Diabetic Macular Edema treatment limits in Poland

Diabetic Macular Edema (DME) is a severe disease, re-lated to Diabetic Retinopathy (DR). All diabetic patients are at risk of DME development. The disease severity may vary from mild to moderate, with a risk of loss of vision. Diabetic Retinopathy, including Diabetic Macular Edema patients in Poland, are treated within Diagnosis Related Groups (JGP) system, that allows settlement of costs of performed medical procedures, including vitre-oretinal procedures, fotocoagulation, and administration of VEGF inhibitors. In this article authors tried to analyse what are the costs of treatment of DME patients within Diagnosis Related Groups (JGP) in Poland, what are the trends in expenditures of DME treatment, and what are the recommended steps to the decision makers in vision loss prevention amongst mellitus patients in Poland? The study

DME treatment in Poland within the public system is remarkably below needs, and it does not meet standards of vision loss prevention amongst mellitus patients. The situation is mainly caused by under-diagnosis at the primary healthcare outpatient clinics, long waiting time for an ophthalmologist consultations and treatment budget limits within JGP groups in hospitals.
Diabetic Macular Edema (DME) is a severe disease, related to the Diabetic Retinopathy (DR). All diabetic patients are at risk of DME development. The disease severity may vary from mild to moderate, with risk of loss of vision. 25% to 30% non ophthalmology treated, and up to 15% ophthalmology treated diabetic patients might be affected by moderate loss of vision due to DME. Based on the Rohit Varma, Neil M. Dressler study published in JAMA Ophthalmology weighted DME prevalence in USA is 3,8% (2.7%-4.9%) of diabetes, however the meta-analysis of 35 studies (22,896 patients from United States, Australia, Europe and Asia) calculates DME prevalence on 7.48% (7.39-7.57) of the overall diabetes population.
Progression to DME affects 3% of mild non-proliferative DR eyes, 38% moderate and severe non-proliferative DR eyes and relates up to 71% eyes of the proliferative Diabetic Retinopathy -the most vision-threatening form of the disease,.
According to the Los Angeles Latino Eye Study and in the Proyecto VER study -18% of participants with diabetes of more than 15 years' duration had the proliferative DR, with no PDR percentage difference between Type 1 vs Type 2 diabetes.
Polish National Health Fund (NFZ) estimates diabetes patients on 2 millions in Poland. Based on NFZ data and referring to cited above Rohit Warma as well as Joanne Yau studies, authors calculate DME prevalence from 76.000 to 149.000 patients in Poland.

In this article authors tried to assess what are the Diabetic Macular Edema treatment limits in a Polish healthcare system perspective.
To answer this question, the Polish National Health Fund (NFZ), Diagnosis Related Group (JGP) data were used. For any other calculations in this article, authors accounted 7,48% DME prevalence amongst mellitus patients as the most relevant to Poland.
NFZ regularly publishes JGP statistics, and since year 2009, there are specific common treatment baskets relevant to eye diseases (JGP B1 to B98).
As for the ICD-10 classification, Diabetic Retinopathy H 36.0 with ICD-9 procedures (E10-E14) are included in NFZ hospital JGP statistics presented in the Like in other diseases in Poland, there may be some budget limitations, that reduces level of treatment due to potential high cost of treatment to the healthcare system. To answer this doubt, there are calculated DR and DME patients costs of treatment within the JGP groups, presented in the figure 1.

Figure 1. DME patients vs Total Costs of treatment vs Average treatment cost
According to the data presented in the figure 1, authors observe a stable, low annual treatment costs for DME patients treated within the JGP groups. The calculation of the number of treated patients, average cost of treatment and total costs of treatment of DME patients within the JGP system are presented in the Trend of DR treatment costs within JGP groups is presented in the figure 2.

Discussion
This study aimed to show, what are the DME treatment costs in Poland, based on NFZ JGP statistics.
The results show, small and decreasing number of treated DME patients within the JGP groups in Poland which is contrary to the disease prevalence and treatment needs that should focus on vision loss prevention amongst diabetes mellitus patients. However, the current JGP system points within the groups as of B16, B17, B83, B84 and B98 allows DME treatment, but in fact the valuation of a group, consisting form ICD-9 procedures is not directly linked with DME treatment (in opposite to i.a. age-related macular degeneration -AMD). Also, hospitals are not interested in treatment of either DR or DME patients within low valued JGP groups (like B84 -laser fotocoagulation ) as it is not economically attractive, so they have retained the treatment within the most highest valued groups like B16 and B17 -vitrectomy -which is mainly used for the highest severe DR and DME patients.
Taking into account current situation in outpatient clinics where there is a very limited patients' access (long queues) to the specialist, that limits DR and DME early stage diagnosis also considering JGP system structure and valuation, all of these circumstances markedly prevents from proper DR and DME treatment and vision loss prevention in the discussed population.
Current direct costs of DME treatment in Poland are low, and there is a space for improvement, as indirect costs of not treating the DME, including social security costs due to the deterioration of vision amongst diabetes patients might significantly exceed the costs of the disease treatment. Also further analyses, especially calculating DME costs in a social security system perspective might be helpful in taking any decisions regarding changes in the current treatment possibilities within the JGP groups system.
On top of the pharmacoeconomical divagations, there is a need to start a national program of evaluation of prevalence and incidence of diabetes mellitus related diseases including Diabetic Retinopathy and Diabetic Macular Edema.