October 29, 2013

The Leading Cause of Blindness

Diabetes mellitus is the leading cause of blindness for the working age population in the developed world.[1] The incidence of diabetes is increasing exponentially as our population ages and obesity rates continue to rise. In fact, as of 2010, 25.8 million Americans had diabetes.[2] Among people older than 65 years, nearly 27% have diabetes.[2] With the aging of the nearly 78 million Baby Boomers, the first of whom reached 65 in 2011, this presents a healthcare challenge. A substantial increase in the prevalence of diabetes in the coming decades can be anticipated.

The estimated lifetime risk of developing diabetes for an American born in 2000 is at least 40% for black persons and more than 50% for Hispanic women.[3] With such a high prevalence, an increasing incidence of visually disabling disease can be expected.

Anecdotally, however, many clinicians working in systems that reward providers for better outcomes have seen a considerably reduced incidence of treatable retinopathy. Adherence to treatment, improved patient self-management, and use of evidence-based practices have undoubtedly reduced morbidity in diabetes and most likely reduced the incidence and severity of diabetic eye disease. Improved glycemic control can reduce the complications of diabetes, as illustrated in the Diabetes Control and Complications Trial.[4] Conversely, eye care providers who work with new immigrants to the United States who have had little previous access to healthcare consistently report a much higher incidence of visually disabling disease from diabetes.

In the early 1970s, patients with diabetes were expected to be blind within 15-20 years of diagnosis. By 2010, it was acknowledged that for persons with diabetes who were able to maintain optimal glycemic control from the time of diagnosis, the rate of vision loss and longevity would differ little from that in people who do not have diabetes.[5]

Teleretinal Imaging for Diabetic Eye Disease

Screening for retinal disease in patients with diabetes is still in many ways continuing the old paradigm. Patients spend time being evaluated in an eye doctor’s office. The visit requires that the patient endure the vision effects of the dilating eye drops and the restrictions that these impose over several hours. Furthermore, these examinations are expensive, and as the federal government takes a greater role in healthcare, it becomes a cost and coverage consideration.

The gold standard for screening for visually threatening diabetic eye disease has long been a dilated fundus examination by a licensed independent eye care provider (optometrist or ophthalmologist). Currently, about 20,000 ophthalmologists and 35,000 optometrists practice in the United States. With the standard for a diabetic retinal examination being every 1-2 years for each patient with diabetes (depending on the level of control), there are not enough eye care professionals to manage the burden of the roughly 26 million people with diabetes in the country. This is an important reason why patients with diabetes have historically often failed to achieve the annual Healthcare Effectiveness Data and Information Set (HEDIS) standard for retinal examinations in patients aged 18-75 years with diabetes.[6]

Over the past 20 years, telemedicine programs have been developed to allow digital retinal photographs to be interpreted by an expert in a remote center. For the past 8 years, the Department of Veterans Affairs has deployed a care management pathway for patients with diabetes by working with multiple stakeholders to develop a program to screen for and assess risk for vision loss from this highly prevalent disease. More than 1 million patients have been screened to date, and although all of the data are not yet available, when segments of the population have been studied, results indicate that approximately 1% of patients have severe retinopathy.

Of greater importance, 75% of patients do not need immediate eye care.[7] Therefore, patients who might present in subspecialty retina clinics can be deferred, clearing the schedule for those with diseases that require more immediate treatment.

Adoption of the Care Management Pathway

Adoption of the care management pathway made the most sense to the Department of Veterans Affairs, and 8 years later, it is the standard against which other quality management programs are judged. Of greatest importance, a broad consensus of providers also felt that this program would be best for patients by enhancing the assessment of diabetic retinopathy in a safe manner that is validated by sound science and is also cost-effective.

The care management pathway uses trained imagers who acquire the digital retinal photographs from the patient and trained readers (licensed optometrists or ophthalmologists) who review the photographs. The location of the imager and the patient may be thousands of miles away from the eye doctor who is reading the photograph. The eye doctor is essentially evaluating a patient whom he or she is likely to never meet. Imagers are additionally trained in care management to the extent that they can act as liaisons between the patient, the eye care team, and the primary care provider.

This program has been highly successful in the Department of Veterans Affairs throughout the nation. Patients report a very high rate of satisfaction, are minimally inconvenienced, and ultimately should have better outcomes in not only diabetic eye risk management but also all aspects of diabetes care that are amenable to self-management.[8] The value of the retinal photograph is also remarkably powerful in educating the patient and enabling them to see the “diabetes in their eyes.”

The concept is similar to that of the patient-centered medical home, which relies on a multidisciplinary team, including care coordinators, to work with patients in self-management. Most results are positive in terms of glycemic control, availability of the team, and patient satisfaction.[9]

Beyond the VA

Can such a program be broadly applied to the screening and risk assessment of patients with diabetes outside of the Department of Veterans Affairs? On the basis of the Department’s experience with more than 1 million patients screened safely over an 8-year period, the answer is yes.

Not surprisingly, patients have enthusiastically embraced this program[8] — in part because the time required for a complete eye examination with dilation is considerably longer than for a nonmydriatic teleretinal study, and without dilation, they can immediately resume their daily activities. Furthermore, face-to-face examinations are more costly to both patients and third-party insurers. Nonmydriatic teleretinal imaging is more time-efficient, improves adherence to self-care, and can offer favorable cost-effectiveness in assessing the degree of diabetic retinopathy compared with a standard clinical examination.

The job of the eye care community is to work proactively with primary care providers and other stakeholders to ensure that screening and risk management is accomplished for all patients with diabetes and, if necessary, that these patients are managed for visually disabling diabetic eye disease before irreversible vision loss occurs. Our fellow Americans deserve it, and our government may soon demand it.


No comments

Be the first one to leave a comment.

Post a Comment