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Retina  |   February 2024
Healthcare Resource Utilization and Costs in an At-Risk Population With Diabetic Retinopathy
Author Affiliations & Notes
  • Vivian Rajeswaren
    Department of Ophthalmology, University of Colorado School of Medicine, Aurora, CO, USA
  • Vivian Lu
    Department of Ophthalmology, University of Colorado School of Medicine, Aurora, CO, USA
  • Hongan Chen
    Department of Ophthalmology, University of Colorado School of Medicine, Aurora, CO, USA
  • Jennifer L. Patnaik
    Department of Ophthalmology, University of Colorado School of Medicine, Aurora, CO, USA
  • Niranjan Manoharan
    Department of Ophthalmology, University of Colorado School of Medicine, Aurora, CO, USA
  • Correspondence: Niranjan Manoharan, Department of Ophthalmology, University of Colorado School of Medicine, Mail Stop F731, 1675 Aurora Court, Aurora, CO 80045, USA. e-mail: niranjan.manoharan@cuanschutz.edu 
Translational Vision Science & Technology February 2024, Vol.13, 12. doi:https://doi.org/10.1167/tvst.13.2.12
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      Vivian Rajeswaren, Vivian Lu, Hongan Chen, Jennifer L. Patnaik, Niranjan Manoharan; Healthcare Resource Utilization and Costs in an At-Risk Population With Diabetic Retinopathy. Trans. Vis. Sci. Tech. 2024;13(2):12. https://doi.org/10.1167/tvst.13.2.12.

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Abstract

Purpose: Several investigators have suggested the cost-effectiveness of earlier screening, management of risk factors, and early treatment for diabetic retinopathy (DR). We aimed to evaluate the extent of health care utilization and cost of delayed care by insurance type in a vulnerable patient population.

Methods: A retrospective analysis of patients with DR was conducted using electronic medical record (EMR) data from January 2014 to December 2020 at Denver Health Medical Center, a safety net institution. Patients were classified by disease severity and insurance status. DR-specific costs were assessed via Current Procedural Terminology (CPT) codes over a 24-month follow-up period.

Results: Among the 313 patients, a higher proportion of non-English speaking patients were uninsured. Rates of proliferative DR at presentation differed across insurance groups (62% of uninsured, 42% of discount plan, and 33% of Medicare/Medicaid, P = 0.016). There was a significant difference in the total median cost between discount plan patients ($1258, interquartile range [IQR] = $0 – $5901) and both Medicare patients ($751, IQR = $0, $7148, P = 0.037) and Medicaid patients ($593, IQR = $0 – $6299, P = 0.025).

Conclusions: There were higher rates of proliferative DR at presentation among the uninsured and discount plan patients and greater total median cost in discount plan patients compared to Medicare or Medicaid. These findings prioritize mitigating gaps in insurance coverage and barriers to preventative care among vulnerable populations.

Translational Relevance: Advanced diabetic disease and increased downstream health care utilization and cost vary across insurance type, suggesting improved access to preventative care is needed in these specific at-risk populations.

Introduction
Diabetes mellitus (DM) is a chronic systemic disorder with an estimated worldwide prevalence of 463 million in 2019 with a projected increase to 578 million by 2030 and nearly 700 million by 2045.1,2 Diabetic retinopathy (DR) is a microvascular complication of DM affecting nearly one third of individuals with diabetes and is the leading cause of preventable blindness among adults aged 20 to 74 in the United States and worldwide.35 Analysis of trends underlying vision loss reveal a worldwide increase in cases of DR from 1990 to 2010.6 In developed countries, lower socioeconomic status was independently associated with increased incidence of DR in type 1 diabetes mellitus (T1DM).7 In the United States, the number of individuals with DR is projected to triple by 2050 and disproportionately affect Blacks, Hispanics, and adults over 65 years of age.8 DR is associated with lower health-related quality of life,9,10 and increased risk of all-cause mortality.11 DR leads to a significant public health burden, particularly in underserved communities. 
It is well-established that retinopathy progression to vision-threatening diabetic retinopathy (VTDR) is associated with severity of retinopathy at baseline presentation.12 
The prevalence of DR also increases with the duration of diabetes,13 as nearly all individuals with T1DM and the majority of individuals with type 2 diabetes (T2DM) develop DR within 20 years from disease onset.4,5 Estimates in the United States of the cumulative incidence of DR after DM onset are approximately 59.0% at 4 years14 and 97% at 25 years15 in patients diagnosed before the age of 30 years.14,15 These findings underscore a need for earlier preventative care before the onset of irreversible visual damage. 
The estimated direct medical cost of DR in the United Staes was $493 million in 2004 for adults aged 40 and older.16 Several investigators have described the cost-effectiveness of earlier screening, management of risk factors, and early treatment for DR.1719 However, implementation and compliance to these protocols in vulnerable groups remains inadequate, suggesting a need for interventions targeted specifically to these populations. There is minimal research on the economic and treatment burden for underserved patients with DR. We hypothesized that delayed presentation of DR leads to increased downstream health care utilization and costs for patients in lower socioeconomic conditions. Understanding the extent of health care utilization and cost of delayed treatment provides insight into improving preventative care among these vulnerable populations. 
Methods
Participants and Study Design
This retrospective cohort study was conducted using records from patients with DR who were seen at the Denver Health Eye Clinic at Denver Health Medical Center (DHMC) between January 2014 and December 2020. DHMC is a safety-net institution that serves nearly a quarter of the Denver population including those who are uninsured and/or underserved. Patients with DR were identified by International Classification of Diseases (ICD) diagnosis codes through an electronic medical record (EMR). Inclusion criteria were diagnosis of DR and DR treatment-naive status. Exclusion criteria were incarceration during the study period and unknown insurance status. This study was approved by the Colorado Multiple Institutional Review Board (COMIRB) and adheres to the Declaration of Helsinki. Participant consent was not required as this study met criteria for institutional review board (IRB)-waived informed consent. All data related to the study were entered into REDCap, a secure web-based COMIRB-approved database. 
Patient Characteristics
The following demographic characteristics were collected: age, sex, race, primary language, and health plan type. The study population was classified into five patient groups based on health insurance status. Health insurance groups included Medicare, Medicaid, private, uninsured, and two discounted healthcare programs specific to low-income patients in Colorado. These two programs are the Colorado Indigent Care Program (CICP), providing discounted health care at participating hospitals and clinics for patients who do not qualify for Medicaid, and the Denver Financial Assistance Program (DFAP), which provides discounted health care at DHMC for patients ineligible for Medicaid or CICP. Whereas patients with CICP and DFAP are by definition uninsured, these groups were combined into their own insurance group for the purpose of statistical comparison. In this study, the uninsured group refers to patients without medical insurance who did not receive discounted care through CICP or DFAP. 
Clinical characteristics determined at the initial visit were the presence of hypertension (HTN), HbA1c, duration of diabetes, and DR severity. Complications of DR assessed within the study timeframe included vitreous hemorrhage (VH), diabetic macular edema (DME), and neovascular glaucoma (NVG). DR severity was evaluated by an optometrist or ophthalmologist at the initial visit and stratified into five categories according to the International Clinical Disease Severity Scale for DR20: (1) no retinopathy; (2) mild non-proliferative retinopathy (NPDR); (3) moderate NPDR; (4) severe NPDR; and (5) proliferative diabetic retinopathy (PDR). 
Outcome Measures
Disease specific healthcare costs and resource utilization were determined by Current Procedural Terminology (CPT) codes for DR in the 24-month period following the initial visit to the DHMC Eye Clinic. The CPT terminology is defined by the American Medical Association (AMA) and provides a uniform method for reporting medical services under public and private insurance programs.21 Codes for the following procedures were assessed: patient visits (excluding visits within the 90-day postoperative period), intravitreal injection (IVI), panretinal photocoagulation (PRP), and vitreoretinal surgery. The cost of each CPT code was defined by the facility price for a hospital setting in Colorado (Supplementary Table S1). Procedure costs were calculated by multiplying the cost of each CPT code by the corresponding procedure count per patient. The total cost during the study period was the sum total of all procedure costs for each patient. All costs were adjusted to 2022 cost values. 
Statistical Analysis
Standard summary descriptive statistics were used to assess differences in demographic and clinical characteristics across patient insurance groups. Frequency and percentage of healthcare services and associated costs are provided by insurance group. Comparisons across groups were performed using the Chi-square or Fisher's exact test for categorical variables and ANOVA or Kruskal-Wallis test for continuous variables. The Kruskal-Wallis test, a rank-based nonparametric test, was used to compare costs across groups as cost was not normally distributed. The Wilcoxon rank sum test was used for pairwise comparisons between insurance groups to assess differences for our primary outcome of total cost. SAS version 9.4 was used for all statistical analyses (SAS Institute, Cary, NC, USA). 
Results
In Table 1, we show select demographic and clinical characteristics across the five insurance groups. The mean age of patients was significantly different across all groups (P < 0.0001) and, as expected, was highest in the Medicare group (64.3, SD = 9.9). Race/ethnicity also significantly differed across insurance groups (P = 0.017), with Hispanic patients comprising the majority of patients in the DFAP/CICP and uninsured groups (78.1% and 70.3%, respectively). The DFAP/CICP and uninsured patients also had a high percentage of non-English primary languages (90.6% and 63.9%, respectively) and differences across insurance groups were significant (P < 0.0001). Comparison of clinical characteristics showed a significant difference in hypertension among insurance groups (P = 0.010) and DR severity (P = 0.016). Nearly 62% of uninsured patients and 61% of privately insured patients had PDR, whereas only about one-third of Medicare and Medicaid patients were diagnosed with PDR. In addition, prevalence of vitreous hemorrhage during the study timeframe significantly differed by insurance status (P = 0.036) and was highest in the uninsured (35.1%) and lowest in the Medicaid group (14.2%). There were no significant differences in sex, duration of diabetes, HbA1c, or prevalence of DME and NVG across groups. 
Table 1.
 
Demographic and Clinical Characteristics by Insurance Status
Table 1.
 
Demographic and Clinical Characteristics by Insurance Status
In Table 2, DR specific healthcare resource utilization and costs are described. Median number of clinic visits were highest in the DFAP/CICP group (2, interquartile range [IQR] = 1 to 10) and differences across groups were significant, P = 0.047. Cost of clinic visits also significantly varied by insurance status (P = 0.047) with the highest cost in the DFAP/CICP group at $156 (IQR = $0 to $780), which was twice the median cost for other insurance groups. The median number of IVI during the study period significantly differed across all insurance groups (P = 0.019), with the greatest median value of 9.0 (IQR = 1 to 42) in the DFAP/CICP discount healthcare group and lowest median value of 3.0 (IQR = 1 to 27) in the uninsured group. This translated to the DFAP/CICP group having the highest median total IVI cost at $834 (IQR = $93 to $3892) and the lowest in the uninsured group at $278 (IQR = $93 to $2502, P = 0.019). Differences across insurance groups were not significant by injection status, total number, and cost of PRP or vitreoretinal surgery. Total overall cost by insurance groups did not reach statistical significance across all groups (P = 0.064). 
Table 2.
 
DR Cost by Insurance Status
Table 2.
 
DR Cost by Insurance Status
Pairwise comparisons for the median total cost between insurance groups are shown in Table 3. There was a significant difference in the total median disease-specific cost between DFAP/CICP patients ($1258, IQR = $0 to $5901) and Medicare patients ($75, IQR = $0 to $7148, P = 0.037) and DFAP/CICP patients ($1258, IQR = $0 to $5901) and Medicaid patients ($593, IQR = $0 to $6299, P = 0.025). All other pairwise comparisons were not significant. 
Table 3.
 
Pairwise Comparisons for Total Cost
Table 3.
 
Pairwise Comparisons for Total Cost
We present the total cost by insurance group stratified by PDR status in Table 4. We found a significant difference across insurance groups for patients diagnosed with PDR, P = 0.046. The highest total cost was in the DFAP/CICP group at $2777 (IQR = $78 to $5901) and the lowest total cost was in the uninsured at $1466 (IQR = $307 to $4994). Total cost stratified by patients without PDR was not significantly different across insurance groups. 
Table 4.
 
Total Cost Stratified by PDR Status
Table 4.
 
Total Cost Stratified by PDR Status
Discussion
This retrospective study evaluated the relationship between health insurance status and the economic burden of DR in an underserved population. The findings described herein demonstrate that advanced diabetic disease and increased downstream health care utilization and cost vary by insurance type. Improved access to preventative care is needed in these specific at-risk populations. 
In this study, health insurance was categorized into five groups, Medicaid, Medicare, private insurance, uninsured, and discount healthcare. Per standard Medicaid eligibility requirements, individuals in this group had limited annual incomes and were either disabled, pregnant, or financially responsible for children, elderly, or disabled family members.22 The Medicare group was predominantly comprised of individuals 65 years and older in addition to younger individuals with certain health conditions, such as end-stage renal disease (ESRD) and amyotrophic lateral sclerosis (ALS), in accordance with standard Medicare enrollment criteria.22,23 The private insurance group consisted of individuals in a safety net population, who typically cannot afford the cost of follow-up care. Individuals in the DFAP/CICP groups met eligibility criteria based on household income and proof of Denver residence. They tended to present with advanced DR and enrolled in a discount health care plan soon after presentation. Patients in the uninsured group did not qualify for discounted health care and were typically unable to return for further treatments due to high self-pay costs, despite high rates of presentation with advanced DR. 
A high percentage of patients in the uninsured group were Spanish-speaking and Hispanic minorities. This group also had the greatest levels of PDR at the initial visit and VH during the study timeframe. Studies have shown that socioeconomic deprivation24,25 and lack of insurance26 are associated with increased prevalence of PDR24,25 and more severe DR at initial presentation to care.24,26 The uninsured group also had the lowest mean number of eye clinic visits in our study. Financial concerns,27,28 lack of insurance,2830 decreased access to care,28,29 and language and communication difficulties29 are established barriers to receiving eye examinations and likely contributed to decreased utilization of eyecare in our uninsured group. Furthermore, Chan et al. described an increased risk of PDR and related complications in patients with fewer eyecare visits.27 These findings may explain the higher prevalence of PDR and VH in our uninsured patients. Additionally, the presence of PDR is greater in patients with a longer duration of diabetes, elevated HbA1c, high blood pressure, and Hispanic race.3133 We did not find significantly elevated HbA1c, duration of diabetes, or prevalence of HTN in the uninsured compared to the other insurance groups in the present study. 
The private insurance group had the second highest levels of PDR and VH and low rates of follow-up patient appointments during the study timeframe. There is limited research on the prevalence of PDR and VH in patients with DR with private insurance. Regarding follow-up eye care, a study on individuals with PDR showed patients with private and government insurance were more likely to be nonadherent to clinical recommendations for follow-up compared to self-pay patients.34 In our study, we did not examine rates of follow-up eye care stratified by PDR status, thus it is difficult to compare our results with these findings. Moreover, given the small size of our private insurance group and specific safety net study population, our results may not be representative of most patients with private health insurance. 
With respect to health care utilization and costs, individuals in the DFAP/CICP discount health care group had the highest number and total cost of eye clinic visits. Frequency and cost of injections were highest in the private insurance and DFAP/CICP groups. When stratified by the presence of PDR, costs to the healthcare system were markedly increased for all insurance groups compared to NPDR. The total cost for patients with PDR was greatest in DFAP/CICP, followed by the private insurance group, with similar costs for Medicaid and Medicare and the lowest cost in the uninsured. Individuals in the DFAP/CICP and private insurance groups cost the system the most given their initial poor glycemic control and ability to pay for discounted or covered health care, respectively. Costs for Medicaid and Medicare patients were lower than the discount and private insurance groups, presumably a result of receiving covered health care and ocular care and low rates of PDR relative to the other insurance groups. Costs for uninsured patients were limited as they were likely less able to follow-up due to the financial burden of health care. 
There are few studies examining the economic burden of DR in the United States. Other studies investigating the cost of DR for Medicare16,35,36 and privately insured patients16,37 included the costs of inpatient care,16,36,37 outpatient care,16,3537 emergency services,37 prescription medications,37 and other services attributable to visual impairment.16,3537 These findings are not comparable with our cost values as we only included DR specific costs of care at an eye clinic and did not include the cost of medications, inpatient care, emergency care, or other services. We also specifically examined a safety net population in a local community hospital in Denver, Colorado, which may differ from study populations in other research. 
In 2019, the American Diabetes Association (ADA) recommended a comprehensive, dilated eye examination every 1 to 2 years if retinopathy is not present at the initial diagnosis of DM.38 However, as of 2020, only 58.3% of adults with DM completed annual eye examinations.39 Within the past 10 years, the use of tele-retinal screening for conditions such as DR has gained momentum.40 Recent studies of tele-retinal DR screening have also demonstrated reduced costs for patients and the health care system.4143 Savings are attributed to reduced burden on eye clinics as patients without ocular findings do not need an in-person examination.41,42,44,45 Furthermore, identifying pathology early in the disease course is expected to lead to decreased downstream health care costs and fewer individuals with DR related loss of vision, saving an estimated hundreds of millions of dollars for the federal government in health care and social security spending for the disabled and unemployed.46 These findings demonstrate the cost-effectiveness of tele-retinal screening for DR and point to the necessity of earlier insurance coverage for screening and preventative treatment to reduce gaps in care for underserved populations and decrease financial burden on the healthcare system. 
Strengths and Limitations
Strengths of our study include specifically examining a safety net population serving low-income patients with predominantly Medicaid coverage. However, our study is limited as findings might not be generalizable to populations with higher socioeconomic status and different ethnic diversity. Moreover, a 24-month follow-up period may not be sufficient to fully observe differences in costs and outcomes with a slowly progressing disease such as DR. Further research is warranted with a larger cohort over a greater period of follow-up to assess long-term DR specific economic burden at the population level. 
Conclusions
Disparities in DR care arise from a number of economic and societal factors, most notably inadequate health insurance and a lack of insurance coverage for preventative screening and early treatment for at-risk populations. In addition, communication and language barriers disproportionally affect minority and underserved populations, contributing to increased disease severity at presentation. Furthermore, delayed diagnosis leads to individual and system level economic burden and vision threatening complications. Efforts to promote equity in DR care should focus on mitigating gaps in insurance coverage and barriers to preventative care in vulnerable communities in order to improve visual outcomes. 
Acknowledgments
Supported in part by a challenge grant from Research to Prevent Blindness to the Department of Ophthalmology at the University of Colorado School of Medicine. 
Disclosure: V. Rajeswaren, None; V. Lu, None; H. Chen, None; J.L. Patnaik, None; N. Manoharan, None 
References
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Table 1.
 
Demographic and Clinical Characteristics by Insurance Status
Table 1.
 
Demographic and Clinical Characteristics by Insurance Status
Table 2.
 
DR Cost by Insurance Status
Table 2.
 
DR Cost by Insurance Status
Table 3.
 
Pairwise Comparisons for Total Cost
Table 3.
 
Pairwise Comparisons for Total Cost
Table 4.
 
Total Cost Stratified by PDR Status
Table 4.
 
Total Cost Stratified by PDR Status
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