Attachment D -- Public Comments from the American Optometric Assoc

243 N. Lindbergh Blvd  St. Louis, MO 63141 Blvd  (314) 991‐4100 

June 18, 2012
Doris Lefkowitz
Reports Clearance Officer
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850
Ms. Lefkowitz,
The American Optometric Association (AOA) submits these timely comments in response to the
the Agency for Healthcare Research and Quality (AHRQ) request for the Office of Management
and Budget (OMB) to approve the proposed information collection project: ‘‘CHIPRA Pediatric
Quality Measures Program Candidate Measure Submission Form.’’ The AOA represents
approximately 36,000 doctors of optometry, optometry students and paraoptometric assistants
and technicians and appreciates the opportunity to provide comment on this measure submission
form.
The AOA has followed the work of the National Advisory Council for Healthcare Research and
Quality (AHRQ NAC) Subcommittee on Children’s Healthcare Quality Measures for Medicaid
and CHIP Programs (SNAC). The AOA has attended recent SNAC meetings and, when needed,
has provided input as the committee recommends quality measures related to children’s health
care in the Medicaid and CHIP programs.
Understanding the need for some uniformity between federal clinical quality measure programs,
the AOA appreciates the consistency between the AHRQ Pediatric Quality Measures Program
Candidate Measure Submission Form and the criteria that the National Quality Forum’s (NQF)
Measures Applications Partnership (MAP) developed for measure selection. The four criterion
for NQF endorsement are: “1) Importance to measure and report 2) Scientific acceptability of the
measurement properties 3) Usability and 4) Feasibility.” These criteria track with AHRQ’s
request for information which solicits input regarding the importance of the proposed measure,
scientific soundness of the proposed measure, and understandability and feasibility of the
proposed measure. The AOA was pleased to see the similarities in the NQF MAP measure
selection criteria and the information that AHRQ has proposed to obtain from those submitting
measures for consideration in the Medicaid and CHIP programs.
The AOA also understands AHRQ’s requirement for measure submitters to provide research
evidence regarding the relationship between a structure or process of health care that influences
outcomes or an outcome that is influenced by a structure or process of health care. The
requirement for measure submitters to provide key findings along with key citations will be
helpful in ensuring that the quality measures incorporated in CHIP and Medicaid are truly

evidence based and not based on processes that have simply become common. As an example,
in the past, the SNAC discussed the possibility of recommending a measure related to vision
screening for children. However, the direct and indirect data show that “screening” does not
adequately lead to treatment and better outcomes. Research has shown that, “Although
treatments for amblyopia or unilateral refractive error can improve vision in preschool-aged
children and screening tests have utility for identifying vision problems, additional studies are
needed to better understand the effects of screening compared with no screening.”1 The AOA
believes that data show that the majority of vision screenings fail to adequately identify millions
of children with undiagnosed and untreated vision problems including amblyopia, strabismus and
significant refractive errors. An actual eye examination by an optometrist or ophthalmologist
results in prompt diagnosis and treatment, improving health outcomes, while simple vision
screening does not. The AOA fully supported the SNAC’s previous determination not to include
the “vision screening measure” in the core set of 25 measures that the Committee recommended
to the Secretary for Medicaid and CHIP programs. AHRQ should continue to weed out
measures, such as the vision screening measure, that do little to actually improve health
outcomes.
The AOA also supports AHRQ’s effort to collect information regarding how proposed measures
identify disparities by race, ethnicity, socioeconomic status, and special health care needs.
Encouraging nominators to test measures in diverse populations is prudent as is the requirement
for measure submitters to demonstrate that the proposed measure is responsive to child health
needs. The AOA also supports AHRQ’s effort to collect information regarding whether there is
health information technology that has been or could be incorporated into the measure
calculation. AHRQ has not explicitly requested electronic measure specifications be submitted
for proposed measures and instead seems to be assessing whether electronic specifications could
be developed for the measure, if necessary. Given the time and difficulty associated with
developing appropriate electronic specifications for quality measures, the AOA appreciates that
AHRQ has not made the existence of electronic specifications a firm requirement for measure
selection and recommendation.
Finally, the AOA believes that it is critical to ensure involvement of multiple stakeholders in all
phases of quality measure development, especially in the management of chronic conditions such
as Attention Deficit Hyperactivity Disorder (ADHD). The AOA understands the need for the
specific measurement category for children with ADHD, but has ongoing concerns that vision
and eye health have not been integrated into diagnosis, treatment and management of ADHD.
The symptoms of prevalent and clinically significant hyperopia (20.9%) and convergence
insufficiency (5%) track ADHD symptomatology and yet the patient’s potential vision problems
are too often ignored either out of ignorance or because the patient might have passed a “vision
screening.” This reliance on vision screenings is problematic. Because typical vision screening
is only 27% sensitive, there are many false negative screening results. Children whose vision
problems are not identified by vision screening may receive an incorrect ADHD diagnosis
because the underlying vision problem remains undiagnosed. Ultimately, this can lead to
unnecessary ADHD treatment. As an example, the recent Convergence Insufficiency Treatment
Trials (CITT), a National Eye Institute funded study, showed that 45% of the children with

1

Pediatrics 2011; 127:e442–e479

convergence insufficiency reported attention problems. The CITT concluded that children with
parent reported ADHD, or related learning problems, may benefit from comprehensive vision
evaluation to assess for the presence of convergence insufficiency.2 Other studies of
accommodative dysfunction and convergence insufficiency found that the frequency and severity
of vision-specific symptoms were directly related to an increase in learning problems, such as
ADHD. Studies showed that cognitive problem/inattention, hyperactivity, and ADHD indices in
children with accommodative dysfunction and convergence insufficiency were significantly
different from normative values.3 It has been estimated that 10 to 20% of the 21 million ADHD
drug prescriptions written in 2011 were actually for children with uncorrected and non-diagnosed
vision problems. The AOA would like better assurances that comprehensive eye examination be
integrated into these ADHD phases of quality measure development.
On behalf of our membership and the millions of beneficiaries that our members serve, we thank
AHRQ for considering these comments and using the feedback to help improve the CHIP and
Medicaid programs. Please contact Michael Duenas, O.D. AOA Chief Public Health Officer at
MRDuenas@aoa.org or 703-837-1008 if you have questions or need additional information
about these comments.
Sincerely,

Dori Carlson, OD
President

Headquarters: 243 N Lindbergh Blvd. • St. Louis, MO 63141 • (314) 991-4100 • FAX: (314) 991-4104
Visit our World Wide Website at http://www.aoa.org

2
3

Optom Vis Sci. 2009 Oct;86(10):1169-77
Optometry. 2005 Oct;76(10):588-92.