In 2013, an innovative neurology is emerging which is overcoming all kinds of hurdles: genetics, biotechnology, medical imaging, neurosurgery, the pharmaceutical industry… fundamental and clinical research are uniting so that at last we can understand these diseases, treat them and hopefully soon cure them.
The one thing you cannot forget right now is Dementia. From the very real concerns over the care given in our institutions to the most abstruse research findings, dementia continues to make the headlines in the national press. This attention is certainly welcome after many years of relative neglect but the question is very much “Why now”? Perhaps the main answer to the question is that people are living longer.
When contemplating what is new in asthma the temptation is to focus only on new developments – information regarding pathways of inflammation or potential products that may modify the asthma disease process. However, as recent years have seen few new treatments become available, it is more beneficial to focus on the progress in understanding asthma and how the treatment has changed with time.
If you could find out when you were going to die, would you want to know? A groundbreaking research aims to tell patients exactly that, with a test to determine how long you have left to live poised to hit markets in Britain.
Individuals with dyspnea, or shortness of breath, have an increased long-term mortality risk compared with individuals without dyspnea, according to a new study presented at the 2014 American Thoracic Society International Conference.
Despite being of a healthier weight, lean patients with nonalcoholic fatty liver disease (NAFLD) have a higher overall mortality rate than patients with NAFLD who are overweight or obese, according to new research presented at Digestive Disease Week (DDW).
New research by Andrew Stokes, a doctoral student in demography and sociology in the School of Arts and Sciences at the University of Pennsylvania, suggests that many obesity studies substantially underestimate the mortality risks associated with excess weight in the United States. His study, "Using Maximum Weight to Redefine Body Mass Index Categories in Studies of The Mortality Risks of Obesity," was published recently in the open-access journal Population Health Metrics.
High prediagnosis body mass index (BMI) is associated with increased mortality after colorectal cancer diagnosis, according to a study presented at the annual meeting of the American Association for Cancer Research, held from April 5 to 9 in San Diego.
In 2012, Dr. Nir Krakauer, an assistant professor of civil engineering in CCNY's Grove School of Engineering, and his father, Dr. Jesse Krakauer, MD, developed a new method to quantify the risk specifically associated with abdominal obesity.
A new screening technology reveals a signature of mortality in blood samples. Researchers have identified four biomarkers that help to identify people at high risk of dying from any disease within the next five years.
It is always nice to know that the top clinical research centers in the nation are continually working to update their treatment guidelines. The American College of Cardiology (ACC), along with the American Heart Association (AHA) and the Center for Disease Control (CDC) have updated their clinical practice guidelines for cardiovascular disease as of November 2013. How do their findings affect our knowledge of disease prevention, and how do they relate to underwriting?
So, what is the latest information on AIDS and human immunodeficiency virus (HIV) 30 years after its discovery and 15 years after the introduction of powerful treatments which have changed the course of the disease in the countries where these drugs are readily available? The HIV/AIDS pandemic is still one of the greatest medical threats at the beginning of the 21st century, with over 35 million people infected in 2010. Do the research results give us cause for hope? Is the revolution in AIDS therapies continuing at a time when the pandemic is clearly persisting and there is no vaccine within sight?
Over the past 30 years, the biology of cancer has been more clearly elucidated. This article explores the movement for re-defining cancer in the context of the research findings, and provokes the question as to whether the insurance industry needs to alter their definitions accordingly.
Cancer death rates in the United States continue to decline. Estimates of survival that include the probability of dying of cancer and other causes stratified by comorbidity level, age, and stage can provide important information to facilitate treatment decisions.
Red blood cell disorders occur as a result of a lack, an excess or a genetic defect in the production of these vital cells. A shortage of red blood cells, or erythrocytes, is evidenced by anaemia. According to the WHO, two billion individuals around the world are affected by anaemia and iron deficiency is said to be the cause of about half of cases.
Comprehensive lifestyle interventions decrease the incidence of type 2 diabetes in high-risk patients, but the benefits are less clear in diagnosed patients, according to a review published in the Oct. 15 issue of the Annals of Internal Medicine.
While being overweight increases the risk of cardiovascular events in patients with type 2 diabetes, overweight is also associated with lower mortality in older patients, according to a study presented at the annual meeting of the European Association for the Study of Diabetes, held from Sept. 23 to 27 in Barcelona, Spain.
New research presented at this year's annual meeting of the European Association for the Study of Diabetes (EASD) in Barcelona, Spain, shows that patients receiving sulfonylureas as first line treatment for type 2 diabetes have higher mortality than those receiving metformin.
Obesity is a lot more deadly than previously thought. Across recent decades, obesity accounted for 18 percent of deaths among Black and White Americans between the ages of 40 and 85, according to a study funded by the Robert Wood Johnson Foundation. This finding challenges the prevailing wisdom among scientists, which puts that portion at around 5%.
According to the National Center for Health Statistics (NCHS), chronic liver disease and cirrhosis is the 12th leading cause of death in the United States. However, this single descriptor might not adequately enumerate all deaths from liver disease. The aim of our study was to update data on liver mortality in the United States.
For individuals with type 1 diabetes, type A personality is associated with lower all-cause mortality, with the correlation modified by depressive symptomatology, according to a study published online July 8 in Diabetes Care.
The rates of liver cancer in the United States more than doubled between 1990 and 2010 while deaths resulting from cirrhosis jumped 43 percent, the National AIDS Treatment Advocacy Project (NATAP) reports.
Coexisting diabetes and end-stage renal disease (ESRD) synergistically boosted the risk of cardiovascular events as much as five-fold compared with patients who had neither condition, according to long-term follow-up in two large cohorts.
Coronary artery disease (CAD) is a leading cause of death of women and men worldwide. CAD's impact on women traditionally has been underappreciated due to higher rates at younger ages in men. Microvascular coronary disease disproportionately affects women. Women have unique risk factors for CAD, including those related to pregnancy and autoimmune disease. Trial data indicate that CAD should be managed differently in women. In this review, we will examine risk assessment for CAD in women, CAD's impact on women, as well as CAD's female-specific presentation and management strategies.
An unintended consequence of tobacco control's success in marginalizing smoking is that smokers may conceal their smoking from those who are best positioned to help them quit: health care providers (HCPs).
Among men with nonmetastatic prostate cancer the risk for other-cause mortality increases with the number of comorbid conditions, particularly in older men, according to a study published online May 20 in the Annals of Internal Medicine.
New research reveals that advanced fibrosis is a significant predictor of mortality in patients with nonalcoholic fatty liver disease (NAFLD), largely brought about by cardiovascular causes. NAFLD alone was not associated with increased mortality according to findings published in the April issue of Hepatology, a journal of the American Association for the Study of Liver Diseases.
Younger stroke survivors have a significantly greater risk of dying prematurely, especially from vascular problems, according to what is believed to be the largest population-based study to date focused exclusively on mortality and stroke in individuals under age 50.
NH2-terminal probrain natriuretic peptide (NT-proBNP) predicts the risk of cardiovascular (CV) mortality in patients with type 2 diabetes without previous CV disease (CVD), according to a study published online April 5 in Diabetes Care.
Prostate-specific antigen (PSA) concentrations in midlife can be used to predict the long-term risk of prostate cancer metastasis or death from prostate cancer, according to a study published online April 16 in BMJ.
For patients diagnosed with type 2 diabetes mellitus (T2DM), body mass index (BMI) around the time of diagnosis has a U-shaped correlation with mortality, according to research published in the April issue of Diabetes Care.
Postmenopausal hormone therapy with estrogen plus progestin is associated with an increased risk of breast cancer, according to a study published online March 29 in the Journal of the National Cancer Institute.
From 2005 to 2009, the prevalence of self-reported hypertension among U.S. adults increased from 25.8% to 28.3%. Among those with self-reported hypertension, use of antihypertensive medications increased from 61.1% to 62.6%. Among states, rates of self-reported hypertension in 2009 ranged from 20.9% to 35.9%.
Middle-aged people with type 2 diabetes, particularly women and those under the age of 55, have a two to three times higher risk of all-cause and cardiovascular mortality than people without diabetes, according to research published online Feb. 22 in Diabetes Care.
For HIV-infected patients whose disease is well-controlled by modern treatment, the risk of death is not significantly higher than in the general population, according to a study published in AIDS, official journal of the International AIDS Society.
Cigarette smoking remains the leading cause of preventable morbidity and mortality in the United States. Despite overall declines in cigarette smoking, a high prevalence of smoking persists among certain subpopulations, including persons with mental illness.
For individuals with coronary artery disease (CAD), central obesity in combination with normal weight is associated with the highest risk of mortality, according to research published in the Feb. 5 issue of the Journal of the American College of Cardiology.
Smokers typically die at least a decade earlier than nonsmokers, but this can be at least partially reversed by quitting smoking, according to a study published in the Jan. 24 issue of the New England Journal of Medicine.
Over the past 30 years in Denmark, mortality from ulcerative colitis (UC) has decreased, but mortality from Crohn's disease (CD) has remained persistently higher than the general population, according to research published in the January issue of Clinical Gastroenterology and Hepatology.
Individuals with stroke and depression have a significantly higher risk of all-cause and stroke mortality, compared to those with neither condition, according to a study released in advance of its presentation at the annual meeting of the American Academy of Neurology, which will be held from March 16 to 23 in San Diego.
Obese people are much more likely to die prematurely from any cause, while those who are overweight have a lower all-cause mortality risk compared to people of normal weight, researchers from the National Center for Health Statistics, Centers for Disease Control and Prevention reported in JAMA, January 2, 2013 issue.
For patients with type 2 diabetes mellitus (T2DM), classification as normal weight or obese within a year of initial diabetes diagnosis correlates with significantly higher mortality, forming a U-shaped association between body mass index (BMI) and mortality, according to a study published online Nov. 8 in Diabetes Care.
Chronic obstructive pulmonary disease (COPD) is a group of progressive, debilitating respiratory conditions, including emphysema and chronic bronchitis, characterized by difficulty breathing, lung airflow limitations, cough, and other symptoms. COPD often is associated with a history of cigarette smoking and is the primary contributor to mortality caused by chronic lower respiratory diseases, which became the third leading cause of death in the United States in 2008.
Depression and increased depressive symptoms correlate with increased mortality among patients with rheumatoid arthritis (RA), particularly men, according to a study presented at the annual meeting of the American College of Rheumatology, held from Nov. 10 to 14 in Washington, D.C.
Elevated serum levels of high-sensitivity C-reactive protein (hs-CRP), a marker of chronic inflammation, correlate with increased mortality from all causes and cancer in men but not in women, according to research published in the November issue of Cancer Epidemiology, Biomarkers & Prevention.
For patients with schizophrenia, adherence to antipsychotic medications, as recommended by the 2009 Schizophrenia Patient Outcomes Research Team (PORT), correlates with reduced mortality, according to research published online Oct. 30 in the Schizophrenia Bulletin.
Update on Predictive Underwriting: Improved Customer Experience and its Impact
Underwriting Not By The Book
Underwriting the Rich and Famous
Life Insurance Suitability Review - Whose Job Is It?
Clinical vs. Insurance Medicine: Meet the Experts
Underwriting Screening Liver Test Abnormalities: "Why" - Not "How High"
Diabetes: Where are We Now?
Thyroid Neoplasms - 2012
As fall approaches, we are facing shorter days. We will set our clocks back an hour on November 4, to gain an hour of sleep, but do people get adequate sleep every night? We want to remind individuals of the importance of adequate sleep and how the lack of it can cause health problems.
The urine protein to creatinine (p/c) ratio is a commonly used and inexpensive laboratory test to determine if excess levels of protein are present in the urine. The question we examine is how effective is that test in predicting the risk of all-cause mortality in a healthy non-diabetic cohort.
For U.K. women, the hazards of smoking and benefits of quitting are considerable, with women who quit before age 30 avoiding more than 97 percent of excess smoking-related mortality, according to a study published online Oct. 27 in The Lancet.
Inclusion of both waist and hip circumference as separate anthropometric measurements may improve risk prediction for obesity-related mortality and morbidity, according to research published online Oct. 17 in Obesity Reviews.
Today’s abundant calorie-rich food often overwhelms the body’s weight regulatory system, with many individuals’ genetic make- up unable to regulate this input, resulting in what has been a massive societal weight gain over the past 35 years by all population segments.
Laboratory testing is an essential part of risk selection. Most insurers run PSA levels to help test and screen for prostate cancer. In fact, the FDA has approved the use of the PSA test to help detect prostate cancer in men 50 and older.
HIV (Human Immunodeficiency Virus) infection is the cause of the Acquired Immune Deficiency Syndrome, AIDS, which presents with multiple infections and tumours. Since 1996, the efficacy and increased use of treatments associating 3 different classes of drugs — “triple therapy” — has significantly reduced the prevalence of AIDS and the mortality rate in HIV-infected individuals in countries with widespread access to health care.
According to a new, long-term study from Regenstrief Institute and Indiana University researchers, cognitive impairment, especially at the moderate to severe stages has an impact on life expectancy similar to chronic conditions such as diabetes or chronic heart failure.
As early detection and treatment for people with cancer becomes increasingly improved and widespread, more and more cancer survivors are applying for insurance with favorable outcomes—and receiving standard policies.
Researchers have developed a potentially useful list of predictors of atherosclerotic sudden cardiac death (SCD) to help clinicians distinguish patients who are likely to die of a heart attack from those who might survive one. Their ultimate goal is to create a risk stratification score applicable for the general population and provide interventions to prevent development of traits that contribute to SCD.
Areca nut is the seed of fruit oriental palm known as Areca catechu. Many adverse effects of nut chewing have been well documented in the medical literature. As these nuts are mixed with some other substances like tobacco and flavouring agents, it has been hypothesized that it might also cause some dependency symptoms among its users. Therefore, the objective of this study was to investigate dependency syndrome among areca nut users with and without tobacco additives and compare it with dependency associated with cigarette smoking among the male Pakistani population.
Osteoporosis is common in patients with COPD but the likely multi-factorial causes contributing to this condition (e.g. sex, age, smoking, therapy) mask the potential contribution from elements related to COPD. In order to study osteoporosis and bone mineral density (BMD) related to COPD, we studied a well-defined group of patients and controls.
Suicide is a leading cause of perinatal maternal deaths in industrialised countries but there has been little research to investigate prevalence or correlates of postpartum suicidality. The Edinburgh Postnatal Depression Scale is widely used in primary and maternity services to screen for perinatal depressive disorders, and includes a question on suicidal ideation (question 10). We aimed to investigate the prevalence, persistence and correlates of suicidal thoughts in postpartum women in the context of a randomised controlled trial of treatments for postnatal depression.
Not a disease you might choose as a common underwriting impairment, malaria, a parasitic disease in humans, is far more common than anticipated and potentially deadly when contracted—causing hundreds of millions of illnesses and probably more than a million deaths a year worldwide. While much of the insurance buying population may not live in endemic areas for malaria, it is quite common in travelers from non-endemic areas who have visited the tropics.
This article from the May 2011 issue discusses options available, including Cardiovascular Magnetic Resonance, Cardiac Computerized Tomography and 3D Echo, and the various advantages and limitations of less invasive cardiac tests.
Chronic obstructive pulmonary disease (COPD) is a disease that requires lifelong adherence to complicated drug therapy regimens. This claims-based analysis of COPD patients, published in Current Medical Research and Opinion, suggests less than optimal compliance with recommended drug therapy treatment for COPD patients based on Chronic Obstructive Lung Disease (GOLD) guidelines. This study further suggests that claims-data analyses provide reasonable aggregate distributions of COPD severity, which can be used by health plans and disease management programs to improve drug therapy management. Link to abstract of article from Informa Health Care.
The measurement of cholesterol in the skin (SC), or "skin sterol," has been put forward as a candidate to eliminate the need for testing blood for lipids and avoiding the inconvenient requirement for examinees to fast prior to the test. This edition of Risk Matters examines the claims for this test and its potential for cardiovascular risk assessment.
As the number of seniors continues to grow, more and more surgical operations are being performed on this segment of the population. Johns Hopkins University reports that approximately half of all operations in this country are performed on patients 65 and older. For patients older than 80, the chance of death during the month following a surgical procedure increases by 26 percent.
Now Johns Hopkins is releasing a study conducted with the American College of Surgeons which assesses the frailty of surgical candidates and attempts to predict the likelihood of post-surgical complications, hospital stay length and need for post-operative nursing care.
Dr. J. Carl Holowaty MD, DBIM revists his September 2005 piece looking at the epidemiological trends relating to obesity, Weighing-In On Obesity, and explores three other important topics: Prostate Cancer and PSA, Viral Hepatitis B and C, and MRSA.
A new approach to analyzing electrocardiograms--a ubiquitous test of the heart's electrical function--could predict who is most likely to die after a heart attack. Researchers at MIT found that measuring how much the shape of the electrical waveform varies from beat to beat identifies high-risk patients better than existing risk factors. If the findings hold up in further clinical trials, the technology could be used to figure out which heart attack patients need the most aggressive treatment.
Heritage Labs' newsletter eEnvoy discusses the mortality associated with albumin and globulin. Using our database of insurance applicants and the Social Security Death Master File, we can measure increases in mortality at levels of albumin and globulin that may surprise many of our readers. The risk rises even before the lowest 2.5th percentile which is the traditional level chosen for a “lower limit of normal”.. We also propose a unique formula to help discern the relationship between albumin and globulin better than the current A/G ratio.
Obesity is associated with increased health-care costs, reduced quality of life, and increased risk for premature death. Common morbidities associated with obesity include coronary heart disease, hypertension and stroke, type 2 diabetes, and certain types of cancer. As of 2007, no state had met the Healthy People 2010 objective to reduce to 15% the prevalence of obesity among U.S. adults. An overarching goal of Healthy People 2010 is to eliminate health disparities among racial/ethnic populations. To assess differences in prevalence of obesity among non-Hispanic blacks, non-Hispanic whites, and Hispanics, CDC analyzed data from Behavioral Risk Factor Surveillance System (BRFSS) surveys conducted during 2006-2008.
In the spring of 2009, an outbreak of severe pneumonia was reported in conjunction with the concurrent isolation of a novel swine-origin influenza A (H1N1) virus (S-OIV), widely known as swine flu, in Mexico. Influenza A (H1N1) subtype viruses have rarely predominated since the 1957 pandemic. The analysis of epidemic pneumonia in the absence of routine diagnostic tests can provide information about risk factors for severe disease from this virus and prospects for its control. (New England Journal of Medicine)
To examine the relationship between alcohol and suicide among racial/ethnic populations, CDC analyzed data from the National Violent Death Reporting System (NVDRS) for the 2-year period 2005--2006 (the most recent data available).
The Pregnancy Risk Assessment Monitoring System (PRAMS) was initiated in 1987 and is an ongoing state- and population-based surveillance system designed to monitor selected maternal behaviors and experiences that occur before, during, and after pregnancy among women who deliver live-born infants in the United States.
To update 2006 state-specific estimates of cigarette smoking, CDC analyzed data from the 2007 Behavioral Risk Factor Surveillance System (BRFSS) survey and examined trends in cigarette smoking from 1998--2007. Results of these analyses indicated substantial variation in current cigarette smoking during 2007.
CDC and the National Cancer Institute (NCI) have combined their cancer incidence data to produce United States Cancer Statistics (USCS): 1999--2005 Incidence and Mortality Data, a web-based report. The report is produced in collaboration with the North American Association of Central Cancer Registries.
In the setting of a worldwide increase in obesity and diabetes, reviews the protective value of current testing strategies. In plausible scenarios, shows that choosing uniform testing with HbA1c produces mortality savings that recover testing costs within short durations.
This Question of the Month came from a client visit where the lipid profile was discussed. The comment expressed was that sometimes all 4 components of the profile are not given, most often the LDL which is sometimes not provided in an APS. When a suggestion was made to use the “lipid formula,” the inquiring underwriter had no knowledge of the formula or how to use it.
Heritage Labs recently had an inquiry concerning the hepatitis B tests offered as part of their reflex panel and the apparent discrepancy with the requirements of certain reinsurers. The case involves a female applicant, age 27, with normal transaminases, and a positive result for hepatitis B surface antigen. Before getting into detail on this case, this technical bulletin recaps the nomenclature for several of the common hepatitis B markers.
During a recent visit to an insurer’s offices, Heritage was asked “What reflex rules are being used by your clients regarding Hepatitis C? Our internal studies convinced our company to start reflex testing even when the LFT’s are highly normal.” -- February 2009 article by Danny Perkins.
What are the two biggest underwriting-related concerns of senior management in direct-writing life insurers?
#1 – Reducing new business acquisition costs
#2 – Reducing application-to-issue cycle time
Both of these issues are conspicuous high priority agenda items in most companies.
The matter of business acquisition costs is, if anything, accentuated by the current economic environment.
What other goals are compelling in this regard?
Improve our image with consumers
Make it easier for customers to do business with us as a “financial services” industry
Facilitate – rather than obstruct – the flow of new business
Recruit and retain producers by offering accommodating requirements while preserving and enhancing favorable mortality
What strategies have 21st century life insurers embraced to facilitate these outcomes?
Teleunderwriting – the core change in how we manage new business and now the dominant mode of risk appraisal in North America and United Kingdom, and rapidly being embraced worldwide
New business processing systems including so-called “underwriting engines”
Automated data search and retrieval in lieu of traditional routine inspection reports
Electronically obtained motor vehicle reports (MVRs) and pharmacy (Rx) profiles
Steep reductions in the use of MD examinations and chest x-rays
What is the #1 remaining “eye sore” among routine screening medical requirements?
The exercise electrocardiogram, or, if you will, treadmill stress test (TST).
Are treadmill stress tests used extensively in the industry?
In the 2007 Life Underwriting Requirements Survey of over 125 U.S. direct-writing companies, we learned the following regarding the use of exercise ECGs as screening requirements:
62.9% of respondents continued using the TST at some age/face amount threshold.
The substantial majority of companies still using TSTs did not mandate them for any amount of coverage under age 35, but most persisted in requiring them at ages 45 and 55.
Most users required TSTs at face amounts of $5 million or higher, but a significant % continued to demand them for amounts as low as > $1 million at ages 45 and over.
96% of TST screening companies required them at age 65.
64% required them at age 75.
55% still required TSTs over age 75
62% said they would continue to require TSTs even if reinsurers did not compel them to do so.
TST Screening: The Clinical Perspective
Is the treadmill stress test used too often in clinical medicine?
“It is likely that it is considerably overutilized…and, in many cases, actually abused as a tool in the clinical armamentarium available to all practitioners of medicine.”
Basil M. RuDusky, MD, FACA
New England Cardiovascular Clinic
Wilkes-Barre, PA Angiology
Is it widely held that TSTs should not be used for screening in clinical medicine?
Yes…and it has been for 30 years!
“An expert panel of cardiologists stated that there were ‘no conditions for which there is general agreement that exercise testing is justified’ in asymptomatic persons.”
Harold J. Sox, MD, et al.
Stanford University School of Medicine Annals of Internal Medicine
“The exercise test historically has been considered a potentially useful modality for coronary disease screening… Nonetheless, the relatively poor accuracy of exercise electrocardiography for diagnosing hemodynamically significant coronary disease, even in symptomatic subjects, has led to recommendations against the use of exercising testing as a screening tool, as well documented by a recent report from the US Preventive Services Task Force.”
Michael Lauer, MD, Chair, et al.
Subcommittee of the American Heart Association Council in Clinical Cardiology Circulation
“The existing data indicate that although disease may be identified, many more patients have false-positive tests. The consequences of such findings include…misuse of data to influence employment and insurance decisions.”
Raymond J. Gibbons, MD, FACC, Chair, et al.
Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) Journal of the American College of Cardiology
Note the years in which the three reports cited above were published!
Is this view also held by experts in primary care?
“Use of the ETT [exercise treadmill test] to screen for CAD in asymptomatic low-to-moderate risk individuals is not indicated.”
Jennifer L. Junnila, MD, MPH and Guy P. Runkle, MD Primary Care Clinical Office Practice
Does the TST have value in screening healthy subjects?
In a study of 4,334 adults, median age 51, there was no significant difference in mortality between those with positive vs. negative tests. The authors made the following statement in the wake of their findings:
“Exercise treadmill testing in such a low-risk population…was unlikely to be useful… Routine exercise treadmill testing in asymptomatic individuals has low clinical yield and it is not a cost-effective strategy.”
Louis Pilote, MD, MPH, PhD, et al.
The Cleveland Clinic The American Journal of Cardiology
The vast majority of insurance applicants screened with TSTs are just that: asymptomatic low-to-moderate risk individuals.
Is the sensitivity and specificity of the TST adequate to justify screening of asymptomatic, low-to-moderate CV risk subjects?
“The ETT is known for its low sensitivity, specificity and accuracy.”
Melvin E. Clouse, MD
Harvard University Medical School Circulation
“Most patients with subsequent cardiovascular death have a negative test result, because the sensitivity for detecting subsequent cardiovascular death is low.”
What is the “fly in the ointment” of using TST screening on asymptomatic and low-to-moderate risk individuals?
The pretest probability of disease is low, even over age 60, in the absence of chest pain or equivalent suspicious symptoms. [Gibbons]
The Framingham study showed that only those with “the highest CHD risk” should be considered for such testing. [Balady]
Why is TST screening obsolete?
“Myocardial infarcts often appear to be caused by ‘insignificant’ lesions by coronary angiography”…and these insignificant lesions, because they do not obstruction blood flow in the arteries, do not cause the TST to be positive, resulting in disconcerting numbers of false-negative tests in high risk cases.
Vincent E. Friedewald, MD et al.
Chief of Cardiology
University of California-San Francisco Medical School The American Journal of Cardiology
Are there significant risks associated with treadmill stress testing which insurers using them, especially at older ages, need to consider?
“Both myocardial infarction and death…can be expected to occur at a rate up to 1 per 250 tests. Good clinical judgment should therefore be used in deciding which patients should undergo exercise testing.”
“…the annual rate of exercise-related cardiovascular events among high-risk events may be substantial, with 0.2% of hypercholesterolemic man having an exercise-related event annually…the annual incidence of exercise-related AMI [acute myocardial infarction] could range from 1 AMI per 593 to 1 per 3852 healthy middle-aged men.”
Paul D. Thompson, MD, FAHA, Co-Chair
Scientific Statement from the American Heart Association Circulation
The medical literature is replete with case citations of MIs and cardiac deaths in persons subjected to TST screening, even with normal treadmill findings and where these tests are done under the direct supervision of cardiologists [Baroffio, Boubrit, Brown, Capezzuto, Gómez-Jauma, Jenkins, Kurata, Lintgen, RuDusky, etc., et al]
Our system of ordering and undertaking TSTs does not allow for credible judgment to be brought to bear as to whether or not a given applicant is a suitable risk. Indeed, one can only marvel at the fact that, in the age of compliance and growing concerns for equivalent vulnerabilities, the majority of insurers continue to wilfully endure these risks.
What have we learned from these clinical studies and findings of experts?
The TST has been judged to be inappropriate for screening of asymptomatic individuals by experts in cardiology for 30 years.
The TST has insufficient sensitivity, specificity and accuracy to justify screening in persons with low-to-moderate risk of coronary disease.
The TST does not pinpoint the individuals with vulnerable disease at highest mortality risk; rather, it is positive for the most part in persons with fixed, stable coronary disease whom we now regularly insure on a highly favorable basis.
The TST imposes upon insurers the very real risk of heart damage and death in applicants as a direct result of routine screening. Indeed, we were told by a prominent chief medical officer that there have been multiple such occurrences in one country where TST screening is (or at least once was) done for insurance purposes. [Bond, personal communication, 2007]
In the face of all of these blatant contraindications, most U.S. insurers continue to require screening exercise electrocardiograms, in many cases over age 75.
Industry-Specific Issues with TST Screening
What are the additional “common sense” arguments against TST Screening by life insurers?
Cost: According to one major industry provider, the standard fee for insurance treadmill stress testing was $713.95 as of February, 2007 [Sears, personal communication]
Slowness: It is widely appreciated that the turnaround time with TSTs is longer than it is, on average, for obtaining medical records from physicians. This would make the TST, along with the chest x-ray, one of the two slowest requirements we currently use.
Client Unfriendliness: It goes without saying that nothing we do for underwriting purposes can compare with the inconvenience to our customers that occurs with treadmill stress testing.
Subjectivity: Unlike most of our contemporary screening tools (resting ECGs and chest x-rays being the other exceptions), TST analysis is highly subjective. Thus, it is commonplace for insurance medical directors to disagree with applicants’ attending physicians over how putative TST findings should be seen from a risk perspective. As a result, they get into counterproductive exchanges of correspondence with these physicians.
Processing Time: Because virtually all TSTs are analyzed solely by medical directors, the processing time is longer for this requirement – again, except for the odious chest x-ray – than any other screening asset in our armamentarium.
Do other screening options exist that would – at the very least – replace the ostensible protective value of exercise electrocardiograms…without all of these many disadvantages?
In recent years, compelling evidence has shown that two inexpensive tests – which can be readily completed in conjunction with the inevitable blood profiles required on all cases where treadmill testing is now required – provide outstanding value in screening for cardiovascular risk in older-age applicants:
NT-proBNP – probably the finest screening test in the history of life insurance, based on a comprehensive review of the world literature.
Hemoglobin A1-c (HbA1-c, glycosylated hemoglobin) – a test used by underwriters in known diabetics and individuals deemed at increased risk for diabetes, HbA1-c has now been convincingly shown to have significant protective value as a screening asset.
In addition, there are a number of other blood tests which should be considered for use in conjunction with NT-proBNP and HbA1-c as adjunctive screening tests, perhaps in a special profile to be used at older ages and for larger face amounts:
Cystatin C – a kidney disease marker which will shown – in a comprehensive literature review to be published shortly – to have additive value as a screening asset when used with NT-proBNP.
Hemoglobin – given the well-demonstrated association between mild anemia (low hemoglobin) and circulatory disease, occult cancer and all-cause mortality, insurers should investigate its potential as a screening asset.
CRP (formerly hs-CRP) – this test was evaluated some years ago by several carriers (unpublished studies) and its use discouraged for reasons not entirely clear to this underwriter. The recent literature shows a strong association between CRP elevations and the risk of CV disease and it argues for further consideration of CRP in underwriting screening.
Because of the far lower cost of screening with such a profile, we could test 15 or more applicants for the same out-of-pocket cost for a single exercise electrocardiogram!
Why does use of exercise electrocardiography continue to compromise our efforts to make underwriting faster and more cost-effective?
Lassitude on the part of many direct insurers, who fail to consider this issue (apparently, in many cases, preferring instead to nibble at “low-hanging fruit” where expense containment is concerned).
Sustained pressure from some reinsurers, who conveniently look away from the TST’s many drawbacks – in part because they are not directly affected by these adversities – while at the same time refusing to examine ever-increasingly evidence for viable alternatives as cited above.
The insidious actions of individuals who either harbor a misperceived “vested interest” in retaining TSTs or have not taken the time to objectively consider all of the evidence here. Instead, they opt for arguing that because clinicians do not screen with these new assets (yet), such screening should not be undertaken by insurers. This, of course, flies directly in the face of the fact that clinical medicine does not screen with other mainstays of insurance screening – for example, cotinine – and furthermore that we do not have to justify to anyone outside our industry any well-reasoned decision to use any (at least, non-genetic material based) test!
What needs to be done?
Eliminate treadmill stress test screening in life insurance underwriting.
Replace whatever any genuine protective value we got from TSTs with that conferred by one or more alternative blood test options.
Retain the use of elective TSTs in only in circumstances, on jumbo cases, where no other viable option exists and at no time beyond a prudent maximum applicant age.
By making these overdue changes, we will take an important step toward bringing 21st century underwriting screening practices in line with key business priorities of direct-writing life insurers.
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Hank George has written a comprehensive research paper on a new test ideally suited for mortality and morbidity risk screening. It will serve well in tandem with NT-proBNP and other blood tests, as an alternative to treadmill ECGs and other slow, costly requirements we currently use.
Heart disease continues to be the leading cause of death for Americans, according to the Centers for Disease Control.1 Fair, inexpensive, and accurate assessment of health risk presents a challenge to all insurance companies. Research in clinical medicine is impacting insurance medicine in new and exciting ways and is transforming how companies assess the cardiac risk of a proposed insured. New laboratory testing evaluating insurance risk profiles will assist in more accurately classifying cardiac risk. It is important, therefore, to review the new and existing laboratory markers that are available in your clients’ cardiac mortality risk.
This paper highlights the menace of overweight and obesity which are on the rise. Health care systems and insurance industries are directly affected. Liability claims are on waiting. The food related damage claims are costly. Insurers are therefore driven to find a solution: classify overweight and obesity as a group, adjust their premium to reflect the cost, and justify the classification and the adjustments.
At the recent AHOU in Miami, Heritage received both a comment and a question. One inquiring mind made the statement that he had “seen a rash of early duration deaths due to pancreatic cancer. Physicians use a particular test to rule pancreatic cancer in or out; had this test been investigated by Heritage Labs for use as a screening tool?” Danny Perkins responds.