Cost-effectiveness framework discussion for vision screening
Reviewed by Fiona Rowe

The authors present a discussion paper on hypothetical, but representative, examples of post-referral costs that may result from different screening options up to the point of discharge from specific services. Data was taken from a recent (2019) systematic review (with 2022 update) in relation to screening programme types, referral rates and diagnostic outcomes, age group and refraction criteria, whilst specifically looking for evidence of cost-effectiveness. They considered five different common examples of screening programmes: 1) single photoscreen at two years, 2) repeat photoscreen one year later with only the most severe cases referred after the first screen, 3) visual acuity screen at three-four years where linear tests are not used or not possible to use, 4) single test episode using linear visual acuity test at four-five years, and 5) adding photoscreen to visual acuity test at the same age. In general, the younger the children, the higher the referral rate and lower the precision in detecting amblyopia and / or refractive amblyopic risk factors, and the more false positives and untestable children. The authors consider two of the above common examples: options 1 and 2, with both being delivered and / or managed by orthoptists, to estimate costs per 100 children referred. Costs were found to be 36% higher in option 1 but with 18% referral vs. 5% referral from option 2. Total costs (mean cost per children x estimated number of referrals) were calculated from eight different types of screening / treatment in a community with an annual birth cohort of 6000 children. They found costs can vary by a factor of 16 or more. This study provides string justification for provision of childhood vision screening, and recommends evaluation of what form of screening carries the least burden and optimum population outcome. The authors conclude all children should be screened before the age of six years.

A population-level post-screening treatment cost framework to help inform vision screening choices for children under the age of seven.
Horwood A, Heijinsdijk E, Kik J, et al.
STRABISMUS
2023;31(3):220–35.