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Telehealth technology may be key to adequate screening of patients with diabetes
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As I discussed in a previous issue, but worth repeating, diabetes affects 382 million people worldwide, fully 3.3% of the population. The number of diabetics is expected to double in the next 20 years.
Type 1 diabetes is caused by a failure to produce adequate insulin and represents about 10% of patients. It usually has an onset at a younger age and a more severe course, and the date of onset is well known. Type 2 diabetes is caused by insulin resistance and represents 90% of patients. In most cases, it is secondary to lifestyle choices increasingly prevalent in advanced countries, including a poor diet, obesity, smoking and lack of physical exercise. The exact date of onset is usually not known because the signs, symptoms and laboratory findings are more subtle.
Hypertension is a common associated diagnosis with both type 1 and type 2 diabetes. Both diabetes and hypertension affect eye health. Once patients begin to develop diabetic eye disease, the ophthalmologist has a good opportunity to discuss appropriate lifestyle changes with the patient, and many patients who modify their behavior can essentially “cure” their disease.
Prolonged hyperglycemia causes vascular endothelial pericyte death and thickening of the basement membrane on histology. This results in incompetence of the vascular walls and increased permeability of the blood vessels, breaking down the so-called blood-aqueous barrier.
Ten years after the onset of diabetes, 80% of patients demonstrate at least mild diabetic retinopathy and 10% manifest diabetic macular edema. Vigilant control of blood sugar levels can delay the onset of these sight-threatening complications, and patients should be educated regarding this fact. The patient with type 1 diabetes should have a dilated fundus examination by year 5 of the disease onset, every 2 years until findings of diabetic eye disease are recognized, and then every year to monitor for disease progression and allow for timely treatment. The patient with type 2 diabetes should be examined promptly after diagnosis because the date of disease onset is usually unknown and yearly thereafter. This is a HEDIS outcome that is monitored by large health plans, and while some do well, nationwide data suggest that the majority of patients with diabetes do not get an annual dilated fundus examination. Even when it is done, it might not be performed by an ophthalmologist, or communication between the eye doctor and primary care physician may not occur.
We can and must do better in this area, and our performance in the future will affect our compensation. This is an area in which electronic health records will likely help. DME is the major cause of central visual acuity loss and can be diagnosed with a skilled fundus examination, but today it is more easily diagnosed with optical coherence tomography or fluorescein angiography. At present, there are several widefield non-mydriatic cameras that allow us the option of using photographic screening of the retina for diabetic eye disease. They are less effective in identifying DME, but reduced visual acuity can serve as an indicator for further examination with OCT or FA. A well-trained ophthalmologist observer can use visual acuity, widefield non-mydriatic fundus photography and, when indicated by reduced vision, OCT to diagnose and grade, with high sensitivity and specificity, the severity and need for treatment in a patient with diabetes.
To achieve the triple goals of the Affordable Care Act — improved quality of patient care, highly satisfied patients and reduced cost — many experts are recommending increased utilization of “telehealth technology.” Patients, government and third-party payers are all supportive of incorporating increased use of telehealth technology. As EHRs, integrated health care delivery networks and accountable care organizations become a part of our everyday practice, we can expect increasing pressure to adopt a more streamlined and cost-efficient health care model. In this environment, many ACOs can be expected to embrace or even mandate telehealth technology solutions to many disease state management challenges. Screening for diabetic eye disease is likely to be one area in which ophthalmology may well adopt telehealth technology to enhance quality of care and reduce costs.
Widefield non-mydriatic fundus photos performed by the primary care physician, perhaps an optometrist or even a technician at a screening center, along with visual acuity, might be reviewed by a distant ophthalmologist skilled in their interpretation, much as is done in radiology today. One can even imagine this being done at the ophthalmologist’s home, with immediate electronic communication with the patient’s health care providers and perhaps even the patient himself.
The ophthalmologist’s role in monitoring and treating the patient with diabetes will remain critical, but the diagnostic challenges may respond to telehealth technology advances. Once patients are diagnosed, they will still need to be counseled regarding beneficial lifestyle modification, encouraged to pursue tight glucose control, and treated promptly and appropriately when diabetic retinopathy or macular edema occurs. This will require cooperative care between multiple health care providers and an engaged and informed patient.
The challenges are significant, but an objective look at the current low number of diabetics whose retinas are appropriately examined at proper intervals by an ophthalmologist suggests to me that we need to look at alternative delivery models, including telehealth technology.