Vision Rehabilitation for Elderly Individuals with Low ...

Technology Assessment

Technology

Assessment

Program

Vision Rehabilitation for Elderly Individuals with Low Vision or Blindness

Agency for Healthcare

Research and Quality

540 Gaither Road

Rockville, Maryland 20850

October 6, 2004

TABLE OF CONTENTS

Table of Contents ................................................................................ i

Tables................................................................................................. v

Tables (Appendix B) ...........................................................................vi

Table (Appendix C) ............................................................................vi

Tables (Appendix D)...........................................................................vi

Table (Appendix F)............................................................................ vii

Tables (Appendix G) ......................................................................... vii

Figure ............................................................................................... viii

Figure (Appendix E) ......................................................................... viii

Executive Summary ........................................................................... 1

Scope of Report ............................................................................... 17

Background ...................................................................................... 20

Low Vision and Blindness ............................................................. 20

Definitions of Low Vision and Blindness.................................... 20

Causes of Low Vision and Blindness ........................................ 23

Consequences of Low Vision or Blindness ............................... 25

Estimate of Number of Individuals in Elderly Medicare

Population who Might Benefit from Vision Rehabilitation

Services .................................................................................... 25

Vision Rehabilitation Services....................................................... 36

Training and Credentialing of Vision Rehabilitation

Personnel .................................................................................. 37

State Statutory and Regulatory Requirements for Unlicensed

Vision Rehabilitation Personnel................................................. 46

Page i

Clinical Practice Guidelines .......................................................... 46

Patient Evaluation ..................................................................... 49

Management and Rehabilitation................................................ 51

Referral and Multidisciplinary Care ........................................... 52

Follow-up Care .......................................................................... 53

Ongoing Trials............................................................................... 53

Methods............................................................................................ 53

Key Question, Analytic Framework, and Outcomes...................... 53

Key Question Addressed........................................................... 54

Analytic Framework for Addressing Effectiveness of Vision

Rehabilitation ............................................................................ 54

Outcomes Assessed ................................................................. 55

Literature Searches....................................................................... 59

Inclusion/Exclusion Criteria........................................................... 59

Data Extraction ............................................................................. 63

Evaluation of the Quality of Evidence Base .................................. 64

Statistical Methods........................................................................ 64

Evidence Base ................................................................................. 64

Evidence Synthesis .......................................................................... 66

Comprehensive Services .............................................................. 67

Quality of Included Studies........................................................ 67

Details of Study Enrollees and Study Generalizability .............. 68

Details of Programs Evaluated.................................................. 69

Outcomes Assessed ................................................................. 73

Findings of Included studies...................................................... 74

Findings of other Systematic Reviews ...................................... 79

Subsection Summary ................................................................ 79

Page ii

Optical Aids and Low-Vision Devices ........................................... 81

Quality of Included Studies........................................................ 81

Details of Study Enrollees and Study Generalizability .............. 82

Outcomes Assessed ................................................................. 84

Findings of Included Studies ..................................................... 84

Findings of Systematic Reviews................................................ 87

Subsection Summary ................................................................ 89

Orientation and Mobility Training .................................................. 90

Quality of Included Studies........................................................ 90

Details of Study Enrollees and Study Generalizability .............. 91

Details of Programs Evaluated.................................................. 91

Outcomes Assessed ................................................................. 93

Findings of Included Studies ..................................................... 94

Findings of Systematic Reviews................................................ 96

Subsection Summary ................................................................ 96

Adaptive Techniques Training ...................................................... 98

Quality of Included Study .......................................................... 98

Details of Study Enrollees and Study Generalizability .............. 98

Details of Program Evaluated.................................................... 99

Outcomes Assessed ................................................................. 99

Findings of Included Studies ..................................................... 99

Findings of Systematic Reviews.............................................. 100

Subsection Summary .............................................................. 101

Group Intervention Programs...................................................... 101

Quality of Included Studies...................................................... 102

Details of Study Enrollees and Study Generalizability ............ 103

Details of Programs Evaluated................................................ 103

Outcomes Assessed ............................................................... 105

Page iii

Findings of Included Studies ................................................... 106

Findings of Systematic Reviews.............................................. 108

Subsection Summary .............................................................. 108

Supervision of Services and Outcome........................................ 109

Bibliography.................................................................................... 113

APPENDICES: Supporting Documentation and Evidence Tables . 131

Appendix A. Full Text of Medicare Program Memorandum

(29th May 2002)........................................................................... 132

Appendix B. Education and Certification of Non-Medicare

Physician Vision Rehabilitation Personnel.................................. 136

Occupational Therapists.......................................................... 137

Physical Therapists ................................................................. 143

Low-Vision Therapist............................................................... 148

Orientation and Mobility Specialists ........................................ 161

Rehabilitation Teacher ............................................................ 168

Appendix C. Ongoing Trials ........................................................ 176

Appendix D. Outcome Measures ................................................ 184

Appendix E. Literature Searches ................................................ 191

Electronic Database Searches ................................................ 192

Hand Searches of Journal and Nonjournal Literature ............. 196

Appendix F. Excluded Studies .................................................... 197

Appendix G. Evidence Tables..................................................... 200

Page iv

TABLES

Table 1. ICD-9-CM Definitions of Low Vision and Blindness ............20

Table 2. Primary Causes of Low Vision in the Elderly.......................24

Table 3. State-by-State Low Vision and Blindness Prevalence

Estimates.............................................................................30

Table 4. Evidence Base ....................................................................65

Table 5. Types of Vision Rehabilitation Services Evaluated .............66

Table 6. Quality of Studies of Comprehensive Vision

Rehabilitation Services........................................................67

Table 7. Outcomes Assessed ...........................................................73

Table 8. Quality of Studies of Low-Vision Devices and

Optical Aids .........................................................................82

Table 9. Outcomes Assessed ...........................................................84

Table 10. Systematic Reviews of Optical Aids and

Low-Vision Devices .............................................................88

Table 11. Quality of Studies of Orientation and Mobility Training .......91

Table 12. Outcomes Assessed ...........................................................93

Table 13. Quality of Studies of Adaptive Techniques Training............98

Table 14. Quality of Studies of Group Intervention Programs...........102

Table 15. Outcomes Assessed .........................................................105

Table 16. Rehabilitation Services Supervision and Personnel..........109

Page v

TABLES (APPENDIX B)

Table B-1. Typical Curriculum of a Degree Course in

Occupational Therapy................................................ 137

Table B-2. Typical Curriculum of a Degree Course in

Physical Therapy ....................................................... 143

Table B-3. Pennsylvania College of Optometry Low-Vision

Therapy Certificate and Master's Program Courses.. 148

Table B-4. Typical Curriculum of an O&M Specialist Degree

Course ....................................................................... 161

Table B-5. Typical Curriculum of Rehabilitation Teacher

Degree Program ........................................................ 168

TABLE (APPENDIX C)

Table C-1. Ongoing Trials ........................................................... 176

TABLES (APPENDIX D)

Table D-1. Instruments used to Evaluate Activities of Daily

Living ......................................................................... 184

Table D-2. Instruments used to Evaluate Mood .......................... 188

Table D-3. Instruments used to Evaluate Psychosocial

Functioning ................................................................ 189

Table D-4. Instruments used to Evaluate Quality of Life ............. 190

Page vi

TABLE (APPENDIX F)

Table F-1. Excluded Studies ....................................................... 197

TABLES (APPENDIX G)

Table G-1. Systematic Reviews and Technology Assessments.. 200

Table G-2. Study Design Details ................................................. 202

Table G-3. Study Design Characteristics Pertaining to Internal

Validity ....................................................................... 206

Table G-4. Patient Enrollment Criteria......................................... 211

Table G-5. Characteristics of Enrolled Patients I:

Residential Status and Underlying Pathology............ 214

Table G-6. Characteristics of Enrolled Patients II

(Demographics) ......................................................... 218

Table G-7. Charactersics of Enrolled Patients III

(Comorbidities) .......................................................... 224

Table G-8. Rehabilitation Program Details .................................. 228

Table G-9. Study Findings ........................................................... 240

Page vii

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