Understanding the Barriers and Facilitators to Vision Screening Youth at Well-Child Visits at University of Michigan Medicine Clinics

Megan Gibson

Pronouns:

Research Mentor(s): Olivia Killeen
Research Mentor School/College/Department: Department of Ophthalmology / Medicine
Program: UROP
Session: Session 1 (9:00am – 9:50am)
Authors: Megan Gibson, Rhea Sridhara, Anna Wang, Aleah Miller, Theodora Vorias, Amani Mubeen, Olivia Killeen

Abstract

Introduction/Background It has been estimated that 1 in 5 children in America suffer from vision problems; these issues can worsen over time and lead to permanent vision loss if not detected early1. However, if children receive proper screenings, these conditions can be diagnosed and treated in a timely fashion2. It is recommended that children ages 3-5 years receive annual screening at their well-child visit1. Although this is an important guideline, many clinics and doctor’s offices fail to meet these standards causing vision screening rates to steadily decline from 2016 to 20204. Studies from 10+ years ago found that barriers to vision screening include children being absent for screening, providers lacking opportunities to screen children6, distractions, time, patient difficulties, and a lack of reimbursement7. Facilitators to vision screening included incorporating screenings into normal routines and using electronic medical documentation systems that flag missing results significantly improve rates7. The purpose of this study is to gain a contemporary understanding of the barriers and facilitators to vision screening at well-child visits to inform future quality improvement initiatives. Methods To determine the barriers and facilitators to vision screening at 3-5 year old well child visits, 20 physicians and 18 medical assistants (MAs) from University of Michigan clinics in southeast Michigan were interviewed. Interviewees came from 9 clinics, including 5 pediatric clinics and 4 family medicine clinics. Each interview was semi-structured so that additional questions and follow-ups could be asked by the interviewer when necessary. Each interview was recorded and transcribed for further analysis. Three investigators read and coded the transcribed interviews by using modified grounded theory (MGT); MGT allowed investigators to organize findings into various categories such as barriers and facilitators. Furthermore, coding and categorization of findings were completed using MAXQDA software. Disagreements in the coding of the transcripts were reconciled via consensus between investigators. Once coding was completed and disagreements were resolved, the number of codes in each category was calculated to determine the most frequent barriers and facilitators to vision screening. Results Key barriers and facilitators to vision screening were identified. The most frequently mentioned barrier from both physicians and MAs was patient factors such as attention span, cooperativeness, disabilities, siblings, etc; the prevalence of this barrier was 31.5% and was mentioned by 97% of interviewed healthcare workers. Physicians and MAs reported a variety of statements regarding this issue such as “We get a lot [of children] that don’t have the attention span to stand there, and they get bored”, “Some are very intimidated. They’re shy, so that does limit us. They’ll whisper to their mom’s leg, and they don’t want to talk to us” and “Sometimes it’s clear that kiddo doesn’t have the other skills necessary to do that screening accurately right? They’ve got to recognize the pictures; they’ve got to be able to say what it is. They’ve got to be able to do it without help from a parent”. Two other barriers that were most frequently brought up when a barrier was referenced were time (13.8%) and lack of skills and training (12.8%). Regarding time, interviewees stated “Sometimes it’s like pulling teeth. It could probably take about ten minutes on the little ones, and it’s frustrating, and it’s probably highly inaccurate” and “The perfect patient, it takes six minutes, and most patients take much longer than that, which ends up being a big part of the time they’re allotted for their rooming process”. Additionally, complaints mentioned about skills and training were similar to “There’s so much MA turnover that they felt like the testing was so inconsistent that they did not trust the results, so there’s no clinical relevance” and “They don’t all get the same consistent training, either. I mean, we do our best to try to make that happen, but it’s not always possible”. The main facilitator mentioned by doctors and MAs was having staff that were adequately trained and had tricks to ease the vision screening process. This was referred to 18.7% of the time that a facilitator was mentioned. One trick that was mentioned by various MAs is that they “take them up to the chart first and point at some stuff to see what they know, and if they call the moon a banana, then I know “Okay, that’s a banana to them” A coffee cup, if they just say cup or something like that…”. Another trick used by a MA was “I could do a full eye chart with a four or five-year-old in Japanese. Since the language barrier became an obstacle, it was easier just to learn and try to get through it”. Additionally, many of the doctors discussed how their MAs receive weeks of training when starting and because they do it so much, vision screening seems to be a natural process. Some of the other commonly mentioned facilitators were having vision screening incorporated into daily routines (17.5%) and using a photoscreener (15.4%). Only one Michigan Medicine clinic in the Ann Arbor area currently uses a photoscreener. Interviewees described “It helps us with the children who have developmental disabilities or if there’s a language barrier with the vision scanner”, “The vision scanner itself, like I said, has expedited so fast, like our rooming process, where like to use the vision scanner is really only like 30 to 45 seconds tops” and “I think parents might be more amenable and more concerned and feel that our concerns are more valid seeing it coming from a machine screener. It sort of seems more real”. Quotes from interviews that correlate the benefit of having vision screening in a clinic’s workflow are “We have a really organized protocol for [vision screening] and it’s pretty strict and our MAs, it’s part of our routines so starting at four we do vision screens” and “I think that the medical assistants have just kind of gotten into a rhythm with making it part of the intake of the height, the weight, and then they just head over to the eye chart. I think it’s just kind of become routine for them”. Conclusion A combination of factors act as barriers to vision screening, including time, patient factors and lack of staff skills. Since many children at a young age have low attention spans, are shy, and sometimes have difficulty concentrating, the vision screening process is taxing and takes too much time to complete with the rest of the rooming process. Some clinics also face extreme MA turnover and lack a consistent training regimen for incoming staff which also results in difficulties. However, factors such as staff skills, incorporating screening into the daily workflow and using a photoscreener all help the vision screening process run smoothly and in a timely fashion. By having the skills to approach children with attention and cooperation issues and make the process as “painless” as possible for the child, the vision screening process becomes less “painful” for the MA as well. Similarly, by incorporating the screening into the rooming process, vision screening becomes more of a habit and routine which better enforces that it is completed. Also, the photoscreener, especially, is technology that could produce drastic improvements in clinics and make daily shifts for MAs and physicians much easier. Ultimately, this information will be used to implement changes among clinics to improve vision screening and ultimately decrease preventable long-term vision problems.

Interdisciplinary