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Crunching the numbers at the DRCC
CHAMPLAIN DIABETES REGIONAL COORDINATION CENTRE November, 2011
Diabetic Retinopathy and Associated Costs
Diabetic Retinopathy
Diabetes affects the blood vessels in the body, including those in the eyes. Diabetic retinopathy is damage to the
blood vessels in the eye caused by hyperglycaemia. The damage to the blood vessels in the eyes can result in two
problems that lead to loss of vision: retinal swelling (macular edema) and new blood vessel growth. In response to the
damaged blood vessels and poor blood circulation over time, abnormal blood vessels grow in order to bring additional
oxygen; however, these new blood vessels are weak and can break, causing bleeding and resulting in vision loss. As a
separate event, the leaky blood vessels can cause retinal swelling affecting the centre of sight (macular edema), also
causing vision loss. Advanced stages of diabetic retinopathy (also known as proliferative diabetic retinopathy) are
treated with retinal laser (photocoagulation) and sometimes surgery[1]. Retinal swelling can be treated with injections
of medication or laser therapy to reduce blood vessel leakage. Left untreated, diabetic retinopathy can lead to
blindness[2]. Risk factors for diabetic retinopathy include:
• Blood glucose (A1C) out of range,
• Length of time living with diabetes,
• Renal disease, and
• Hypertension.[3]
The best way to prevent vision loss and slow the progression of diabetic retinopathy is to control blood sugars, and
maintain healthy blood pressure and lower LDL cholesterol levels [4]. Early stages of diabetic retinopathy have no
warning signs, so getting regular eye screening is vital to detect the disease. It is recommended that people living
with diabetes get their eyes screened for diabetes retinopathy at least once every two years as per the Ontario
Diabetes Strategy; the Eye Health Council of Ontario (EHCO) recommends retinal exams on an annual basis[5].
Statistics
The latest data from the Baseline Diabetes Database Initiative shows that 67.5% of the 83,144 adults living with
diabetes in Champlain received a retinal eye exam in the past 2 years. This rate is very close to the provincial rate of
67.1% of people living with diabetes who received the retinal eye exam[6].
Table 1 Percentage of adults living with diabetes receiving the recommended retinal eye exam* (as of
September 30, 2010)[6]
% people living with diabetes, age 18 or over,
who have received a retinal eye exam within
past 2 years
n Received Champlain
% Received Champlain
% Received Ontario
55563
67.5%
67.1%
*Re$nal eye exams by optometrists and ophthalmologist where fee for service was submi;ed. Champlain Diabetes Regional Coordination Centre | 613-238-3722 | 420 Cooper St. Ottawa, ON, K2P 2N6
[email protected]
When we look at some retinal eye interventions commonly used to treat diabetes retinopathy (retinal laser/
photocoagulation and vitrectomy), the rates in Champlain are slightly lower than those in Ontario (Table 2). These
treatments do not cure diabetic retinopathy but can slow or stop the progression of the disease[1]. Table 2 Percent of adults living with diabetes who had retinal treatments, 2006/07 Champlain and Ontario [7]
Champlain Women
Champlain Men
Ontario Women
Ontario Men
Age standardized number of adults
aged 20+ with diabetes per 100’000
who had laser photocoagulation1
1123
1332
1194
1382
Age standardized number of adults
aged 20+ with diabetes per 100’000
who had vitrectomy2
206
271
220
284
Roles and Referrals
Optometrists are professionally trained eye care providers who have the knowledge and skills to perform dilated eye
exams for retinopathy assessment[5]. Although retinal eye screening can be conducted by either an optometrists or
an ophthalmologist, the scope of practice of ophthalmology covers more advanced eye care. It may therefore be more
appropriate to have patients screened by optometrists, who will identify patients potentially requiring therapy and refer
the advanced cases to ophthalmologists.
There are around 1500 Optometrists in Ontario. You can find a list of local optometrists at http://www.optom.on.ca/
find_an_optometrist.
In the Champlain region, there were 56 Ophthalmologists in 2010 according to the Ontario
Physician Human Resources Data Centre[8]; however, it is estimated that around one third to one half of those
ophthalmologists are specialists and therefore would not be available to conduct diabetic screening[9].
The newly released guidelines from the Eye Health Council of Ontario (EHCO) contain recommendations on frequency
and type of assessment based on client characteristics, referrals, communication flow and follow-up. The EHCO
guidelines recommend using a referral form with both optometrists and ophthalmologists, which includes a request for
a report about the eye exam to be sent to the primary care provider[5].
Costs to the Patient
There should be no yearly cost to patients with diabetes for their one yearly routine eye exam, whether
conducted by an optometrist or ophthalmologist.
What is covered by OHIP: One routine eye exam every 12 months is funded by OHIP for people living with
diabetes (diagnostic code 250), age 20-64[10]. This exam can be conducted by an optometrist or ophthalmologist.
The eye care providers must identify the patient as having diabetes to receive this coverage[11].
Adults under 20 or 65 years of age and older are covered by OHIP for a yearly routine eye exam, whether or not they
have diabetes[10].
What isn’t covered by OHIP: Services outside of those listed above for the routine eye exam are not covered by
OHIP as part of the visit. They include retinal photography, fitting for glasses, production of glasses, lenses,
dispensing fees, contact lens fitting and lenses, and any additional eye exams within the 12 months. A table of
common costs have been provided below.
1
2
Re$nal laser/photocoagula$on is a treatment for diabe$c re$nopathy which stops or slows the leakage of blood and fluid in the eye.
Vitrectomy is a surgery to remove some or all of the vitreous humor from the eye. It may be concurrent with or followed by laser treatment.
Champlain Diabetes Regional Coordination Centre | 613-238-3722 | 420 Cooper St. Ottawa, ON, K2P 2N6
[email protected]
Table 3 Elements covered in a routine eye exam, extracted from the Schedule of Benefits for Optometry
Services[12]
1. relevant history (ocular medical history, past medical history, family history);
2. visual acuity examination;
3. ocular motility examination;
4. refraction and the provision of a written refractive prescription if required;
5. slit lamp examination of the anterior segment;
6. ophthalmoscopy by one or more of direct, binocular indirect ophthalmoscope (BIO), monocular indirect
ophthalmoscope (MIO) or non-contact fundus lens;
7. advice and/or instruction to the patient;
8. a letter outlining the findings of the examination provided to the patient’s physician or a nurse practitioner (RN EC)
upon his or her request.
Op#onal: if required in accordance with generally accepted professional standards, any or all of the following elements:
1. tonometry (assessment for glaucoma); 2. visual field examina$on by confronta$on field;
3. dilated fundus examina$on by one or more of direct, binocular indirect ophthalmoscope (BIO), monocular indirect ophthalmoscope (MIO) or non contact fundus lens.
Any additional activities, outside of follow-up from the routine eye exam, would have to be paid by the patient.
Ø If a patient has had an eye exam in the past 12 months for new glasses, they would not be covered for an
additional retinal assessment.
Ø If, during a routine eye exam, the optometrist finds evidence of diabetes that has not previously been
diagnosed, the eye exam will not be covered until the patient has seen their primary health care provider and
has been diagnosed having diabetes[11].
Note: The College of Optometry recommends services during a major eye exam that are not considered essential by OHIP and
are not covered; please see the Optometric Practice Reference for more information[13]. The patient should ask the eye care
providers up front about what services are covered and what further testing during the appointment might incur additional costs.
Table 4 List of common optometric services and average costs for clients
Services
Adult full eye exam
Cost to patient/client
No cost
(1 per year for people with DM)
$100-$125+
Retinal Photographs
$30-$50+
Retinal OCT
$30-$50
Contact Lens Rx
$75-200+
Glasses, lenses and frames
$100-$600+
Comments
People living with diabetes are covered for one
routine eye exam a year at no cost. Additional
optometric appointments are not covered by OHIP.
Optional though commonly recommended as part
of yearly visits.
Optional though commonly recommended as part
of yearly visits.
Not covered under routine eye exam by OHIP.
May be covered by third party insurance for some
clients.
Not covered as part of routine eye exam. May be
covered by third party insurance for some clients.
Cost depends on prescription, type of frames, and
type of lens desired.
Champlain Diabetes Regional Coordination Centre | 613-238-3722 | 420 Cooper St. Ottawa, ON, K2P 2N6
[email protected]
Costs to the Healthcare System
Diabetic retinopathy amounts to $257.5 million dollars in direct health care costs in Canada, with an additional 263.6
million dollars in indirect costs from lost productivity, rehabilitation, etc. [14] Generally speaking, it costs the health
care system less money if a retinal eye exam is conducted by optometrists as opposed to an ophthalmologist (see
Table 5). As many ophthalmologists bill for the consultation, the retinal eye exam would then cost the health care
system twice the amount compared with the same service provided by an optometrist. With an estimated 83,144
adults living with diabetes in Champlain, a saving of $40 per person would amount to 3,325,760 dollars without any
loss in service.
Table 5 Provider specific costs to the Ontario Healthcare System for retinopathy screening[12, 15, 16]
Eye Care Provider
Reimbursement for Retinal Eye exam
Description
Routine eye exam (see table above for list of
Optometrist
V409 $43.80
services)
A235 $82.30
Consultation by a physician
Ophthalmologist
A253 $82.30
Consultation by an optometrist
Leah Bartlett and Elizabeth Lindsay with advice from:
• the Knowledge Translation Working Group on «Retinopathy Screening for Patients with Diabetes» led by the Office of CME,
Faculty of Medicine, University of Ottawa and
• the Eye Health Council of Ontario
References
1. American Optometric Association. Diabetic Retinopathy. http://www.aoa.org/diabetic-retinopathy.xml [cited 2011 October
26].
2. National Eye Institute. Facts about Diabetes Retinopathy. http://www.nei.nih.gov/health/diabetic/retinopathy.asp 2009 [cited
2011 October].
3. Noble, J. and V. Chaudhary, Five things to know about Diabetic retinopathy. CMAJ, 2010. 182(15): p. 1646.
4. Aiello, L.P., M. Cahill, and J. Wong, Systemic Consideration in the Management of Diabetic Retinopathy. American Journal of
Ophthalmology, 2001. November: p. 760-776.
5. ECHO, Guidelines for the Collaborative Management of Persons with Diabetes Mellitus by Eye Care Professionals. 2011. p.
16.
6. MOHLTC, Ontario Diabetes Strategy Key Performance Measures: Highlights from Second Report. 2010, Health Analytics
Branch.
7. Booth, G., et al., Diabetes, in Project for an Ontario Women’s Health Evidence-Based Report Volume 2, A. Bierman, Editor.
2010: Toronto.
8. OPHRDC, Active Physicians by Speciality of Practice and LHIN. 2011.
9. Gottlieb, D.C., Personal communication. 2011: Ottawa.
10. MOHLTC (2005) Changes to OHIP Coverage for Eye Care Services. http://www.health.gov.on.ca/english/public/pub/ohip/
eyecare.html.
11. MOHLTC, Bulletin: Changes to Eye Care Services for Patients Age 20 to 64 Years. 2004.
12. MOHLTC, Schedule of Benefits for Optometry Servies (April 1, 2009). 2009. p. 10.
13. COO, College of Optometrists of Ontario: Optometric Practice Reference (Revised May 2007). 2011: p. 128.
14. CNIB and COS, The cost of vision loss in Canada. 2009. p. 124.
15. MOHLTC, Schedule of Benefits: Physician Services Under the Health Insurance Act (September 1, 2011), in Diagnostic and
Therapeutic Services. 2011. p. J77-J84.
16. MOHLTC, Schedule of Benefits: Consultations and Visits (September 1, 2011). 2011. p. A109-A115.
Making the numbers talk by Leah Bartlett, Epidemiologist DRCC
Champlain Diabetes Regional Coordination Centre | 613-238-3722 | 420 Cooper St. Ottawa, ON, K2P 2N6
[email protected]