Improving DR outcomes through comprehensive medical management

Ophthalmologists tackle diabetes-related blindness at ground level.

Diabetes currently afflicts more than 30 million Americans (about 9.4% of the population). The American Diabetes Association estimates that more than seven million people are not even aware that they have this debilitating disease.

While many people with diabetes learn they have the disease via a high-fasting blood glucose test, fully 20% discover they are diabetic as a result of an eye exam.¹

From diabetes to blindness
Diabetes may be associated with systemic co-morbidities including kidney disease, peripheral neuropathy and vasculopathy. Additionally, untreated diabetics are at risk for the disabling consequences of diabetic retinopathy, cataract and glaucoma. 

Approximately 30% of people with diabetes have retinopathy; fortunately, early detection and treatment can reduce the risk of blindness by 95%.² Recent advances offer hope to those at risk from the devastating effects of this disease. Aiello and colleagues at the Diabetes Control and Complications Trial, found the risk of developing diabetic retinopathy was reduced by 76% and progression slowed by 54% in response to intensive treatment.³

Early intervention is central to successful treatment of diabetic retinopathy. In its early stages, however, when treatment has the greatest likelihood of success, patients are typically asymptomatic. Thus, an annual eye exam – combined with a robust medical management program – is a critical component of any health and wellness program to reduce blindness from this disease. 
 

High costs 
Diabetes costs the United States an estimated $327 billion annually, with $237 billion coming from direct medical costs and $90 billion coming from decreased productivity.⁴ And with nearly 30% of diabetics suffering from retinopathy,⁵ diabetes-related visual impairment costs can total more than $500 million per year.⁶

A study by Zhang and colleagues found that medical costs for diabetics were significantly higher for those with diabetic retinopathy (DR) than those without retinopathy (DR).⁷ Specifically, those diabetics with even moderate diabetic retinopathy had notably higher medical costs than who did not have retinopathy, but had other diabetes-related conditions, such as neuropathy, vasculopathy and chronic kidney disease.⁷

A similar study by Schmeir and colleagues published in Retina looked at the costs associated with diabetic retinopathy in the Medicare population.⁸

Researchers examining 5% Medicare claims data from 1997 through 2004 identified 178,383 controls (people with diabetes but no evidence of diabetic retinopathy), 33,735 cases of nonproliferative diabetic retinopathy (NPDR) and 6,138 cases of proliferative diabetic retinopathy (PDR).

They found that average annual Medicare payments for care, as well as the average payments for ophthalmic care, were significantly higher for both the NPDR and PDR cases compared to diabetic patients without retinopathy.
 

Managing diabetes, DR
To reduce the risk for and/or severity of diabetic eye disease, it is crucial to create a program of community outreach overseen by healthcare experts dedicated to the management of the disease. In my experience, there are three keys ways to accomplish this. 
 

1. Enhanced data collection via eye care professional portals 

In eye care professional (provider) portals, when claims are submitted, ask a number of diabetes-related questions to stratify risk status. For those members known to have diabetes, include several retinopathy-related questions the eye care professional needs to answer. 

In cases where no diabetes is indicated, include a series of questions and conditions indicative of diabetes to help identify patients who may be at risk for the disease and require more intensive oversight.

2. Personalized diabetes outreach

Establish a system to identify diabetics who have not yet had an annual dilated retinal examination and remind them to get a retinal exam every year to monitor and track the progression (or lack thereof) of their disease.

In this way, you can craft individual outreach solutions for each patient based upon their particular circumstance(s). This leads to improved patient care and better patient outcomes; an important metric for health plan HEDIS and STAR measures.

3. Medical management

Medical management is key for patients with or at risk for diabetes. With comprehensive medical management, you can track the entire spectrum of eye health and vision services. You can then utilize predictive analytics to convert data to actionable strategies to enhance early interventions and improve patient outcomes while ensuring that patient funds and health plan resources are used prudently. 

By aggregating the collective experience of an extensive eye care professional network, diabetic outreach program and medical management team, you have the opportunity to provide the intellectual and operational infrastructure for new insights in the management of diabetic eye disease.

And that can save money as well as lives.

Mark Ruchman, MD
E: Mark.Ruchman@versanthealth.com
Mark Ruchman, MD, is the chief medical officer at Versant Health, a managed vision care company focusing on creating an integrated and seamless experience for health plans, members, and eyecare professionals across the total health value chain. Dr. Ruchman provides all medical and clinical oversight, which includes quality improvement, clinical guidelines, and accreditation standards. Dr. Ruchman has no financial disclosures related to this content. 

References:

1. Schaneman J, et al. The role of comprehensive eye exams in the early detection of diabets and other chronic diseases in an employed population. Popul Health Manag. 2010 Aug;13(4):195-9.

2. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/diabetic-eye-disease.

3. Aiello LP; DCCT/EDIC Research Group. Diabetic Retinopathy and Other Ocular Findings in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study. Diabetes Care. 2014 Jan;37(1):17-23.

4. The cost of diabetes. American Diabetes Association. http://www.diabetes.org/advocacy/news-events/cost-of-diabetes.html.

5. Tomic M, et al. Inflammation, haemostatic disturbance, and obesity: possible link to pathogenesis of diabetic retinopathy in type 2 diabetes. Mediators Inflamm. 2013;2013:818671.

6. Diabetic retinopathy. Centers for Disease Control. https://www.cdc.gov/visionhealth/pdf/factsheet.pdf.

7. Zhang X, et al. Direct medical cost associated with diabetic retinopathy severity in type 2 diabetes in Singapore. PLoS One. 2017;12(7):e0180949.

8. Schmier JK, et al. Medicare expenditures associated with diabetes and diabetic retinopathy. Retina. 2009 Feb;29(2):199-206.