The USPSTF and Vision Screening in Older Adults

In 2009, the Affordable Care Act required Medicare and private insurance plans to cover, without a copay, preventive services given grades of A (high certainty of substantial net benefit) or B (high certainty of moderate net benefit, or moderate certainty of moderate to substantial net benefit) by the US Preventive Services Task Force (USPSTF). The USPSTF website states that cost is not considered in grading a service. Some critics have questioned whether that is still true (DM Jones and R Bayer. The paradox of authority – transformation of the USPSTF under the Affordable Care Act. N Engl J Med 2016; 375:18).

In 2016, the USPSTF concluded that current evidence was insufficient to assess the balance of benefits and harms of screening the vision of older adults (Grade I) (USPSTF. Screening for impaired visual acuity in older adults. US Preventive Services Task Force recommendation statement. JAMA 2016; 315:908). The Task Force, which did not include an ophthalmologist, limited its assessment to refractive error, cataracts, and age-related macular degeneration; it did not consider the possible benefits of detecting other sight-threatening conditions such as glaucoma or diabetic retinopathy (DW Parke et al. The US Preventive Services Task Force recommendation on vision screening in older adults. A narrow view. JAMA Ophthalmology 2016; 134:485). The USPSTF had determined in 2013 that the evidence was also insufficient to assess the balance and harms of screening for glaucoma (www.uspreventiveservicestaskforce.org).

The USPSTF found adequate evidence that early treatment of refractive error, cataracts, and age-related macular degeneration improves or prevents loss of visual acuity, but inadequate evidence on the harms of screening. It concluded: “The evidence is lacking to provide a coherent assessment, and the balance of benefits and harms cannot be determined.” Go figure.

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