Diabetes-Related Complications: A Focus on Diabetic Macular Edema - Episode 4
Drs Peter Salgo, John Kitchens, Steven Peskin, and Rishi Singh suggest that socioeconomic factors affect patients’ awareness of the relationship between, and risk for developing, eye-related complications of diabetes, and explain the importance of educating patients about routine eye examinations.
Peter Salgo, MD: We’ve been talking about what physicians can do, and how we can make patients more aware of what’s going on. But, what is the level of awareness here, among patients with diabetes, as to the risk of eye-related disease, in the era of the Internet?
They can put diabetes into Google, and they can come back with, “Your eyes are at risk.” Is there a difference between older and younger patients in this?
John W. Kitchens, MD: I think the biggest difference is socioeconomic.
Peter Salgo, MD: Is that right?
John W. Kitchens, MD: Yeah. We know that the young patients are not good. They’re not good at getting their eyes examined. They’re not good at following through on their follow up examinations and things such as that.
John W. Kitchens, MD: And the Medicare patient population is much better at getting their eyes examined and following through on things. So, I think that Google only works if you have access to the Internet. And I think that that’s where we really need to work, is on the lower socioeconomic class of patients to get them seen and treated.
Peter Salgo, MD: What about older patients? Are you implying that they have a better sense of where their eyes are?
John W. Kitchens, MD: That, or possibly that they have better insurance or Medicare. They may have other comorbidities such as cataracts or age-related macular degeneration that actually lead them to knowing when they need to go see the doctor.
Peter Salgo, MD: So, what you’re suggesting is that as you get older, you get a little bit sicker. Somehow or other, you get to see a doctor and once in, then you’re part of the system.
Steven Peskin, MD, MBA, FACP: Yeah, more involved. More involved with your healthcare.
Rishi P. Singh, MD: I think there’s been a lot of studies done on this. And the one I always talk about is the one that was done at the Joslin Diabetes Center, which showed that of patients who had retinopathy, if you asked them “What did you have?”, only 50% of the time they actually told the doctor, “I have this.”
They don’t actually understand their disease. I think there needs to be a lot around patient-centered education. I think that spans both the socioeconomic issues but also the age issues. It’s not a young age or an old age issue, it’s more of an educational issue.
Steven Peskin, MD, MBA, FACP: And just that issue of health literacy and health numeracy. I think this represents a bit of a bias, that it’s the lower socioeconomic.
We know from research that we’ve done that there are people that are Master’s prepared that are also not health literate or health numerate. And so, we’ve got plenty of challenges in front of us to engage those persons so that they understand, appreciate, and they get information that is not a lot of jargon and a lot of medical speak.
Peter Salgo, MD: I personally wouldn’t care if somebody could say I have diabetic retinopathy as long as they said my eyes are at risk and I’m going to go see somebody. The actual diagnosis is probably, in my view I would think, less significant, right?
Rishi P. Singh, MD: But their understanding of what that means and what impact that has is probably quite different. And I think that, again, all of us being physicians here, we have a different aspect or education level than somebody who’s an engineer, or who’s a finance person, on this sort of topic.
Peter Salgo, MD: But just for the record, how many doctors do you know that go for an annual exam? The answer is, in my experience, nobody. I’ll go see John when I get a problem here. Otherwise, I’m a doctor, I’m not sick, right?
Before we leave this, are there specific ways, specific plans that healthcare plans may have to raise awareness of eye-related diabetic problems?
Steven Peskin, MD, MBA, FACP: Again, we look at those persons with any chronic condition, whether it be chronic obstructive lung disease or diabetes. Diabetes—certainly one of the most prevalent.
Then, within those populations of diabetics, we’re looking for certain key indicators such as the dilated annual retina exams, such as evaluation of microalbumin in the urine. We look at those measures. We make that information available to our clinical partners. We also sometimes do selective outreach and certain employers actually ask us to because they, ultimately, are the ones who are paying the bills, right?
Peter Salgo, MD: Unless you listen to Bernie, in which case it’s all going to be single payer.
Steven Peskin, MD, MBA, FACP: The plan sponsors are saying that they want us to do something in addition to what we’re already doing to reach out to their persons on behalf of that employer so that they increase the rates of, for example, a dilated exam.
Peter Salgo, MD: And I was being facetious for a minute. I said unless you’re Bernie and you want a single-payer plan, but even in a single-payer plan, if you have employees that are losing days of work because of their disability … it still comes down the employers, right?
Rishi P. Singh, MD: There was a study done last year that showed that the average diabetic patient has something like 20 visits to the offices of clinicians during the year. Twenty is a heck of a lot. I only get four weeks of vacation, so that’s all of my vacation days in a year. So I can imagine that patient trying to make it up and do the same. It’s a difficult thing to accomplish.
Peter Salgo, MD: It brings to mind this balancing act. Where are you going for vacation? Miami? Or are you going to Oahu? “No, I’m going to the doctor’s office because that’s all the time I’ve got.” That doesn’t really work, right?
Rishi P. Singh, MD: Absolutely, yeah.
John W. Kitchens, MD: It’s hard to expect patients to understand their retinopathy when sometimes they come in and they don’t even know their A1c. And that’s a scary thing. I’d say probably 25% of our patients don’t know what their A1c is.