Purpose
We previously reported costs and outcomes of the Children’s Eye Care Adherence Program (CECAP1), a social worker intervention designed to improve adherence to eye care for underserved children in urban Philadelphia. Using cost findings from CECAP1, we revised the intervention to reduce costs. The aim of this study was to evaluate costs and effectiveness of the revised intervention (CECAP2).
Design
Retrospective cohort study.
Methods
Records of children needing ophthalmic follow-up after 2 community-based vision screening programs were reviewed. We modified CECAP1 to prioritize children more likely to visit, decreased phone calls and scheduling attempts, better documented children already followed by other doctors, and constricted our geographic catchment area for better accessibility. Cost was calculated using time spent executing CECAP2 by our salaried social worker. Effectiveness was defined as the percentage of patients completing at least 1 follow-up visit within the recommended time frame.
Results
Of 462 children referred to CECAP2 from our in-school and on-campus screening programs, 242 (52.4%) completed subsequent recommended eye examinations, a proportion identical to our prior report (52.3%). Social worker time per patient was 0.8 hours; a significant reduction from the previous 2.6 hours ( P < .01). Cost per patient was $32.73; a significant reduction compared to the previous $77.20 ( P < .01).
Conclusions
Programmatic changes to reduce social worker intervention time and target potential patients by likelihood to attend along with constriction of the catchment area led to reduced costs by more than 50%, without impairing CECAP effectiveness.
M ore than 10% of children who fail community-based vision screening are referred to a pediatric ophthalmologist for suspected nonrefractive eye diseases in Philadelphia. This rate is lower than other reports from other programs as we provide correction of refractive error in the field. The most common diagnosis requiring referral is amblyopia, followed by strabismus, congenital anomalies, and ptosis. Connecting children with the care they need after vision screening can be challenging, particularly for underserved children in urban areas whose parents or guardians often face barriers to care such as inconvenience and lack of understanding about follow-up, concerns about costs, lack of effective communication methods, transportation issues, and conflicting family priorities. , Social worker interventions can help families overcome such barriers to improve attendance at follow-up eye care. ,
We previously reported strong improvement in follow-up rates following implementation of the initial Children’s Eye Care Adherence Program (CECAP1), a social worker intervention, from less than 5% prior to the intervention to nearly 60%; however, the program was costly at $77.20/case. , In an effort to improve sustainability of the program, we have subsequently explored ways of reducing costs without sacrificing high effectiveness. The majority of costs in CECAP1 were attributable to social worker time. Therefore, we focused on ways to reduce social worker intervention time and prioritize those patients who are more likely to show for their follow-up. The aim of this study is to evaluate whether this modified intervention (termed CECAP2) impacted costs and/or compliance with follow-up care.
Methods
Recruitment for CECAP2 was performed through 2 avenues, the Wills Eye Vision Screening Program for Children (WEVSPC) and Give Kids Sight Day (GKSD). WEVSPC is provided in partnership with the School District of Philadelphia (SDP) and involves vision screenings for children in grades K-5 during the academic year. All schools were in low-income areas of Philadelphia where assistance was given by our team to help schools comply with the state-mandated vision screening. Each semester, approximately 15 schools were visited. GKSD is an annual 1-day event held at Wills Eye Hospital for children in Philadelphia and surrounding areas who are younger than 19 years old. Although GKSD is open to any child seeking free eye care, efforts target uninsured or underinsured children. Approximately 1,200 children are examined through GKSD annually. The full design and methodology of the WEVSPC and GKSD have been described in detail elsewhere. ,
In accordance with state mandate, parental consent was not required for participation in the WEVSPC school screenings, because they are required school screenings conducted annually in every grade in Pennsylvania. In CECAP1, parental consent was required for children to receive glasses or participate in the social worker intervention. Consent was offered in English, Spanish, and Mandarin Chinese. The SDP shared family contact information with the WEVSPC team unless parental consent was denied. GKSD attendees completed follow-up registration forms on site. The GKSD contact information included at least 5 phone numbers, as well as alternate contacts, e-mail addresses, and physical addresses. The SDP information was less extensive. The insurance status of the GKSD attendees was verified through the on-site registration forms, but that of the WEVSPC participants was identified by the social worker contacting the parents/guardians directly.
The records of children identified as needing ophthalmic follow-up through these 2 screening programs were retrospectively reviewed. Criteria for referral are described elsewhere. , For children who were identified as needing further care, a social worker was involved to assist with scheduling an appointment at our center’s pediatric ophthalmology service. The social worker intervention included identifying and addressing barriers to follow-up ophthalmic care.
The demographic data for this study were collected from the social worker database, including age, sex, child’s grade level, medical insurance type (private insurance, public insurance, or uninsured/self-pay), and language spoken at home. Geographic region was designated based on local districts known to reflect socioeconomic status (eg, West Philadelphia, North Philadelphia). Geographic zone was defined based on distance from the hospital to reflect accessibility: zone 1 (an area within 3 miles of the hospital), zone 2 (an area between 3 and 6 miles), and zone 3 (an area more than 6 miles). All data were de-identified for analysis.
Based on our experience with CECAP1, we modified the intervention to prioritize children more likely to visit. The patients of CECAP1 who have been unable to be contacted after 3 attempts, or patients who changed their appointment more than 2 times, eventually did not show. Therefore, we decreased attempted phone calls from 6 to 3 and scheduled appointments from 3 to 2. We added documentation of whether children were already being followed by other eye doctors on the GKSD registration forms. A similar query was made of parents upon social worker contact after a child seen by the WEVSPC was identified as needing follow-up. The WEVSPC also constricted its geographic catchment area for better accessibility to the 30 schools closest to our center. In addition, we used e-mail or automated reminder calls instead of letters to remind parents of an upcoming appointment.
We termed the intervention performed with those modifications during the 2016-2018 academic years as CECAP phase 2 (CECAP2) and that done without modifications during the 2011-2012 years as CECAP1. CECAP2 included GKSD held in 2016, 2017 and WEVSPC 2016-2017 and 2017-2018, while CECAP1 included GKSD 2012 and Eagles Eye Mobile 2011-2012. The Eagles Eye Mobile, a prior community outreach program of Wills Eye Hospital, in partnership with the Philadelphia Eagles Charitable Foundation, used a mobile eye center that visited schools in low-income area of Philadelphia to examine children in grades K-8 during the academic year, similar to WEVSPC. Eagles Eye Mobile was not included as a recruitment source for CECAP2.
We compared the costs and effectiveness of CECAP2 to those of CECAP1. Costs were calculated using time spent executing CECAP1 and CECAP2 multiplied by the average wage and fringe benefits for a social worker in Philadelphia in 2018 based on data from the Bureau of Labor Statistics. Because the present study was conducted retrospectively, we inferred time for delivery of CECAP2 from the social worker’s work schedule, including time spent with patients and their parents/guardians (average 0.5 hour per patient; 1 hour per patient who spoke a non-English language at home) and time for general project management (average 0.2 hour per patient). In contrast, the CECAP1 data for social worker’s time were prospectively collected. Because CECAP1 included mailings and reminder calls, material costs for supplies and telephone services were captured from the grant expense reports. Total costs for each intervention were calculated as the sum of all social worker time costs (both interventions) plus material costs (CECAP1 only). Reimbursement amounts (revenue) were derived from insurance claims data for patients who attended their first follow-up visits, and the net cost for each intervention was calculated by subtracting reimbursements from total costs. Effectiveness was defined as the number of patients completing at least 1 follow-up visit within the recommended time frame. Demographic characteristics including geographic distribution, insurance status, and spoken languages were also compared between CECAP1 and CECAP2. To allow a direct comparison between CECAP1 and CECAP2, we updated the CECAP1 analysis using parallel methods to those used for CECAP2. Specifically, we evaluated CECAP1 costs in 2018 US dollars, and updated the sample to include an additional 8 patients who were not included in the previously published report, as they were referred in the 2011-2012 years but were lost to follow-up during the study period.
This cohort study was approved by the Wills Eye Hospital Institutional Review Board and was granted a waiver of consent as a retrospective study. All aspects of this study complied with the Health Insurance Portability and Accountability Act of 1996.
Statistical Analysis
Data analysis was performed using SAS 9.4 (SAS Institute Inc, Cary, North Carolina, USA). Comparisons of continuous variables across the 2 interventions were tested with the Wilcoxon rank sum test. Comparisons of continuous variables for >2 groups were compared using the Kruskal-Wallis test for non-normally distributed and ANOVA for normally distributed variables. Categorical variables were compared with the χ 2 test or the Fisher exact test. Multivariable logistic regression and general linear model were also performed to compare the effectiveness and costs between CECAP1 and CECAP2 after adjustment of confounding factors. A 2-sided P value less than .05 was considered statistically significant.
Results
Over the period of CECAP2, 512 of 16,126 children (3.2%) who underwent vision screening in the 2 outreach programs were identified as needing a referral to pediatric ophthalmology with suspicion of nonrefractive eye diseases. Forty-nine of these children (9.6%) were excluded because they were already followed by their own eye doctors. One family in the WEVSPC refused further eye care. Table 1 gives the demographics of the remaining 462 children alongside those of CECAP1.
| CECAP1 (N = 128) | CECAP2 (N = 462) | P Value | |
|---|---|---|---|
| Referral source GKSD School screening | 95 (74.2) 33 (25.8) | 156 (33.8) 306 (66.2) | <.01 |
| Age | 8.1 ± 3.8 | 8.1 ± 2.8 | .62 |
| 0-5 years | 39 (34.2) | 102 (24.8) | <.01 |
| 6-12 years | 63 (55.3) | 291 (70.6) | |
| ≥13 years | 12 (10.5) | 19 (4.6) | |
| Unknown | 14 | 50 | |
| Insurance type | .04 | ||
| Private | 10 (11.6) | 19 (8.0) | |
| Public | 68 (79.1) | 211 (89.0) | |
| Uninsured | 8 (9.3) | 7 (3.0) | |
| Unknown | 42 | 225 | |
| Primary language | .38 | ||
| English | 71 (88.8) | 329 (81.0) | |
| Spanish | 7 (8.8) | 56 (13.8) | |
| Chinese | 0 (0.0) | 9 (2.2) | |
| Other | 2 (2.5) | 12 (2.9) | |
| Unknown | 48 | 56 | |
| Living area | .47 | ||
| North | 20 (23.5) | 100 (25.5) | |
| South | 16 (18.8) | 108 (27.5) | |
| South-west | 3 (3.5) | 17 (4.3) | |
| West | 14 (16.5) | 50 (12.8) | |
| Central | 8 (9.4) | 25 (6.4) | |
| Other | 24 (28.2) | 92 (23.5) | |
| Unknown | 43 | 70 | |
| Zone – distance from hospital | .02 | ||
| <3 miles | 32 (37.2) | 198 (49.5) | |
| 3-6 miles | 30 (34.9) | 87 (21.8) | |
| >6 miles | 24 (27.9) | 115 (28.8) | |
| Unknown | 42 | 62 | |
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