Clinical and Economic Burden of Diabetic Retinopathy

Allen Dobson, Jr., MD, FAAFP: Wade, all of us have been practicing medicine and have probably seen the clinical and personal burden on the quality of life. Do you have any other thoughts related to that and any comorbidities you’ve seen that go along with diabetic retinopathy?

Wade Brosius, DO: There a couple of comorbidities that can play a role, including things such as pregnancy and tobacco use. Certain ethnicities, especially people who are African American, Hispanic, or Native American, have a greater likelihood of having diabetic retinopathy. There are a lot of implications, especially on the economic side. The worst of all these is blindness. People can have increasing rates of glaucoma, retinal detachments, and vitreous hemorrhage, all associated with the progressive diabetic retinopathy.

In patients with diabetes, it’s important that they get regular retinal examinations, because things like laser photocoagulation are effective, and people can use vitrectomies and other things. Those things are very expensive. If it’s caught too late, the impact on the patient’s quality of life is significant. It’s much more important to be proactive to try to get their risk factors under control and to make sure you have regular screenings.

Allen Dobson, Jr., MD, FAAFP: Right. Steven, for this question, it might be interesting to hear your perspective. Diabetic retinopathy represents an economic burden to the patient but also to the health care system. What are you seeing as a payer as far as this patient population and its use of health care dollars? What are some of the key drivers of cost in that population?

Steven Peskin, MD: We’ve frequently said in the last decade that diabetes is one of our epidemics, although that phrase gets thrown around a lot for a lot of different conditions. But diabetes has come on at a torrid pace in our population. It’s a major cost driver for payers. Retinopathy in particular is one of the key quality measures that’s screened. In a pay-for-value or pay-for-performance model, screening for diabetic retinopathy is encouraged. Some of my primary care colleagues mentioned some of the challenges associated with screening.

As a health plan, we look to do things more progressively, such as screening in primary care physicians’ offices using the camera technology and then having the retina ophthalmologist do the overread of that. It’s something that we focus on. Diabetes has several key quality measures, including blood pressure control, screening for A1C [glycated hemoglobin], foot exam, as well as screening for nephropathy. It’s a big effort for health plans, and it also ties into our payment model in some ways, as we’re judged as a health plan on quality measures.

Allen Dobson, Jr., MD, FAAFP: Right. We’ve touched on the fact that screening patients with diabetes for retinopathy is important to do regularly. The question is, why is it such a problem?

Wade Brosius, DO: I’ll hop in here. From my perspective, a lot of it is access. Sometimes getting patients to and from practice visits can be very difficult. It’s one of the things we ask in social determinants of health. Another problem is the increase in cost for the patient, because screenings are just screenings. If we can accomplish that in the primary care office as part of the global cost of care for the practice, we’re able to help decrease the higher cost specialty visits. It’s a HEDIS [Healthcare Effectiveness Data and Information Set] Stars measure, and as Steven was saying, diabetes probably takes the largest bulk of HEDIS Stars measures in value-based contracts because a lot of the other things are triple-weighted.

Screening for diabetic retinopathy can easily be accomplished in a primary care office as part of the overall global visit, where we do a lot of the other screening. We can collect a microalbumin-to-creatinine ratio. We can do the monofilament and tuning fork testing for neuropathy. We can get the blood work that’s necessary for the patient. This can be done easily in 1 fully comprehensive diabetic visit without worrying about other trips to other providers.

Allen Dobson, Jr., MD, FAAFP: In my experience, the problem with diabetic retinopathy is that it doesn’t have symptoms until it’s very late, so screening is extremely important. The progression can be relatively rapid, particularly if you have patients who don’t come in. If you miss it, you may miss the window. You’re right, access is important, along with having some tools for the primary care doctors to do it in the course of regular treatment.

Transcript Edited for Clarity