens from 3 to 5 years and instrument-based screens at ages 12 to 24 months or at 3 to 5 years if unable to participate in traditional visual screens. However, few studies have evaluated the implementation of vision screening in children under 3 years specifically at academic, resident practices.

Objective:

To increase vision screening of children 12 to 35 months from 0% to 50% and 36 to 60 months from 85% to 95% and necessary referrals to ophthalmology from 61 percent to 75 percent by May 2022.

Design/Methods:

A resident-led QI project was conducted from 2021 to 2022 at an urban mixed faculty-resident pediatric primary care practice. Seven Plan-Do-Study-Act cycles were developed on the basis of identified key drivers (Figure 1) and included provider and medical assistant training, integration of a photoscreener into the workflow, updated referral guidelines, and creating billing workflows to support sustainability. Data were tracked with monthly chart reviews of vision screening attempted, completed, and referred with further data collected six months after the study period ended to assess sustainability.

Results:

From August 2021 to May 2022, screening for 12 to 35 month-olds increased from 0% to 80%, and screening for 36 to 60 month-olds increased from 85% to 100%, achieving the stated aims of the study. Sustainability data showed 64% and 100% screening in 12 to 35 month-olds and 36-60 month-olds respectively. (Figure 2) Appropriate referrals to ophthalmology increased from 61% to an average of 84% with a shift in the median line for average referral rate. (Figure 3)

Conclusion(s):

The creation of a vision screening and referral workflow as well as the integration of an instrument-based photoscreener increased screening and referral rates for children 1 to 5 in our academic mixed resident faculty practice. Instrument-based photoscreeners are particularly useful for children who cannot engage in visual acuity testing and may provide earlier detection of preventable vision loss, yet few studies have demonstrated successful implementation in children under 3 in the primary care setting. The use of QI methodology in this resident-led study shows promise for sustainability despite yearly resident turnover and could be a model for other similar practice sites.