MAKING EYE HEALTH
A POPULATION
HEALTH IMPERATIVE
VISION FOR TOMORROW
Steven M. Teutsch, Margaret A. McCoy, R. Brian Woodbury,
and Annalyn Welp, Editors
Committee on Public Health Approaches to Reduce Vision Impairment
and Promote Eye Health
Board on Population Health and Public Health Practice
Health and Medicine Division
A Report of
THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu
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This activity was supported by American Academy of Ophthalmology; American Academy of Optometry; American Optometric Association; Association for Research in Vision and Ophthalmology; National Alliance for Eye and Vision Research; National Center for Children’s Vision and Eye Health; Prevent Blindness; Research to Prevent Blindness; Contract No. 200-2011-38807, TO#32 with the U.S. Department of Health and Human Services [Centers for Disease Control and Prevention]; and Contract No. HHSN2632012000741, TO#61 with the U.S. Department of Health and Human Services [National Institutes of Health]. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
International Standard Book Number-13: 978-0-309-43998-5
International Standard Book Number-10: 0-309-43998-1
Digital Object Identifier: 10.17226/23471
Library of Congress Control Number: 2016956972
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2016. Making Eye Health a Population Health Imperative: Vision for Tomorrow. Washington, DC: The National Academies Press. doi: 10.17226/23471.
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COMMITTEE ON PUBLIC HEALTH APPROACHES TO REDUCE VISION IMPAIRMENT AND PROMOTE EYE HEALTH
STEVEN M. TEUTSCH (Chair), Adjunct Professor, University of California, Los Angeles, Fielding School of Public Health; Senior Fellow, Public Health Institute; Senior Fellow, Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California
SANDRA S. BLOCK, Professor, Illinois College of Optometry, Medical Director, School-based Vision Clinics, Global Clinical Advisor Special Olympics Lions Clubs International Opening Eyes
ANNE L. COLEMAN, Professor of Ophthalmology and Epidemiology, Stein Eye Institute, David Geffen School of Medicine, University of California, Los Angeles
KEVIN FRICK, Professor and Vice Dean for Education, Carey Business School, Johns Hopkins University
KAREN GLANZ, George A. Weiss University Professor, Director, University of Pennsylvania Prevention Research Center
LORI GROVER, Senior Vice President for Health Policy, King-Devick Technologies, Inc.
EVE HIGGINBOTHAM, Vice Dean, Perelman School of Medicine, University of Pennsylvania
PETER D. JACOBSON, Professor of Health Law and Policy, School of Public Health, University of Michigan
EDWIN C. MARSHALL, Professor Emeritus of Optometry and Public Health, Indiana University
CHRISTOPHER MAYLAHN, Program Research Specialist, Office of Public Health Practice, New York State Department of Health
JOYAL MULHERON, Managing Director, Sagacity Group, LLC
SHARON TERRY, President and CEO, Genetic Alliance
CHERYL ULMER, Retired, Institute of Medicine
ROHIT VARMA, Grace and Emery Beardsley Professor and Chair, University of Southern California (USC) Department of Ophthalmology; Director, USC Eye Institute; Associate Dean for Strategic Planning and Network Development, Keck School of Medicine of USC
HEATHER E. WHITSON, Associate Professor of Medicine (Geriatrics) and Ophthalmology, Duke University Medical Center and Durham Veterans Affairs Medical Center
Study Staff
MARGARET A. McCOY, Study Director
ASHNA KIBRIA, Associate Program Officer (until August 2015)
R. BRIAN WOODBURY, Research Associate
ANNALYN WELP, Research Assistant
BETTINA RITTER, Research Assistant (until November 2015)
MARJORIE PICHON, Senior Program Assistant
ROSE MARIE MARTINEZ, Senior Director, Board on Population Health and Public Health Practice
Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
SUSAN A. COTTER, Southern California College of Optometry
JORGE CUADROS, University of California, Berkeley
DAVID S. FRIEDMAN, Johns Hopkins University
MARSHA GOLD, Mathematica Policy Research, Inc.
EMMETT B. KEELER, Pardee RAND Graduate School
RICARDO MARTINEZ, Adeptus Health Inc.
GLEN MAYS, University of Kentucky
DAVID O. MELTZER, The University of Chicago
ALAN R. MORSE, Lighthouse Guild International
CYNTHIA OWSLEY, University of Alabama at Birmingham
ROBERT M. PESTRONK, Ruth Mott Foundation
LOUISE POTVIN, Université de Montréal
SUSAN A. PRIMO, Emory University School of Medicine
DEJURAN RICHARDSON, Lake Forest College
BETSY SLEATH, University of North Carolina Eshelman School of Pharmacy
FRANK A. SLOAN, Duke University
ALFRED SOMMER, Johns Hopkins University
JOHN C. TOWNSEND, Veterans Health Administration
M. ROY WILSON, Wayne State University
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by BOBBIE BERKOWITZ, Columbia University School of Nursing and Columbia University Medical Center, and BRADFORD H. GRAY, Urban Institute. They were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
Contents
Statement of Task and Scope of Study
Definition of Key Terms in Eye and Vision Health
A Population Health Approach to Improve Eye and Vision Health and Reduce Vision Impairment
2 UNDERSTANDING THE EPIDEMIOLOGY OF VISION LOSS AND IMPAIRMENT IN THE UNITED STATES
Anatomy of the Eye and Function of the Visual System
The Epidemiology of Vision Impairment in the United States
Understanding the Etiology of Vision Impairment in the United States
Characterizing Vision Impairment for Population Health
Estimating the Preventable Burden from Refractive Error and Cataracts
Consequences of Vision Impairment
5 THE ROLE OF PUBLIC HEALTH AND PARTNERSHIPS TO PROMOTE EYE AND VISION HEALTH IN COMMUNITIES
Overview of the Governmental Public Health System
Building Capacity and Strategies to Promote Eye and Vision Health
Opportunities to Incorporate Eye and Vision Health: The Public Health Agenda
Expanding Access to Community-Based Vision Screening Services and Follow-Up Care
6 ACCESS TO CLINICAL VISION SERVICES: WORKFORCE AND COVERAGE
The Clinical Eye and Vision Care Workforce
7 TOWARD A HIGH-QUALITY CLINICAL EYE AND VISION SERVICE DELIVERY SYSTEM
The Need for Evidence-Based Guidelines: Establishing the Baseline
Assessing Quality and Improvement Initiatives
Promoting Diagnosis and Follow-Up Care Transitions Through Integration
Workforce Training and Education to Promote Eye and Vision Health
Vision Rehabilitation Interventions and Models
Barriers and Opportunities in Vision Rehabilitation
Novel Technologies, New Therapies, and Promising Research
9 EYE AND VISION HEALTH: RECOMMENDATIONS AND A PATH TO ACTION
Translating a Conceptual Framework into Action: Recommendations
Facilitate Public Awareness Through Timely Access to Accurate and Locally Relevant Information
Generate Evidence to Guide Policy Decisions and Evidence-Based Actions
Expand Access to Appropriate Clinical Care
Enhance Public Health Capacities to Support Vision-Related Activities
Promote Community Actions That Encourage Eye- and Vision-Healthy Environments
Acronyms and Abbreviations
AAMC | Association of American Medical Colleges |
AAN | American Academy of Neurology |
AAO | American Academy of Ophthalmology |
AAP | American Academy of Pediatrics |
AAPOS | American Association for Pediatric Ophthalmology and Strabismus |
ACA | Patient Protection and Affordable Care Act of 2010 |
ACF | Administration for Children and Families |
ACO | accountable care organization |
ACVREP | Academy for Certification of Vision Rehabilitation and Education Professionals |
ADA | Americans with Disabilities Act of 1990 |
ADL | activity of daily living |
AER | Association for Education and Rehabilitation of the Blind and Visually Impaired |
AFB | American Foundation for the Blind |
AHRQ | Agency for Healthcare Research and Quality |
AMD | age-related macular degeneration |
APHA | American Public Health Association |
ASPPH | Association of Schools and Programs of Public Health |
AOA | American Optometric Association |
AOTA | American Occupational Therapy Association |
AUPO | Association of University Professors of Ophthalmology |
AWV | annual wellness visit |
BLS | Bureau of Labor Statistics |
BPEDS | Baltimore Pediatric Eye Disease Study |
BPHC | Bureau of Primary Health Care |
BRFSS | Behavioral Risk Factor Surveillance System |
BROS | Blind Rehabilitation Outpatient Specialist |
CCG | categorical condition group |
CCTV | closed caption television |
CDC | Centers for Disease Control and Prevention |
CEA | Cost-Effectiveness Analysis |
CED | coverage with evidence development |
CHC | community health center |
CHIP | Children’s Health Insurance Program |
CHNA | community health needs assessment |
CLVT | certified low vision therapist |
CMS | Centers for Medicare & Medicaid Services |
COMS | certified orientation and mobility specialist |
CQI | continuous quality improvement |
CVRT | certified vision rehabilitation therapist |
DME | diabetic macular edema |
DoD | U.S. Department of Defense |
DOL | U.S. Department of Labor |
DOT | U.S. Department of Transportation |
DSI | dual sensory impairment |
ED | U.S. Department of Education |
EEOC | Equal Employment Opportunity Commission |
EHR | electronic health record |
EPA | U.S. Environmental Protection Agency |
EPSDT | early and periodic screening, diagnostic, and treatment |
FDA | U.S. Food and Drug Administration |
FEDVIP | Federal Employees Dental and Vision Insurance Program |
FPL | federal poverty level |
FQHC | federally qualified health center |
FSA | flexible spending account |
HEED | Health Economics Evaluations Database |
HHS | U.S. Department of Health and Human Services |
HRA | health risk assessment |
HRSA | Health Resources and Services Administration |
HSA | health savings account |
HUD | U.S. Department of Housing and Urban Development |
ICD | International Classification of Diseases |
IDEA | Individuals with Disabilities Education Act |
IHS | Indian Health Service |
ILVS | interdisciplinary low vision service |
IPPE | initial preventive physical exam |
IOL | intraocular lens |
IOM | Institute of Medicine |
IOP | intraocular pressure |
KAP | Knowledge, Attitudes, and Practices |
LALES | Los Angeles Latino Eye Study |
LCD | local coverage determination |
LCIF | Lions Club International Foundation |
LHD | local health department |
MCBS | Medicare Claims Beneficiary Survey |
MCHB | multicultural health broker |
MEPEDS | Multi-Ethnic Pediatric Eye Disease Study |
MEPS | Medicare Expenditure Panel Survey |
NAAL | National Assessment of Adult Literacy |
NACCHO | National Association of County and City Health Officials |
NACDD | National Association of Chronic Disease Directors |
NAMCS | National Ambulatory Medical Care Survey |
NAPVI | National Association for Parents of Children with Vision Impairments |
NBEO | National Board of Examiners in Optometry |
NCD | national coverage determination |
NCQA | National Committee for Quality Assurance |
NEHEP | National Eye Health Education Program |
NEI | National Eye Institute |
NEOS | New England Ophthalmological Society |
NHAMC | National Hospital Ambulatory Medical Care Survey |
NHANES | National Health and Nutrition Examination Survey |
NHIS | National Health Interview Survey |
NHS EED | National Health Service Economic Evaluation Database |
NHSC | National Health Service Corps |
NIDDK | National Institute of Diabetes and Digestive and Kidney Diseases |
NIH | National Institutes of Health |
NIOSH | National Institute for Occupational Safety and Health |
NQF | National Quality Forum |
NRT | nicotine replacement therapy |
OHPDP | Office of Health Promotion and Disease Prevention |
OSHA | Occupational Safety and Health Administration |
PACT | Patient Aligned Care Team |
PBA | Prevent Blindness America |
PCMH | patient-centered medical home |
PEP | protective eyewear promotion |
PHAB | Public Health Accreditation Board |
PHD | public health department |
QALY | quality-adjusted life year |
QOL | quality of life |
RCT | randomized controlled trial |
RLSB | Royal London Society for Blind People |
ROC | Resuscitations Outcomes Consortium |
SES | socioeconomic status |
TAYE | Think About Your Eyes |
USDA | U.S. Department of Agriculture |
USPSTF | U.S. Preventive Services Task Force |
UV | ultraviolet |
VA | U.S. Department of Veterans Affairs |
VEGF | vascular endothelial growth factor |
VHI | Vision Health Initiative |
VHIPP | Vision Health Integration and Preservation Program |
VISOR | Vision Impairment Services in Outpatient Rehabilitation |
VPUS | Vision Problems in the U.S. |
VSP | Vision Service Plan |
WHO | World Health Organization |
Preface
Losing one’s eyesight, at any age, is frightening. That fear has merit: compared to their peers, people with vision loss have reduced independence and quality of life, lower performance in school, lower wages and job attainment, and higher health costs. Fortunately, two of the most common causes of vision loss among adults (i.e., refractive errors and cataracts) can be readily treated with proper access to, and utilization of, currently available care. This report estimates that undiagnosed or untreated refractive error alone affects between 8.2 and 15.9 million people in the United States. Uncorrectable vision impairment affects another 6.4 million people. The toll of correctable vision loss among children who do not received adequate detection, follow-up, and treatment is troubling. Ensuring that people receive proper visual acuity screenings and preventive eye care services and adhere to effective eye protection practices would eliminate thousands of preventable or correctable cases of vision impairment that result each year from amblyopia and eye injuries. Success in simply applying current knowledge would reduce significant health care disparities, because avoidable vision loss disproportionately affects minorities and the poor. Failure of the United States to address these sources of preventable suffering and disparity is simply not acceptable.
But the population health imperative for eye health does not end with eliminating avoidable vision loss. Even if all vision impairment due to refractive errors, cataracts, or avoidable conditions vanished, millions of people would still be visually impaired. Although recent advances in eye care are impressive and have reduced the vision loss that results from genetic conditions and common, age-related eye diseases (e.g., age-related
macular degeneration, glaucoma, diabetic retinopathy), there remains no cure. Due to the aging of our population and the strongly age-related incidence of many eye diseases, we project a near doubling, by 2050, in the prevalence of “chronic vision impairment.” The good news for people living with vision impairment and blindness is that vision impairment is a surmountable obstacle. With proper training, equipment, and accommodations, people with vision impairment can lead independent, productive, joyful lives. The problem is that many individuals today do not receive the full complement of resources they need to overcome vision-related disability.
An important and immediate population health need is to bolster our ability as a nation to manage the rising challenge of chronic vision impairment. Despite enormous potential costs for individuals, caregivers, and society, chronic vision impairment receives little emphasis in most national and public health agendas focused on chronic conditions. Chronic vision impairment frequently co-occurs with, and may be a risk factor for, many comorbid conditions including other sensory impairments, depression, anxiety, and cognitive impairment. Comorbidities add to the challenge of living with and accommodating vision loss, and in turn, vision impairment complicates one’s ability to manage other health conditions. Due to its prevalence and potential interference with other health domains, chronic vision impairment must not only receive greater attention as a chronic condition in its own right, but also be a part of all dialogues and action plans geared toward maximizing health and well-being in an aging society.
The primary goal of this Committee was to outline population health strategies to promote eye health and reduce vision impairment and its consequences in the United States. The ultimate objective is straight-forward: (1) no person should live with vision impairment that could have been avoided or could be treated and (2) every person with chronic vision impairment should have access to community and health services that minimize the impact of vision loss on overall health and life. Making this objective a reality will be complicated. It will require action from national, state, and local stakeholders. It will require practical changes to policies and systems as well as cultural changes that involve shifts in paradigms and ways of thinking.
This report represents the collective conclusions and recommendations of a diverse group of experts, each of whom brought their expertise and perspectives. The Committee recognizes and salutes the many devoted people across the nation already working tirelessly to promote eye and vision health and lessen the burden of vision impairment. This report emphasizes the need to address the underlying social and environmental conditions that contribute to unacceptable health disparities as well as to make quality clinical eye care and support services available to everyone. To accomplish this will take the concerted action of eye professionals, payers,
clinical care systems, public health, and community organizations. We can eliminate preventable vision loss and ensure that each person with chronic vision impairment has every opportunity to live a full and productive life. We need to do so.
Steven M. Teutsch, Chair
Committee on Public Health Approaches to Reduce Vision Impairment and Promote Eye Health