Research Letters

Insights into inpatients with poor vision: A high value proposition

Abstract

BACKGROUND

Vision impairment is an under‐recognized risk factor for adverse events among hospitalized patients, yet vision is neither routinely tested nor documented for inpatients. Low‐cost ($8 and up) nonprescription “readers” may be a simple, high‐value intervention to improve inpatients' vision. We aimed to study initial feasibility and efficacy of screening and correcting inpatients' vision.

METHODS

From June 2012 through January 2014 we began testing whether participants' vision corrected with nonprescription lenses for eligible participants failing a vision screen (Snellen chart) performed by research assistants (RAs). Descriptive statistics and tests of comparison, including t tests and χ2 tests, were used when appropriate. All analyses were performed using Stata version 12 (StataCorp, College Station, TX).

RESULTS

Over 800 participants' vision was screened (n = 853). Older (≥65 years; 56%) participants were more likely to have insufficient vision than younger (<65 years; 28%; P < 0.001). Nonprescription readers corrected the majority of eligible participants' vision (82%, 95/116).

DISCUSSION

Among an easily identified subgroup of inpatients with poor vision, low‐cost readers successfully corrected most participants' vision. Hospitalists and other clinicians working in the inpatient setting can play an important role in identifying opportunities to provide high‐value care related to patients' vision. Journal of Hospital Medicine 2015;10:311–313. © 2015 Society of Hospital Medicine

© 2015 Society of Hospital Medicine

Vision impairment is an under‐recognized risk factor for adverse events among hospitalized patients.[1, 2, 3] Inpatients with poor vision are at increased risk for falls and delirium[1, 3] and have more difficulty taking medications.[4, 5] They may also be at risk for being unable to read critical health information, including consent forms and discharge instructions, or decreased quality of life such as simply ordering food from menus. However, vision is neither routinely tested nor documented for inpatients. Low‐cost ($8 and up) nonprescription reading glasses, known as readers may be a simple, high‐value intervention to improve inpatients' vision. We aimed to study initial feasibility and efficacy of screening and correcting inpatients' vision.

METHODS

From June 2012 through January 2014, research assistants (RAs) identified eligible (adults [18 years], English speaking) participants daily from electronic medical records as part of an ongoing study of general medicine inpatients measuring quality‐of‐care at the University of Chicago Medicine.[6] RAs tested visual acuity using Snellen pocket charts (participants wore corrective lenses if available). For eligible participants, readers were tested with sequential fitting (+2/+2.25/+2.75/+3.25) until vision was corrected (sufficient vision: at least 20/50 acuity in at least 1 eye).[7] Eligible participants included those with insufficient vision who were not already wearing corrective lenses and had no documented blindness or medically severe vision loss, for whom nonprescription readers would be unlikely to correct vision deficiencies such as cataracts or glaucoma. The study was approved by the University of Chicago Institutional Review Board (IRB #9967).

Of note, although readers are typically used in populations over 40 years of age, readers were fitted for all participants to assess their utility for any hospitalized adult patient. Upon completing the vision screening and readers interventions, participants received instruction on how to access vision care and how to obtain readers (if they corrected vision) after hospital discharge.

Descriptive statistics and tests of comparison, including t tests and [2] tests, were used when appropriate. All analyses were performed using Stata version 12 (StataCorp, College Station, TX).

RESULTS

Over 800 participants' vision was screened (n=853); the majority were female (56%, 480/853), African American (76%, 650/853), with a mean age of 53.4 years (standard deviation 18.7), consistent with our study site's demographics. Over one‐third (36%, 304/853) of participants had insufficient vision. Older (65 years) participants (56%, 136/244) were more likely to have insufficient vision than younger participants (28%, 168/608; P<0.001).

Participants with insufficient vision were wearing their own corrective lenses during the testing (150/304, 49%), did not use corrective lenses (53/304, 17%), or were without available corrective lenses (99/304, 33%) (Figure 1A).

Figure 1

(A) The proportion of patients screened with insufficient vision. (B) The proportion of eligible patients with vision corrected by readers. Note: percentages may not add to 100 due to rounding.

One‐hundred sixteen of 304 participants approached for the readers intervention were eligible (112 reported medical eye disease, 65 were wearing lenses, and 11 refused or were discharged before intervention implementation).

Nonprescription readers corrected the majority of eligible participants' vision (82%, 95/116). Most participants' (81/116, 70%) vision was corrected using the 2 lowest calibration readers (+2/+2.25); another 14 participants' (12%) vision was corrected with higher‐strength lenses (+2.75/+3.25) (Figure 1B)

DISCUSSION

We found that over one‐third of the inpatients we examined have poor vision. Furthermore, among an easily identified subgroup of inpatients with poor vision, low‐cost readers successfully corrected most participants' vision. Although preventive health is not commonly considered an inpatient issue, hospitalists and other clinicians working in the inpatient setting can play an important role in identifying opportunities to provide high‐value care related to patients' vision.

Several important ethical, safety, and cost considerations related to these findings exist. Hospitalized patients commonly sign written informed consent; therefore, due diligence to ensure patients' ability to read and understand the forms is imperative. Further, inpatient delirium is common, particularly among older patients.[8] Existing or new onset delirium occurs in up to 24% to 35% of elderly inpatients.[8] Vision is an important risk factor for multifactorial inpatient delirium, and early vision correction has been shown to improve delirium rates, as part of a multicomponent intervention.[9] Hospital‐related patient costs per delirium episode have been estimated at $16,303 to $64,421.[10] The cost of a multicomponent intervention was $6341 per case of delirium prevented,[9] whereas only 1 potentially critical component, the cost of readers ($8+), would pale in comparison.[1] Vision screening takes approximately 2.25 minutes plus 2 to 6 minutes for the readers' assessment, with little training and high fidelity. Therefore, this easily implemented, potentially cost saving, intervention targeting inpatients with poor vision may improve patient safety and quality of life in the hospital and even after discharge.

Limitations of the study include considerations of generalizability, as participants were from a single, urban, academic medical center. Additionally, long‐term benefits of the readers intervention were not assessed in this study. Finally, RAs provided the assessments; therefore, further work is required to determine costs of efficient large‐scale clinical implementation through nurse‐led programs.

Despite these study limitations, the surprisingly high prevalence of poor vision among inpatients is a call to action for hospitalists. Future work should investigate the impact and cost of vision correction on hospital outcomes such as patient satisfaction, reduced rehospitalizations, and decreased delirium.[11]

Acknowledgements

The authors thank several individuals for their assistance with this project. Andrea Flores, MA, Senior Programmer, helped with programming and data support. Kristin Constantine, BA, Project Manager, helped with developing and implementing the database for this project. Edward Kim, BA, Project Manager, helped with management of the database and data collection. The authors also thank Ainoa Coltri and the Hospitalist Project research assistants for assistance with data collection, Frank Zadravecz, MPH, for assistance with the creation of figures, and Nicole Twu, MS, for assistance with the project. The authors thank other students who helped to collect data for this project, including Allison Louis, Victoria Moreira, and Esther Schoenfeld.

Disclosures: Dr. Press is supported by a career development award from the National Heart Lung and Blood Institute (NIH K23HL118151). A pilot award from The Center on the Demography and Economics of Aging (CoA, National Institute of Aging P30 AG012857) supported this project. Dr. Matthiesen and Ms. Ranadive received support from the Summer Research Program funded by the National Institutes on Aging Short‐Term Aging‐Related Research Program (T35AG029795). Dr. Matthiesen also received funding from the Calvin Fentress Fellowship Program. Dr. Hariprasad reports being a consultant or participating on a speaker's bureau for Alcon, Allergan, Regeneron, Genentech, Optos, OD‐OS, Bayer, Clearside Biomedical, and Ocular Therapeutix. Dr. Meltzer received funding from the National Institutes on Aging Short‐Term Aging‐Related Research Program (T35AG029795), and from the Agency for Healthcare Quality and Research through the Hospital Medicine and Economics Center for Education and Research in Therapeutics (U18 HS016967‐01), and from the National Institute of Aging through a Midcareer Career Development Award (K24 AG031326‐01), from the National Cancer Institute (KM1 CA156717), and from the National Center for Advancing Translational Science (2UL1TR000430‐06). Dr. Arora received funding from the National Institutes on Aging Short‐Term Aging‐Related Research Program (T35AG029795) and National Institutes on Aging (K23AG033763).

References

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