Pragmatic randomized trial of a distress screening program using an effectiveness-implementation hybrid design.

5 Background: Implementation of guideline-recommended distress screening in oncology remains challenging. Evidence suggests that multicomponent care pathways to identify distress severity with algorithm-based referral and management are effective, yet testing of pragmatic implementation in community settings remains limited. We conducted a pragmatic randomized trial of a distress screening program in a large healthcare system to evaluate effectiveness and simultaneously examined implementation outcomes. Methods: We designed a highly pragmatic study per the Pragmatic-Explanatory Continuum Indicator Summary-2 with adaptive workflow design. Randomization was at the medical center level (N=6); eligible patients had a new diagnosis of breast cancer (no exclusions). Eligible patients were offered the distress screening program as part of usual care: PHQ-9 screening, algorithm-based scoring and referral, referral tracking, and audit and feedback of performance data. Control sites had access to the PHQ-9 and scoring algorithm. We compared number screened, distress severity, and referral. We conducted qualitative interviews with stakeholders on implementation barriers and facilitators. Results: We enrolled 1,436 eligible patients; 692 control, 744 intervention. Groups were similar in demographic and tumor characteristics (Table); 80% of patients completed screening at intervention sites vs <1% at control sites. Of those screened at intervention sites, 10% scored in the medium/high range indicating need for referral; 94% received an appropriate referral. We conducted 20 interviews; the program was found to be highly feasible and acceptable. Conclusions: Our pragmatic, adaptive approach resulted in the large majority of patients screened and appropriately referred with a high degree of acceptability and feasibility. Our results can promote more widespread, sustained adoption of effective distress screening programs. Clinical trial information: NCT02941614. [Table: see text]

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Techniques' Comparison and Report of the North Carolina Experience

PEDIATRICS ◽

10.1542/peds.83.5.843 ◽

1989 ◽

Vol 83 (5) ◽

pp. 843-848

Author(s):

Thomas R. Kinney ◽

Martha Sawtschenko ◽

Mary Whorton ◽

Jean Shearin ◽

Christy Stine ◽

...

Keyword(s):

North Carolina ◽

Filter Paper ◽

Screening Program ◽

Medical Center ◽

Sample Collection ◽

Capillary Tubes ◽

Blood Samples ◽

Screening Programs ◽

The North ◽

Duke University

Controversy still exists as to the best laboratory method to use to screen newborns for sickle cell disease and other hemoglobinopathies. The proposed methods include hemoglobin electrophoresis, column chromatography, isoelectric focusing, and high performance liquid chromatography. There is also debate concerning the preferred method of sample collection. The proposed methods of sample collection include cord blood or blood obtained from the infant collected in a tube with anticoagulant or on filter paper. We compared hemoglobin electrophoresis patterns from infant blood samples collected in heparinized capillary tubes and on filter paper. This comparison was performed because hemoglobin electrophoresis of dried blood samples collected on filter paper has been advocated as a practical, reliable, and inexpensive method for mass screening programs, although the limitations of this technique have not been explored fully. We also summarize data from the North Carolina Newborn Hemoglobinopathy Screening Program, which relates to the advantages and limitations of hemoglobin electrophoresis from filter paper blood specimens. MATERIALS AND METHODS Specimens Four sets of specimens were used for this study: (1) specimens collected at Duke University Medical Center to compare hemoglobin electrophoresis patterns of hemolysates from filter paper and heparinized capillary tubes, (2) specimens collected by the North Carolina program for hemoglobinopathy screening, (3) specimens routinely collected at Duke University in heparinized capillary tubes for newborn hemoglobinopathy screening, and (4) samples for retesting to examine the error rate of the state program and to confirm screening results compatible with a hemoglobinopathy. Samples for Direct Comparison Between Filter Paper and Heparinized Specimens

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Promoting De-Implementation of Inappropriate Antimicrobial Use in Cardiac Device Procedures By Expanding Audit and Feedback: Protocol for Hybrid III Type Effectiveness/ Implementation Quasi-Experimental Study

10.21203/rs.3.rs-1149610/v1 ◽

2021 ◽

Author(s):

Westyn Branch-Elliman ◽

Rebecca Lamkin ◽

Marlena Shin ◽

Hillary J Mull ◽

Isabella Epshtein ◽

...

Keyword(s):

Clinical Outcomes ◽

Qualitative Interviews ◽

Inappropriate Prescribing ◽

Audit And Feedback ◽

Primary Study ◽

Antimicrobial Use ◽

Provider Education ◽

Implementation Barriers ◽

Cardiac Device ◽

Formative Evaluations

Abstract Background: Despite a strong evidence base and clinical guidelines specifically recommending against prolonged post-procedural antimicrobial use, studies indicate that the practice is common following cardiac device procedures. Formative evaluations conducted by the study team suggest that inappropriate antimicrobial use may be driven by information silos that drive provider belief that antimicrobials are not harmful, in part due to lack of complete feedback about all types of clinical outcomes. De-implementation is recognized as an important area of research that can lead to reductions in unnecessary, wasteful, or harmful practices, such as excess antimicrobial use following cardiac device procedures; however, investigations into strategies that lead to successful de-implementation are limited. The overarching hypothesis to be tested in this trial is that a bundle of implementation strategies that includes audit and feedback about direct patient harms caused by inappropriate prescribing can lead to successful de-implementation of guideline-discordant care.Methods: We propose a Hybrid Type III effectiveness-implementation stepped-wedge intervention trial at three high-volume, high-complexity VA medical centers. The main study intervention (an informatics-based, real-time audit-and-feedback tool) was developed based on learning/unlearning theory and formative evaluations and guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) Framework. Elements of the bundled and multifaceted implementation strategy to promote appropriate prescribing will include audit-and-feedback reports that include information about antibiotic harms, stakeholder engagement, patient and provider education, identification of local champions, and blended facilitation. The primary study outcome is adoption of evidence-based practice (de-implementation of inappropriate antimicrobial use). Clinical outcomes (cardiac device infections, acute kidney injuries and Clostridioides difficile infections) are secondary. Qualitative interviews will assess relevant implementation outcomes (acceptability, adoption, fidelity, feasibility).Discussion: De-implementation theory suggests that factors that may have a particularly strong influence on de-implementation include strength of the underlying evidence, the complexity of the intervention, and patient and provider anxiety and fear about changing an established practice. This study will assess whether a multifaceted intervention mapped to identified de-implementation barriers leads to measurable improvements in provision of guideline-concordant antimicrobial use. Findings will improve understanding about factors that impact successful or unsuccessful de-implementation of harmful or wasteful healthcare practices.Trial Registration: Clinicaltrials.gov (NCT05020418)

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Assessing the Community Context When Implementing Cervical Cancer Screening Programs

10.1093/med/9780190647421.003.0032 ◽

2018 ◽

Author(s):

Prajakta Adsul ◽

Purnima Madhivanan

Keyword(s):

Cervical Cancer ◽

Cancer Screening ◽

Cervical Cancer Screening ◽

Cultural Context ◽

Health Workers ◽

Screening Program ◽

Qualitative Interviews ◽

Community Context ◽

Successful Implementation ◽

Screening Programs

This case study demonstrates the use of qualitative, community-based, participatory research to understand the context in which cervical cancer screening programs are implemented in rural India, thereby enabling not just successful implementation but also future sustainability of the program in the community. A series of studies were undertaken to understand the cervical cancer screening program in its current state and provide information for the implementation of future programs. These studies included (1) qualitative interviews with physicians delivering cervical cancer care in the private and public sector, (2) focus group discussions with health workers in primary health care clinics, and (3) photovoice study with women residing in the communities. Study findings helped identify elements of the social and cultural context of rural communities, thereby providing a rich understanding of factors influencing of cervical cancer screening that can be integrated into pre-intervention capacity development in the future.

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223Atrial fibrillation screen, management and guideline recommended therapy (AF SMART II) in the rural primary care setting: eHealth tools to support all stages of screening

EP Europace ◽

10.1093/europace/euaa162.082 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

J Orchard ◽

J Li ◽

B Freedman ◽

R Webster ◽

C Hespe ◽

...

Keyword(s):

General Practice ◽

Treatment Guidelines ◽

Screening Program ◽

Oral Anticoagulants ◽

Audit And Feedback ◽

Screening Process ◽

Screening Programs ◽

Electronic Screening ◽

General Practices ◽

The Impact

Abstract Funding Acknowledgements National Heart Foundation of Australia: CVRN Grant and Vanguard Grant; investigator-initiated grant from Pfizer-BMS; AliveCor provided free devices BACKGROUND Internationally, most atrial fibrillation (AF) management guidelines recommend screening for AF in people aged ≥65 years, as well as treatment with oral anticoagulants (OAC) for those at high stroke risk ( CHA2DS2-VA ≥2). However, in practice, gaps remain in both screening and treatment. In Australian general practice in 2017, the estimated rate of AF screening was 11%, and only about 60% of diagnosed AF patients received guideline-based OAC. Our 2018 screening study using eHealth tools in metropolitan general practices increased screening to 16% of eligible patients, leading to further refinement of the eHealth tools. PURPOSE To investigate the impact of an AF screening program in rural general practices, using a suite of custom-designed eHealth tools designed to increase the proportion screened and treated for AF in accordance with guidelines. METHODS General practices (n = 8) in rural New South Wales, Australia participated in the study between September 2018 – June 2019. General practitioners (GPs) and practice nurses conducted opportunistic screening of eligible patients (i.e. aged ≥65 years without existing AF diagnosis) using a smartphone electrocardiogram during practice visits. Practices were also provided with 1) an electronic screening prompt (which appeared when an eligible patient’s file was opened); 2) electronic decision support based on ESC/Australian treatment guidelines; and 3) regular customised data reports aimed at quality improvement (Figure 1). A clinical audit tool was used to extract deidentified data from practices. RESULTS A total of 3,103 eligible patients (mean age 75.1 ± 6.8 years, 47% male) who attended the 8 practices during the study period were screened (median screening period 4.6 months). Practices screened a median of 35% of eligible patients (range 9-51% per practice), with 4/8 practices screening >40% of eligible patients. 36 (1.2%) new cases of AF were confirmed (mean age 77.0 years, 64% male, mean CHA2DS2-VA = 2.9). GPs (n = 22) screened 30% (range 1-182 per GP) of patients and nurses (n = 40) screened 70% (range 1-192 per nurse). OAC treatment rates of patients with AF with CHA2DS2-VA≥2 were 82% (screen-detected), 78% (clinically-detected during study period) and 75% (pre-existing AF), with no significant differences between groups. CONCLUSIONS In the rural general practice setting, an AF screening program supported by eHealth tools resulted in 35% of eligible people screened, which is substantially higher than the 16% achieved in our previous study. Half the practices screened 40-50% of eligible patients, suggesting this may represent a ‘ceiling’ of patients captured by opportunistic AF screening programs. OAC treatment rates were higher than previous studies at baseline and were trending upwards during the study. eHealth tools, particularly including customised data reports as part of an audit and feedback system, may be a valuable addition to future screening programs. Abstract Figure 1 - screening process

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1277. Universal Screening Is Key: Identifying Gaps in Adolescent HIV Infection Diagnosis at Local Pediatric Health System When Compared With Regional Adult Hospital

Open Forum Infectious Diseases ◽

10.1093/ofid/ofy210.1110 ◽

2018 ◽

Vol 5 (suppl_1) ◽

pp. S389-S389

Author(s):

Zachary Most ◽

Lorraine James ◽

Gohar Warraich ◽

Kathleen Costello ◽

Stephen Dietz ◽

...

Keyword(s):

Hiv Infection ◽

Universal Screening ◽

Negative Impact ◽

Screening Program ◽

Medical Center ◽

Hiv Screening ◽

Hiv Diagnosis ◽

Screening Programs ◽

Hiv Test ◽

Missed Opportunity

Abstract Background Undiagnosed sexual partners with HIV infection may contribute to up to 30% of new infections annually. Routine HIV screening of high-risk populations has been shown to be effective and is recommended by the CDC. Despite this recommendation, many adolescents are not screened. The negative impact on the adolescent population from inadequate screening has not been fully quantified. Methods Through a retrospective chart review, the course prior to diagnosis of HIV-infected adolescents diagnosed at Children’s Medical Center Dallas (CMC) and Parkland Hospital (PH, the proximate adult county hospital with a universal HIV screening program) was reviewed. Subjects were included if they had a confirmed, positive HIV test between 13 and 21 years of age, and excluded if they had a previous HIV diagnosis. Inpatient, outpatient, and ED encounters at CMC and PH following the subjects’ 13th birthday and before their HIV diagnosis were quantified. Missed opportunity encounters (MOE) were defined as above encounters where there was no HIV screen performed that took place after the date 3 months following their most recent HIV screen. Data were collated by facility and compared. Results 204 subjects met inclusion criteria: 140 (69%) male, 155 (76%) black, and 87 (43%) followed by CMC. There were 412 total encounters (2.02 per subject) out of which 284 (1.39 per subject) qualified as MOE. Seventy-two subjects had at least one MOE. At the CMC ED, there were 6.7 MOE for every new HIV adolescent diagnosis, compared with PH ED where there were 0.9 (P < 0.01) (Figure 1). Adolescents identified through the PH ED were older (PH, 18.8 years vs. CMC, 16.1 years, P < 0.01) (Figure 2), and had a trend toward a lower CD4 count (PH, 337 cells/m3 vs. CMC, 449 cells/m3, ns). Three adolescents were identified with AIDS (CD4 <200) through HIV screening at PH, vs. 1 at the CMC ED. Conclusion Missed opportunity encounters for HIV screening of adolescents are greater in number in pediatric emergency departments without universal screening programs, when compared with similar adult settings with such a program. Implementing a universal HIV screening protocol at pediatric EDs in HIV endemic areas may help to identify HIV-positive adolescents at younger ages and improve long-term outcomes. Disclosures All authors: No reported disclosures.

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See, Test & Treat: A 5-Year Experience of Pathologists Driving Cervical and Breast Cancer Screening to Underserved and Underinsured Populations

Archives of Pathology & Laboratory Medicine ◽

10.5858/arpa.2016-0094-sa ◽

2016 ◽

Vol 140 (12) ◽

pp. 1411-1422

Author(s):

Barbarajean Magnani ◽

Beth Harubin ◽

Judith F. Katz ◽

Andrea L. Zuckerman ◽

William C. Strohsnitter

Keyword(s):

Breast Cancer ◽

Cancer Screening ◽

Breast Cancer Screening ◽

Screening Program ◽

Medical Center ◽

Academic Medical Center ◽

Medical Specialties ◽

Screening Programs ◽

Cancer Screening Program ◽

Current Health Care System

Context.— See, Test & Treat is a pathologist-driven program to provide cervical and breast cancer screening to underserved and underinsured patient populations. This program is largely funded by the CAP Foundation (College of American Pathologists, Northfield, Illinois) and is a collaborative effort among several medical specialties united to address gaps in the current health care system. Objective.— To provide an outline for administering a See, Test & Treat program, using an academic medical center as a model for providing care and collating the results of 5 years of data on the See, Test & Treat program's findings. Design.— Sources include data from patients seen at Tufts Medical Center (Boston, Massachusetts) who presented to the See, Test & Treat program and institutional data between 2010 and 2014 detailing the outline of how to organize and operationalize a volunteer cancer-screening program. Results.— During the 5-year course of the program, 203 women were provided free cervical and breast cancer screening. Of the 169 patients who obtained Papanicolaou screening, 36 (21.3%) had abnormal Papanicolaou tests. In addition, 16 of 130 patients (12.3%) who underwent mammography had abnormal findings. Conclusions.— In general, women from ethnic populations have barriers that prevent them from participating in cancer screening. However, the CAP Foundation's See, Test & Treat program is designed to reduce those barriers for these women by providing care that addresses cultural, financial, and practical issues. Although screening programs are helpful in identifying those who need further treatment, obtaining further treatment for these patients continues to be a challenge.

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Human Papillomavirus Selected Properties and Related Cervical Cancer Prevention Issues

Current Pharmaceutical Design ◽

10.2174/1381612826666200422094205 ◽

2020 ◽

Vol 26 (18) ◽

pp. 2073-2086

Author(s):

Saule Balmagambetova ◽

Andrea Tinelli ◽

Ospan A. Mynbaev ◽

Arip Koyshybaev ◽

Olzhas Urazayev ◽

...

Keyword(s):

Cervical Cancer ◽

Human Papillomavirus ◽

Cancer Prevention ◽

Screening Program ◽

Hpv Infection ◽

Cervical Cancer Prevention ◽

Point Of View ◽

Prevention Strategies ◽

Middle Income ◽

Screening Programs

High-risk human papillomavirus strains are widely known to be the causative agents responsible for cervical cancer development. Aggregated damage caused by papillomaviruses solely is estimated in at least 5% of all malignancies of the human body and 16% in cancers that affect the female genital area. Enhanced understanding of the complex issue on how the high extent of carcinogenicity is eventually formed due to the infection by the Papoviridae family would contribute to enhancing current prevention strategies not only towards cervical cancer, but also other HPV associated cancers. This review article is aimed at presenting the key points in two directions: the current cervical cancer prevention and related aspects of HPV behavior. Virtually all applied technologies related to HPV diagnostics and screening programs, such as HPV tests, colposcopy-based tests (VIA/VILI), conventional and liquid-based cytology, currently available are presented. Issues of availability, advantages, and drawbacks of the screening programs, as well as vaccination strategies, are also reviewed in the article based on the analyzed sources. The current point of view regarding HPV is discussed with emphasis on the most problematic aspect of the HPV family concerning the observed increasing number of highly carcinogenic types. Present trends in HPV infection diagnostics throughout the human fluids and tissues are also reported, including the latest novelties in this field, such as HPV assay/self-sample device combinations. Besides, a brief outline of the related prevention issues in Kazakhstan, the leading country of Central Asia, is presented. Kazakhstan, as one of the post-soviet middle-income countries, may serve as an example of the current situation in those terrains, concerning the implementation of globally accepted cervical cancer prevention strategies. Along with positive achievements, such as the development of a nationwide screening program, a range of drawbacks is also analyzed and discussed.

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Accuracy of emergency physicians’ self-estimates of CT scan utilization and its potential effect on an audit and feedback intervention: a randomized trial

Implementation Science Communications ◽

10.1186/s43058-021-00182-1 ◽

2021 ◽

Vol 2 (1) ◽

Author(s):

Celine Larkin ◽

Alexandra M. Sanseverino ◽

James Joseph ◽

Lauren Eisenhauer ◽

Martin A. Reznek

Keyword(s):

Randomized Trial ◽

Repeated Measures ◽

Intervention Group ◽

Potential Effect ◽

Audit And Feedback ◽

Emergency Physicians ◽

Feedback Intervention ◽

Experimental Conditions ◽

Actual Performance ◽

Ct Utilization

Abstract Background Audit and feedback (A&F) has been used as a strategy to modify clinician behavior with moderate success. Although A&F is theorized to work by improving the accuracy of clinicians’ estimates of their own behavior, few interventions have included assessment of clinicians’ estimates at baseline to examine whether they account for intervention success or failure. We tested an A&F intervention to reduce computed tomography (CT) ordering by emergency physicians, while also examining the physicians’ baseline estimates of their own behavior compared to peers. Methods Our study was a prospective, multi-site, 20-month, randomized trial to examine the effect of an A&F intervention on CT ordering rates, overall and by test subtype. From the electronic health record, we obtained 12 months of baseline CT ordering per 100 patients treated for every physician from four emergency departments. Those who were randomized to receive A&F were shown a de-identified graph of the group’s baseline CT utilization, asked to estimate wherein the distribution of their own CT order practices fell, and then shown their actual performance. All participants also received a brief educational intervention. CT ordering rates were collected for all physicians for 6 months after the intervention. Pre-post ordering rates were compared using independent and repeated measures t tests. Results Fifty-one of 52 eligible physicians participated. The mean CT ordering rate increased significantly in both experimental conditions after the intervention (intervention pre = 35.7, post = 40.3, t = 4.13, p < 0.001; control pre = 33.9, post = 38.9, t = 3.94, p = 0.001), with no significant between-group difference observed at follow-up (t = 0.43, p = 0.67). Within the intervention group, physicians had poor accuracy in estimating their own ordering behavior at baseline: most overestimated and all guessed that they were in the upper half of the distribution of their peers. CT ordering increased regardless of self-estimate accuracy. Conclusions Our A&F intervention failed to reduce physician CT ordering: our feedback to the physicians showed most of them that they had overestimated their CT ordering behavior, and they were therefore unlikely to reduce it as a result. After “audit,” it may be prudent to assess baseline clinician awareness of behavior before moving toward a feedback intervention.

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Adrenoleukodystrophy Newborn Screening in California Since 2016: Programmatic Outcomes and Follow-Up

International Journal of Neonatal Screening ◽

10.3390/ijns7020022 ◽

2021 ◽

Vol 7 (2) ◽

pp. 22

Author(s):

Jamie Matteson ◽

Stanley Sciortino ◽

Lisa Feuchtbaum ◽

Tracey Bishop ◽

Richard S. Olney ◽

...

Keyword(s):

Newborn Screening ◽

Program Implementation ◽

Screening Program ◽

Birth Prevalence ◽

Variant Of Uncertain Significance ◽

Implementation Challenges ◽

Screening Programs ◽

Uncertain Significance ◽

Long Term Follow Up

X-linked adrenoleukodystrophy (ALD) is a recent addition to the Recommended Uniform Screening Panel, prompting many states to begin screening newborns for the disorder. We provide California’s experience with ALD newborn screening, highlighting the clinical and epidemiological outcomes observed as well as program implementation challenges. In this retrospective cohort study, we examine ALD newborn screening results and clinical outcomes for 1,854,631 newborns whose specimens were received by the California Genetic Disease Screening Program from 16 February 2016 through 15 February 2020. In the first four years of ALD newborn screening in California, 355 newborns screened positive for ALD, including 147 (41%) with an ABCD1 variant of uncertain significance (VUS) and 95 males diagnosed with ALD. After modifying cutoffs, we observed an ALD birth prevalence of 1 in 14,397 males. Long-term follow-up identified 14 males with signs of adrenal involvement. This study adds to a growing body of literature reporting on outcomes of newborn screening for ALD and offering a glimpse of what other large newborn screening programs can expect when adding ALD to their screening panel.

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Epidemiological Findings of Refractive Errors and Amblyopia among the Schoolchildren in Hatta Region of the United Arab Emirates

Dubai Medical Journal ◽

10.1159/000512521 ◽

2021 ◽

pp. 1-7

Author(s):

Salam Chettian Kandi ◽

Hayat Ahmad Khan

Keyword(s):

Visual Acuity ◽

Visual Field ◽

United Arab Emirates ◽

Refractive Error ◽

Screening Program ◽

Low Vision ◽

Refractive Errors ◽

Vision Screening ◽

Screening Programs ◽

School Based

Introduction: Uncorrected refractive errors and amblyopia pose a major problem affecting schoolchildren. We had previously observed that many schoolchildren in the Hatta region presented to the ophthalmology clinic with uncorrected refractive errors and amblyopia, which led us to undertake this research. As per the WHO, the term “visual impairment” can be “low vision” or “blindness.” Based on the presenting vision, “low vision” is defined for children who have vision of <6/18 to 3/60 or having visual field loss to <20° in the better-seeing eye. Children defined to have “blindness” have presenting vision of <3/60 or corresponding visual field of <10°. Purpose: To estimate the magnitude of uncorrected refractive errors and amblyopia among the schoolchildren aged 6–19 years and to assess the efficacy of school-based refractive error screening programs in the Hatta region of the United Arab Emirates. Methods: An epidemiological, cross-sectional, descriptive study was conducted on the entire student population studying in the government schools of the region. Those who failed the Snellen visual acuity chart test and those who were wearing spectacles were evaluated comprehensively by the researcher in the Department of Ophthalmology of the Hatta Hospital. Data were entered in the Refractive Error Study in School Children (RESC) eye examination form recommended by the WHO, and were later transferred to Excel sheets and analyzed by SPSS. Results: 1,591 students were screened and evaluated from the end of 2016 to mid-2017. About 21.37% (n = 340) had impaired vision with 20.9% (n = 333) refractive errors, of which 58% were uncorrected. Among the refractive error group, 19% (64 subjects) had amblyopia (4% of total students). The incidence of low vision was 9.5% and blindness was 0.38%. Low vision was found to be 9.5% and blindness 0.38%, taking in to account presenting visual acuity rather than best-corrected visual acuity for defining low vision and blindness. Conclusion: A significant number of students were detected to have uncorrected refractive errors among the vision impaired group (59%, n = 197) despite a school-based vision screening program in place. Seventy-eight percent of the amblyopia cases (n = 50) were found to be in the 11–19 years age group. Noncompliance with optical corrections was the reason for the high number of cases. A rigorous vision screening program and refractive services, complimented with awareness among parents and teachers, are recommended.

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