Case 1: New Patient Screening and Initial Diagnosis of Diabetic Retinopathy
Allen Dobson, Jr., MD, FAAFP, reviews the case of a 67-year-old man with type 2 diabetes and the panel discusses initial diagnosis and management.
Allen Dobson, Jr., MD, FAAFP: Let’s talk about a patient case. I’ll throw one out there that will maybe help drive home some of what we’re talking about. You have a 67-year-old new patient coming from a previous provider who initiated care with you. They’ve had type 2 diabetes for 12 years that isn’t well controlled, along with hypertension, hyperlipidemia, and cataracts. No screening is done. He tells you that he feels like he has floaters and definite decreased visual acuity. But he thought it was from staring at the computer screen all day and getting older. Talk a little about that. Is this the clinical manifestations of diabetic retinopathy? Is there any way to comment on what you think this patient has?
Wade Brosius, DO: From my perspective, this is a worrisome story. Because if you’re catching things in the early stages, more times than not, patients are completely asymptomatic. But if you look at the symptoms of proliferative retinopathy, they typically include things like the sudden appearance of floaters, dots, specks, or streaks in their vision. They’ll start having cobwebs across their vision. They’ll start having distorted shapes of objects, and sometimes loss of vision. If you’re a betting person, based on this story, you’d be worried about the possibility that this patient has pretty aggressive and truly proliferative retinopathy. This is a situation where you’d probably have the ophthalmologist on speed dial. Although you can get your scan in the office, there’s a high likelihood that you’ll be making a call that day to your ophthalmology colleague.
Allen Dobson, Jr., MD, FAAFP: It sounds like this is a patient who would need a dilated exam. Is there any way to tell by clinical symptoms if it’s proliferative or nonproliferative? That requires a dilated exam, right?
Shelton Hager, MD: Yes. One of the other things is that this is what I’d call a knee-to-knee intervention, where I sit with him and say, “Look, your horse is out of the barn. We need to get you into care very quickly. Because if you’re having visual changes and you’re diabetic for this length of time, you may very well have proliferative retinopathy, which may result in blindness.”
Allen Dobson, Jr., MD, FAAFP: Obviously, getting their diabetes and hypertension under the control, all that is important. Are there any other things that can be done that would be beneficial in preventing future loss or maybe even reversing some of the loss that they’re already describing?
Wade Brosius, DO: There’s likely to be either procedural or medical intervention in this particular case. You’d like to think that if we get lucky, we might be able to have laser done to try and have that. But in this particular case, if I were a betting person, I’d think that this person is already built into—sadly, for Steve’s sake—very expensive anti-VEGFs [vascular endothelial growth factors], where we’re going to talk with the patient about and say, “Listen, I hope you don’t mind having a needle in the eye,” because they’re very much going down that track.
Allen Dobson, Jr., MD, FAAFP: You said it, that it’s a speed dial to the ophthalmologist. I have a question about both of your organizations. Have you proactively set up partnerships with ophthalmologists and others where you have a collaborative practice arrangement set up to hopefully ease the transition for patients and improve communication?
Shelton Hager, MD: Yes. There’s a regional retinal specialist. They’re the only one in town. Therefore, by necessity, we have a collaborative agreement because patients aren’t going anywhere else. But we work with him very quickly.
Wade Brosius, DO: With us being in a suburban marketplace, we probably have the better part of a half-dozen different groups, many of which have largely regional or national names. But we have tight ties with the ophthalmologists for a lot of reasons, one of which being that we want excellent care. But don’t forget that also in the realm of value-based contracting, having the doctors have very accurate and specific diagnoses with the appropriate ICD-10 [International Classification of Diseases, 10th Revision] diagnoses so we can catch a risk is important as well. We’ve been able to have a good partnership with our ophthalmology colleagues. That way, we get timely, appropriate care, and try to hone in on making sure patients get the best quality of care.
Steven Peskin, MD: Another part of that is the collaborative care agreements. A primary care group will have collaborative care agreements with pulmonologists, ophthalmologists, cardiologists, gastroenterologists, and so forth to smooth the path to increase the connectivity between the subspecialists and primary care physicians for better care coordination. There are some cost aspects related to the contracts, which are part of the broader value-based construct.
Allen Dobson, Jr., MD, FAAFP: I was going to comment along that line. Your payer can be a huge partner with that because they can steer you to the highest quality specialist. In a rural area, or if you’re a 1-doctor practice, it’s hard to get the attention of a high-end specialty group to make sure your patients get that coordination. That’s part of what we’ve done with our community care network. We’ve aggregated the smaller practices so that we can create a set of referral patterns and supports so that we don’t miss that segment of the population who aren’t easily referred and may have to travel an hour. Any hiccup in the process means they’re going to fall through the cracks. But discussing and doing collaboration with our payer partners is important, particularly because the value-based contract is really important.
Steven Peskin, MD: With people on Medicaid, sometimes it’s tougher to get, and we know that the rates tend to be quite a bit lower. We have care navigators, and if there’s some challenge with someone whose insurance coverage is a bit skinnier, then we’ve got interventions there as well.
Allen Dobson, Jr., MD, FAAFP: That’s always the case with payment types or older patients who have trouble traveling. They need additional help to make sure they don’t fall through the cracks.
Transcript Edited for Clarity
Man With Newly Diagnosed Type 2 Diabetes: What HbA1c Goal-And How to Get There?
May 8th 2013The patient, an active 49-year-old man, had an HbA1c of 8.6 after diabetes was first diagnosed. It’s now 7.6 with metformin and lifestyle measures. Is the current A1c goal adequate, or should you treat more aggressively?
