Peter Salgo, MD: Hello everyone. Thank you for joining us for this American Journal of Managed Care Peer Exchange video program, “Diabetes-Related Complications: A Focus on Diabetic Macular Edema.”
My name is Dr. Peter Salgo, and I’m a Professor of Medicine and Anesthesiology at Columbia University College of Physicians and Surgeons, and I’m the Associate Director of Surgical Intensive Care at New York-Presbyterian Hospital.
Joining me in this discussion is Dr. John Kitchens, a Vitreoretinal Surgeon of Retina Associates of Kentucky; Dr. Steven Peskin, Executive Medical Director of Population Health at Horizon Healthcare Innovations, Associate Clinical Professor at Robert Wood Johnson Medical School; and Dr. Rishi Singh, a Staff Physician at Cleveland Clinic, an Assistant Professor of Ophthalmology at Case Western Reserve University. Again, thank all of you for joining us. We’ve got a lot to cover, so why don’t we start?
What are the common eye related complications that are often associated with diabetes? Dr. Singh, you want to kick us off?
Rishi P. Singh, MD: The most common ones typically are the ones we hear about from our patients. They have trouble seeing from cataracts, they can develop glaucoma, and probably, the one that’s most severe and most irreparable is diabetic retinopathy. That’s the one that develops over time. The length of diabetes really indicates how much of diabetic retinopathy will develop over time.
Peter Salgo, MD: It sounds bad. It is bad, but, in the cosmic scheme of things, how common is retinopathy? Can we compare the incidence of that to the other complications such as cataracts that we were talking about?
Rishi P. Singh, MD: Well, in the lifetime of a patient, cataract formation is almost a likelihood in all of us. In fact, it doesn’t matter if we’re diabetic or not. But in the diabetic population, they do develop it earlier. Those patients with diabetes, about 25% of them, currently have diabetic retinopathy.
Peter Salgo, MD: Twenty-five percent. Now, in any other disease state, including this disease state, 25% is huge, isn’t it?
Steven Peskin, MD, MBA, FACP: It is.
Peter Salgo, MD: What are the symptoms associated with it? Can any clinician pick this up or do you need an ophthalmologist?
John W. Kitchens, MD: Early on, Peter, the symptoms can be very mild and gradually progressive. We really talk about 2 things that can threaten vision with diabetic retinopathy. Diabetic macular edema ... that causes mild blurring to moderate blurring of vision is the most common cause of vision loss in diabetic patients. And it can progress on to proliferative diabetic retinopathy where abnormal blood vessels grow into the back of the eye, and those blood vessels can bleed, leak, and are the leading cause of blindness for these patients.
Peter Salgo, MD: Now, even I as an internist, don’t like the sound of macular edema—diabetic macular edema. On the scale of seriousness of complications, it occurs to me diabetic macular edema probably is up there among the worst. Is that fair?
Steven Peskin, MD, MBA, FACP: Yeah, I’d say that’s a pretty profound complication.
John W. Kitchens, MD: It’s a very common complication and it can occur anywhere along the spectrum. So, you can see diabetic macular edema with mild- to moderate- to severe- non-proliferative retinopathy, even into proliferative. Obviously, the worst retinopathies are more likely are to have diabetic macular edema. The one caveat is it is also one of the most treatable things that we encounter.
Peter Salgo, MD: Okay, we’re going to get to that. But, what I’d like to do before we do that, before we start treating it, let’s estimate, because this is now the 21st century and health economics is everywhere, as much as it may disturb some of our colleagues to think about money, what’s the cost burden? Let’s discuss the cost burden of diabetic retinopathy, diabetic macular edema, and the other related complications. What do you think?
John W. Kitchens, MD: It’s substantial. When you think about both medical and non-medical cost burdens, it’s upwards of about $3 billion.
Peter Salgo, MD: That’s federal budget kind of numbers.
John W. Kitchens, MD: B with a billion.
Peter Salgo, MD: Three billion dollars. Where does this expense come from? Where are we spending the money? Why is there this cost?
Rishi P. Singh, MD: The annual diabetic patient costs the system through test strips, and through monitoring, and through primary care visits, and everything else. The patient with diabetic retinopathy, they cost the system a significant amount more.
Peter Salgo, MD: Why?
Rishi P. Singh, MD: In fact, there’s been a study that was done a while ago that said that the average diabetic patient costs the system about $9,000 a year. But the diabetic patient with retinopathy can cost the system about $29,000 per year. And that comes from a lot of different things.
First, it comes from the drugs we use to treat the patient, the evaluations we need to do it, the imaging that goes along with it, sometimes surgery for those patients and that surgery can be expensive, and not to mention these patients are active-age patients like you and I and anyone on this stage today. We have patients that are working-age adults and that requires them to be out of work, disability, and potentially other socioeconomic factors that go along with it.
Peter Salgo, MD: My sense is that that last cost is the big one.
Rishi P. Singh, MD: Yeah.
Peter Salgo, MD: We can estimate the cost of medications and doctor’s visits, but those are kind of encapsulated, and controllable, and estimable. But it’s that fuzzy edge where all the money gets spent. Is that fair?
Steven Peskin, MD, MBA, FACP: Yeah. We look very assiduously at high-risk and rising-risk populations. So, the diabetic population, overall, is one that we focus on and other organizations of our type working with our clinical partners. Then, within those subsets, those with chronic kidney disease, those with diabetic retinopathy, those with cardiovascular disease, or peripheral vascular disease, get special focus and attention.
Because we know, as we just said, that those subpopulations within the broad population of diabetics are substantially more complex, costly, and those that we really need to focus a lot of effort on.
Peter Salgo, MD: From a general internist that I am, diabetes is always there. It’s one of these big diseases.
Steven Peskin, MD, MBA, FACP: Ever present.
Peter Salgo, MD: It’s everywhere and what you see, in my experience, is all these other expenses: “I couldn’t go to work.” “I had to have help at home,” “I got an ulcer and it got infected and then I needed vascular attention,” or “I couldn’t see,” “I can’t drive,” “I’m hiring someone to help me here.”
This is all a generic picture of money through the door, right?
Steven Peskin, MD, MBA, FACP: Absolutely.
Peter Salgo, MD: It’s a bad disease.
Rishi P. Singh, MD: Absolutely. And the biggest part of this is associated with the depressive issues that go along with this disease. Blindness is one of those things, especially in this age group, that can lead to a lot of depressive issues and that’s been shown in a lot of things.
By the way, I think there’s also a little bit of psychology behind the diabetic patient. They assume, because they’re diabetic, sometimes, that they shouldn’t see as well as other patients around them.
Peter Salgo, MD: Is that fair though? Is that a fair assumption?
Rishi P. Singh, MD: Not in this stage of the day when we have such great therapeutics available to us, and really just revolutionary interventions we have for these conditions now. There should be no patient who feels that way at this stage.
Peter Salgo, MD: I think we’ve all seen that, right? “Well, I had a little problem with my eyes but it’s just my diabetes.” That’s not fair anymore?
John W. Kitchens, MD: Peter, it’s a downward spiral. If you think about it, if you can’t see, how are you going to dose your insulin? How are you going to know what pills you’re taking? How are you going to make it to your doctors’ visits? So, now you’re increasing the burden onto your family. And those are all the indirect costs that add up.
Peter Salgo, MD: Yeah, that’s what I was referring to.