Diabetes-Related Complications: A Focus on Diabetic Macular Edema - Episode 5
Peter Salgo, MD: One of the things about knowing your A1c is now that you know it, and if it’s not good, let’s fix it. That being said, let’s take a look at this in the setting of diabetic retinopathy progressing to diabetic macular edema. What is the progression here?
Rishi P. Singh, MD: So typically, patients on the first time of diagnosis may, or may not, have any retinopathy at all. And really, that’s a hard thing to pick up by just clinical examination.
You may have to do what’s called a fluorescein angiogram to pick up subtle retinopathy. But, for the vast majority of people, they’re followed over time. They develop non-proliferative disease, which potentially, when I explain this to a patient, is the closure of capillaries and the hypoxia that occurs because of damage to the microvasculature in diabetic retinopathy.
Eventually, that becomes closed completely. You then develop increased hypoxic conditions, and vascular endothelial growth factor is needed, where you develop new blood vessels. That’s called the proliferative state. Diabetic microedemas, as Dr. Kitchens mentioned, can occur at any point during this continuum—from the beginning to the end.
So you can have that one patient who comes in, first time diagnosis, and has diabetic macular edema. You can have that patient who has had proliferative disease treatments and done well and then has a diabetic macular edema 25 years into the diagnosis. So it can occur at any really given part of that spectrum.
Peter Salgo, MD: Let us assume, and this is the conundrum, right? Let’s assume that all-comers were getting treated fairly well. This may be a false assumption, but let’s just make that assumption. Here you’ve got somebody who comes in early with diabetic macular edema, and some guy, as you said, comes in at 25 years and finally has diabetic macular edema.
Does that imply that it’s not modifiable? That if everybody is being treated well and there’s this wide variance in the development of diabetic macular edema, what we’re doing has no impact? Or are some of these things modifiable?
Rishi P. Singh, MD: We know that the big ones that are modifiable are the hemoglobin A1c. And that determines the rate of progression. So you can develop a two- or three-fold higher rate if your A1c is two points higher. That’s a good rule of thumb.
Peter Salgo, MD: So between 7 and 9, that’s a big difference.
Rishi P. Singh, MD: That is a huge difference. The duration of diabetes, which is a non-modifiable thing but obviously can be tracked. Blood pressure is a big one that can, again, play into that and increase the rates of progression of diabetic retinopathy. And finally, a lipid has been one of the things that has been looked at quite significantly, recently. And the fact that you have lipid lowering drugs and lipid agents on that area have really improved the state of diabetic retinopathy in those patients as well.
Peter Salgo, MD: Diabetic retinopathy is one thing, but progression to diabetic macular edema is quite another. Do they track? Does he track temporarily? In other words, if I can prevent diabetic retinopathy, am I going to, by preventing or slowing this progression, definitely impede the progression to diabetic macular edema?
John W. Kitchens, MD: Absolutely. And the Diabetes Control and Complications Trial and the United Kingdom Prospective Diabetes Study both show in type 1 and type 2, that in patients that lower A1c levels with tighter blood sugar control, this leads to decreased visual complications from diabetic retinopathy.
Peter Salgo, MD: So is it fair to say that those interventions for all-comers to decrease retinopathy will also be interventions, which, for all-comers will decrease the progression to diabetic macular edema?
John W. Kitchens, MD: Absolutely.
Peter Salgo, MD: Wow. We got a simple straightforward clean answer. This isn’t medicine. This is physics. This is great.
That being said, now we go to the healthcare plans. And what programs do the healthcare plans have to improve overall health of patients with diabetes, including the risk of progression of eye-related disease?
Steven Peskin, MD, MBA, FACP: We’re increasingly going to what are called value-based payments—so pay for value versus pay for volume. What does that mean? What is a value-based payment?
A value-based payment incorporates three things. One is commonly referred to as the Triple Aim: better quality of care, better patient experience of care, so satisfaction. “I like my system,” “I like my doctor,” “I got seen on time,” “I didn’t have to wait 45 minutes,” “They were nice to me, polite,” and then total cost.
So, within those three things then, well, how do you accomplish that? So you accomplish that by working with clinical partners rather than against them and it’s not adversarial. So we all have this Triple Aim. We want to see better quality of care as measured by things like glycemic control, as measured by things like getting an annual eye exam, as measured by things like no progression of secondary and tertiary complications. So that’s where we are.
And then the cost is vitally important. Are you cost aware? Let’s not even say cost-effective. Are you cost aware? Are you using appropriate services?
We were talking earlier about why not everyone necessarily needs to be screened with certain advanced imaging all the time. If you’re going to be using a medication and you know you’re going to be using that, I think as you said, why put the suspenders on when you already have the belt on?
Peter Salgo, MD: The point here, I guess, to some degree, is that a lot of this is transparent to patients. They don’t have to care because we’ve shifted the burden to the insurance company. They’re not paying out of pocket for most of this, right? You guys are. So this is a dialogue between the providers and the payers. The most significant word I heard you say, in my opinion, was that now we’re collegial. We’re doing this as partners. We’re not adversarial. Is that new?
Rishi P. Singh, MD: I think it’s become the standard in our society now.
Peter Salgo, MD: It’s nice, isn’t it?
Rishi P. Singh, MD: Yeah. I think for a long time the doctors pushed the insurance companies away and said, “You’re encroaching on my ability to take care of patients.”
And I think now, especially with the Affordable Care Act, I find a lot more times where I’m having conversations with medical directors of insurance companies and talking to them about the need and the issues that are surrounding my care of the patient. And sometimes, they call me and they ask me, “Well, what do you think about this? We have this in front of us and how do you think we should manage this?” And I try to tell them the most cost-effective, best care approach for the patient and hope that they take that advice and go with it.
John W. Kitchens, MD: I’ll take the counterpoint and I’ll say there’s still some adversarial relationships out there with certain providers. There’s things such as tiered therapy, where the doctor is being dictated to by the insurance company what they’re going to pay for. And that typically doesn’t matter if all things are created equal. But some of these medicines aren’t created equal and it creates a barrier between the physician and the patient as to who is making the decisions to their care.
Peter Salgo, MD: Isn’t that, though, one of the ultimate and enduring and almost insoluble questions of medical practice? To whom do you have the greatest responsibility? To society at large and the budget? Or to the patient sitting across the desk from you? And sometimes they’re distinct, aren’t they?
Steven Peskin, MD, MBA, FACP: There absolutely are some inherent dynamic tensions there. You mentioned tiered therapy and we’ve got this area of specialty pharmacy.
Specialty pharmacy now encompasses about 40% of all medication spend. These are the drugs that end in ‘mab,’ many of them. So these are large molecule. Some are actually still small. Oral, solid, small molecule. But because they cost a lot of money, they’re put in this specialty category.
There is definitely a lot of focus by health plans on these specialty medications. So, that can be a source of some tension among the plans and the clinicians.