The 2003 Healthcare Conference

Actuaries Adding Value

5-7 October 2003

Scarman House, The University of Warwick

Workshop Session A1 :

Trends in Critical Illness Risk Costs

Research Group Progress Report

Neil Robjohns Dr Richard Croxson Joanne Wells

Trends in Critical Illness Risk CostsAn update from the Critical Illness Trends Research Group

Update and analysis of cancer trends Cancer screening

Recent and future developments in cardiovascular medicine

Update and analysis of trends in heart attack, coronary artery bypass grafts and angioplasty

Trends in non-Critical-Illness mortality

Critical Illness Trends Research Group

Our Aims :

To examine underlying trends in the factors influencing UK Insured Critical Illness claim rates, and from these, to assess : The historic trend in incidence and death rates for the major

CI’s Any pointers for future trends in Standalone CI, Mortality and

hence Accelerated CI.

Formed in March 2001

Group Members and our Current Focus

Heart Attack MS, TPDCancer & Stroke & non-CI morty

ActuariesAzim Dinani Scott Reid Sue ElliottRichard Morris Joanne Wells Hamish GallowayNeil Robjohns

Medical ExpertsProfessor Rubens Richard CroxsonConsultant Oncologist Consultant Cardiologist

Links : Actuaries Panel on Medical Advances CMIB CI experience investigation ABI CI definitions group

Trends in Critical Illness Risk CostsAn update from the Critical Illness Trends Research Group

Update and analysis of cancer trends Cancer screening

Recent and future developments in cardiovascular medicine

Update and analysis of trends in heart attack, coronary artery bypass grafts and angioplasty

Trends in non-Critical-Illness mortality

Cancer Incidence and Mortality Rates, 1971 - 2000All Ages (standardised), England & Wales

See Legend All CIEngland & Wales

Rates per 10,000

See LegendSee Legend

Cancer Trends 1971 - 2000

Country Sex Event Cancer Site Age Band

F_Q_Std_AllNot in UseNot in Use Not in Use Not in Use Not in Use Not in Use M_Q_Std_All

Not in Use M_I_Std_All Not in Use F_I_Std_AllNot in Use Not in Use Not in Use Not in Use

-

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999

Cancer Incidence and Mortality Rates, 1971 - 2000Ages 40 – 59 (standardised), England & Wales

See Legend All CIEngland & Wales

Rates per 10,000

See LegendSee Legend

Cancer Trends 1971 - 2000

Country Sex Event Cancer Site Age Band

F_Q_Std_40_59Not in UseNot in Use Not in Use Not in Use Not in Use Not in Use M_Q_Std_40_59

Not in Use M_I_Std_40_59 Not in Use F_I_Std_40_59Not in Use Not in Use Not in Use Not in Use

-

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999

Trend in Cancer Incidence and Mortality Rates1971 – 2000, Index 1971 = 100, England & Wales, Men

Men See Legend All CI

Cancer Trends 1971 - 2000

See LegendEngland & Wales

Index YearIndex ( 1971 = 100 )

Country Sex Event Cancer Site Age Band

I_Std_20_39 Not in Use I_Std_40_59 Not in Use Not in Use I_Std_60+ Not in Use Not in Use

Q_Std_20_39 Not in Use Q_Std_40_59 Not in Use Not in Use Q_Std_60+ Not in Use Not in Use

0

20

40

60

80

100

120

140

160

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999

1971

Trends in Cancer Incidence and MortalityBest Estimate Avg Change % pa, England & Wales, by cancer site Men, aged 40 - 59, 1971-2000

-6%

-4%

-2%

0%

2%

4%

6%

8%

10%

-8% -6% -4% -2% 0% 2% 4% 6%

Change in Mortality %pa

Ch

ang

e in

Inci

den

ce %

pa

LungOtherBowelBladderLymphomaProstateOralStomachKidneyMelanomaOesophagusBrainPancreasLeukemiaLarynxTestesDummy

Size of balls represents relative importance of cancer site measured by incidence rates

Trends in Cancer Incidence and MortalityBest Estimate Avg Change % pa, England & Wales, by cancer site Men, aged 40 - 59, for the 1970’s

-6%

-4%

-2%

0%

2%

4%

6%

8%

10%

-8% -6% -4% -2% 0% 2% 4% 6%

Change in Mortality %pa

Ch

ang

e in

Inci

den

ce %

pa

LungOtherBowelBladderLymphomaProstateOralStomachKidneyMelanomaOesophagusBrainPancreasLeukemiaLarynxTestesDummy

Size of balls represents relative importance of cancer site measured by incidence rates

Trends in Cancer Incidence and MortalityBest Estimate Avg Change % pa, England & Wales, by cancer site Men, aged 40 - 59, for the 1980’s

-6%

-4%

-2%

0%

2%

4%

6%

8%

10%

-8% -6% -4% -2% 0% 2% 4% 6%

Change in Mortality %pa

Ch

ang

e in

Inci

den

ce %

pa

LungOtherBowelBladderLymphomaProstateOralStomachKidneyMelanomaOesophagusBrainPancreasLeukemiaLarynxTestesDummy

Size of balls represents relative importance of cancer site measured by incidence rates

Trends in Cancer Incidence and MortalityBest Estimate Avg Change % pa, England & Wales, by cancer site Men, aged 40 - 59, for the 1990’s

-6%

-4%

-2%

0%

2%

4%

6%

8%

10%

-8% -6% -4% -2% 0% 2% 4% 6%

Change in Mortality %pa

Ch

ang

e in

Inci

den

ce %

pa

LungOtherBowelBladderLymphomaProstateOralStomachKidneyMelanomaOesophagusBrainPancreasLeukemiaLarynxTestesDummy

Size of balls represents relative importance of cancer site measured by incidence rates

Trends in Cancer Incidence and MortalityBest Estimate Avg Change % pa, England & Wales, by cancer site Men, aged 40 - 59, 1971-2000

1990's

-6%

-4%

-2%

0%

2%

4%

6%

8%

10%

-8% -6% -4% -2% 0% 2% 4% 6%

Change in Mortality %paC

han

ge

in In

cid

ence

%p

a

1980's

-6%

-4%

-2%

0%

2%

4%

6%

8%

10%

-8% -6% -4% -2% 0% 2% 4% 6%

Change in Mortality %pa

Ch

ang

e in

Inci

den

ce %

pa

1970's

-6%

-4%

-2%

0%

2%

4%

6%

8%

10%

-8% -6% -4% -2% 0% 2% 4% 6%

Change in Mortality %pa

Ch

ang

e in

Inci

den

ce %

pa

Size of balls represents relative importance of cancer site measured by incidence rates

Trend in Cancer Incidence and Mortality Rates1971–2000, Index 1971 = 100, England & Wales, Women

Women See Legend All CI

Cancer Trends 1971 - 2000

See LegendEngland & Wales

Index YearIndex ( 1971 = 100 )

Country Sex Event Cancer Site Age Band

I_Std_20_39 Not in Use I_Std_40_59 Not in Use Not in Use I_Std_60+ Not in Use Not in Use

Q_Std_20_39 Not in Use Q_Std_40_59 Not in Use Not in Use Q_Std_60+ Not in Use Not in Use

0

20

40

60

80

100

120

140

160

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999

1971

Trends in Cancer Incidence and MortalityBest Estimate Avg Change % pa, England & Wales, by cancer site Women, aged 40 - 59, 1971-2000

-6%

-4%

-2%

0%

2%

4%

6%

-6% -4% -2% 0% 2% 4%

Change in Mortality %pa

Ch

ang

e in

Inci

den

ce %

pa

BreastOtherBowelOvaryLungUterusCervixMelanomaLymphomaBrainKidneyLeukemiaOralBladderPancreasStomachDummy

Size of balls represents relative importance of cancer site measured by incidence rates

Trends in Cancer Incidence and MortalityBest Estimate Avg Change % pa, England & Wales, by cancer site Women, aged 40 - 59, for the 1970’s

-6%

-4%

-2%

0%

2%

4%

6%

-6% -4% -2% 0% 2% 4%

Change in Mortality %pa

Ch

ang

e in

Inci

den

ce %

pa

BreastOtherBowelOvaryLungUterusCervixMelanomaLymphomaBrainKidneyLeukemiaOralBladderPancreasStomachDummy

Size of balls represents relative importance of cancer site measured by incidence rates

Trends in Cancer Incidence and MortalityBest Estimate Avg Change % pa, England & Wales, by cancer site Women, aged 40 - 59, for the 1980’s

-6%

-4%

-2%

0%

2%

4%

6%

-6% -4% -2% 0% 2% 4%

Change in Mortality %pa

Ch

ang

e in

Inci

den

ce %

pa

BreastOtherBowelOvaryLungUterusCervixMelanomaLymphomaBrainKidneyLeukemiaOralBladderPancreasStomachDummy

Size of balls represents relative importance of cancer site measured by incidence rates

Trends in Cancer Incidence and MortalityBest Estimate Avg Change % pa, England & Wales, by cancer site Women, aged 40 - 59, for the 1990’s

-6%

-4%

-2%

0%

2%

4%

6%

-6% -4% -2% 0% 2% 4%

Change in Mortality %pa

Ch

ang

e in

Inci

den

ce %

pa

BreastOtherBowelOvaryLungUterusCervixMelanomaLymphomaBrainKidneyLeukemiaOralBladderPancreasStomachDummy

Size of balls represents relative importance of cancer site measured by incidence rates

Trends in Cancer Incidence and MortalityBest Estimate Avg Change % pa, England & Wales, by cancer site Women, aged 40 - 59, 1971-2000

1990's

-6%

-4%

-2%

0%

2%

4%

6%

-6% -4% -2% 0% 2% 4%Change in Mortality %pa

Ch

ang

e in

Inci

den

ce %

pa

1980's

-6%

-4%

-2%

0%

2%

4%

6%

-6% -4% -2% 0% 2% 4%Change in Mortality %pa

Ch

ang

e in

Inci

den

ce %

pa

1970's

-6%

-4%

-2%

0%

2%

4%

6%

-6% -4% -2% 0% 2% 4%Change in Mortality %pa

Ch

ang

e in

Inci

den

ce %

pa

Size of balls represents relative importance of cancer site measured by incidence rates

Trends in Critical Illness Risk CostsAn update from the Critical Illness Trends Research Group

Update and analysis of cancer trends Cancer screening

Recent and future developments in cardiovascular medicine

Update and analysis of trends in heart attack, coronary artery bypass grafts and angioplasty

Trends in non-Critical-Illness mortality

Healthy

Latent … . Cancer

Diagnosed

Cancer

Modelling the impact of cancer screeningOutline of the model

Ht

LC0 LC1 LC2 LCn

DC0 DC1 DC2 DCn

CuredFrom Cancer

DeadFrom Cancer

Ht+1

Modelling the impact of cancer screeningOutline of the model

Key transition rates to be estimated : Hx,t to LC0,x+1,t+1

The probability of ‘starting’ cancer aged x in year t

LCn,x,t to DCn,x+1,t+1

The probability of latent cancer being diagnosed at duration n, for age x in year t

This transition rate changes on introduction of a screening programme

DCn,x+N,t+N to Dead The probability a life diagnosed with cancer from state LCn,x,t dies

from cancer N years later, aged x+N in year t+N (and also estimate transition to cured)

Breast Cancer ScreeningResults from the modelTrend in breast cancer registrations, by age group

0

5

10

15

20

25

30

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Year

Reg

istr

atio

ns

per

10,

000 40 - 44

45 - 49

50 - 54

55 - 59

60 - 64

65 - 69

70 - 74

Breast Cancer ScreeningActual Outcome, 1971 to 2000Trend in breast cancer registrations, by age group

See Legend BreastEngland & Wales

Rates per 10,000

See LegendWomen

Cancer Trends 1971 - 2000

Country Sex Event Cancer Site Age Band

Q_65-69Q_60-64Q_30-34 Q_35-39 Q_40-44 Q_45-49 Q_50-54 Q_55-59

I_50-54 I_55-59 I_60-64 I_65-69I_30-34 I_35-39 I_40-44 I_45-49

-

5.0

10.0

15.0

20.0

25.0

30.0

35.0

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999

Breast Cancer ScreeningResults from the modelChange over time in breast cancer registrations by age

0

5

10

15

20

25

30

40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 65 - 69 70 - 74

Age Band

Reg

istr

atio

ns

per

10,

000

year 5

year 6

year 7

year 8

year 9

year 10

year 11

Breast Cancer ScreeningActual Outcome, 1971 to 2000Change over time in breast cancer registrations by age

0

5

10

15

20

25

30

35

40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 65 - 69 70 - 74

Age Band

Reg

istr

atio

ns

per

10,

000

1987

1989

1990

1991

1992

1993

1995

Prostate Cancer “Screening”Results from the modelTrend in prostate cancer registrations, by age group

0

50

100

150

200

250

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Year

Reg

istr

atio

ns

per

10,

000 50 - 54

55 - 59

60 - 64

65 - 69

70 - 74

75 - 79

80 - 84

Prostate Cancer “Screening”Actual Outcome, USA, 1973 to 1998Trend in prostate cancer registrations, by age group

See Legend ProstateUSA

Rates per 10,000

See LegendMen

Cancer Trends 1971 - 1998

Country Sex Event Cancer Site Age Band

Not in UseQ_75-79Q_50-54 Q_55-59 Q_60-64 Q_65-69 Not in Use Q_70-74

Not in Use I_70-74 I_75-79 Not in UseI_50-54 I_55-59 I_60-64 I_65-69

-

20.0

40.0

60.0

80.0

100.0

120.0

140.0

160.0

180.0

200.0

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

Prostate Cancer “Screening”Results from the modelChange over time in prostate cancer registrations by age

0

50

100

150

200

250

50 - 54 55 - 59 60 - 64 65 - 69 70 - 74 75 - 79 80 - 84

Age Band

Reg

istr

atio

ns

per

10,

000

year 5

year 6

year 7

year 8

year 9

year 10

year 11

Prostate Cancer “Screening”Actual Outcome, USA, 1973 to 1998Change over time in prostate cancer registrations by age

0

20

40

60

80

100

120

140

160

180

200

50 - 54 55 - 59 60 - 64 65 - 69 70 - 74 75 - 79 80 - 84

Age Band

Reg

istr

atio

ns

per

10,

000

1989

1990

1991

1992

1993

1995

1999

Prostate Cancer “Screening”Results from the modelIndexed trend in prostate cancer rates, by age group, Year 1 = 100

0

50

100

150

200

250

300

350

400

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Year

Reg

istr

atio

ns

Ind

ex %

v Y

ear

1

50 - 54

55 - 59

60 - 64

65 - 69

70 - 74

75 - 79

80 - 84

Prostate Cancer “Screening”Actual Outcome, England & Wales, 1971 to 2000Indexed trend in prostate cancer rates, by age group, 1971 = 100

Men See Legend Prostate

Cancer Trends 1971 - 2000

See LegendEngland & Wales

Index YearIndex ( 1972 = 100 )

Country Sex Event Cancer Site Age Band

I_45-49 I_50-54 I_55-59 I_60-64 I_65-69 I_70-74 I_75-79 I_80-84

Q_45-49 Q_50-54 Q_55-59 Q_60-64 Q_65-69 Q_70-74 Q_75-79 Q_80-84

0

50

100

150

200

250

300

350

400

450

500

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999

1972

Cancer Screening Programmes in the NHS

Breast Cancer Currently ages 50 to 64 ; extend to 70 in 2004 Trials underway for ‘high-risk’ women aged 35 to 49

Prostate Cancer No plans for formal screening But PSA test is widely available

Cervical Cancer Currently ages 20 to 64

Colorectal Cancer Pilot study for men and women aged 50 to 69

Cancer Incidence and Mortality Rates, 1971 - 2000Men, Ages 40–59 (standardised), England & Wales, by cancer site

I_Lung_ I_CoRec_ I_Prost_ I_Bladd_ I_Lymph_ I_Oral_ I_Melan_ I_Stoma_

Q_Stoma_Q_Melan_Q_Lung_ Q_CoRec_ Q_Prost_ Q_Bladd_ Q_Lymph_ Q_Oral_

Cancer Trends 1971 - 2000

Country Sex Event Cancer Site Age BandSee Legend See LegendEngland & Wales

Rates per 10,000

40-59 standardisedMen

-

2.0

4.0

6.0

8.0

10.0

12.0

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999

Trends in Critical Illness Risk CostsAn update from the Critical Illness Trends Research Group

Update and analysis of cancer trends Cancer screening

Recent and future developments in cardiovascular medicine

Update and analysis of trends in heart attack, coronary artery bypass grafts and angioplasty

Trends in non-Critical-Illness mortality

Recent & ? Future Developments in Cardiovascular Medicine

Dr. R. S. Croxson MB ChB. FRACP

DiagnosticsTreatmentScreening

Factors Affecting CI Claims

True Increase / Decrease in “Disease” Incidence /

Prevalence

Earlier Diagnosis / Presentation

Treatment: Lower incidence and severity of disease

Postpone presentation

Treatments: Reduce T.P.D (I.P.B)

Diagnostics

HistoryPhysical Examination “Bloods”Electrocardiography (ECG)ImagingInvasive Studies

Bloods

Lipids C Reactive Protein (CRP) – High Sensitivity (HST) TroponinsBrain Natriuretic Peptides BNPGenetic

eFigure 1.3.6 Plaques may enlarge by repeated episodes of rupture and repair. (From Weissberg PL. Atherosclerosis involves more than just lipids: plaque dynamics. Eur Heart J 1991;1:T13–T18, with permission.)

eFigure 1.3.4 Smooth muscle–inflammatory cell interactions in atherosclerosis. IFN-, interferon-; IL-1, interleukin-1; MMP, matrix metalloproteinase; PDGF, platelet-derived growth factor; TNF-, tumor necrosis factor-.

Microvascular obstruction after plaque rupture

Time Course of Serum Markers in Acute Myocardial Infarction

30 Day Event rates relating to Troponins levels (PRISM)

Consensus Document

Myocardial infarction redefined – A consensus document of The Joint European Society of Cardiology / American College of Cardiology Committee for the Redefinition of Myocardial Infarction

European Heart Journal (2000) 21. 1502-1513

Definition of MICriteria for acute, evolving or recent MI. Either one of the following criteria satisfies the diagnosis for an acute, evolving or recent MI:

(1) Typical rise & gradual fall or more rapid rise & fall of biochemical markers of myocardial necrosis with at least one of the following:

(a) ischaemic symptoms

(b) development of pathologic Q waves on the ECG

(c) ECG changes indicative of ischaemia (ST segment elevation or depression)

(d) coronary artery intervention (eg coronary angioplasty)

(2) Pathologic findings of an acute MI

Definition of MI

Criteria for established MI

Any one of the following criteria satisfies the diagnosis of forestablished MI:

1) Development of new pathologic Q waves on serial ECGs. The patient may or may not remember previous symptoms. Biochemical markers of myocardial necrosis may have normalised, depending on the length of time that has passed since the infarction developed.

2) Pathologic findings of a healed or healing MI

TROPONIN IN DIAGNOSIS OF MYOCARDIAL INFARCTION

INSURANCE QUESTIONSINSURANCE QUESTIONS–What about lack of standardisationlack of standardisation ?

–What about false positives ?false positives ?

–WhichWhich specific Troponin assays should be used ?assays should be used ?

–What about analytical variability ?analytical variability ?

–What about troponin values near the referencevalues near the reference limit ? limit ?

–Is this compatible with insurance principles ?insurance principles ?

–Do all clinicians support the troponin infarction definition ? Do all clinicians support the troponin infarction definition ?

Genetics

Coronary Artery Disease: LDL Chol ReceptorsThrombosis / Haemostasis: Factor V LeidenHypertrophic Cardiomyopathy: Sarcomeric ProteinsCardiac Arrhythmias: Long QT Syndrome, VF/VTHypertension: PolymorphismsConnective Tissue Disorders: Marfan Syndrome, FBNI

Electrocardiography

RestingExercise “24Hour” MonitoringHeart Rate Variability

Imaging

X-RaysComputed Tomography (CT)Magnetic Resonance (MR)EchocardiographyNuclear Imaging (Radioisotopes)Coronary Angiography (Invasive)

                            

                              

                              

                              

                              

                              

Treatments

“Lifestyle” – exercise / weight

diet/ smoking

Medications

Interventions (Invasive)

Medical Therapy

Lipid Lowering – “Statins” etc

Anti coagulants, Anti Thrombotics, Fibrinolytics, e.g aspirin, clopidogrel, abciximab

Antihypertensives: Diuretics, ACE Inhibitors, Angiotensin II blockers

Heart Failure Treatment.

Interventions

Heart rhythm disorders Radio frequency ablation - “Cures”Automatic implantable defibrillators (ICD)Pacemakers (heart block, CHF treatment)

Interventions

Coronary artery bypass grafting – arterial grafts, “off pump” surgeryPercutaneous transluminal coronary angioplasty (PTCA)Stenting – drugs eluting stents, restenosisTranscatheter closure of cardiac defects

                                                                                                              

[                                                                  

                        

        

                      

                             

  

                           

             

Screening & Prevention

Primary Prevention: General population

At Risk population

Pre symptomatic

Secondary Prevention: Reduction in ”relapses”

4 5 6 7 8 4 5 6 7 8

180/105

160/95 AGE

140/75 70

120/75

180/105

160/95 AGE

140/75 60

120/75

180/105

160/95 AGE

140/75 50

120/75

180/105

160/95 AGE

140/75 40

120/75

180/105

160/95 AGE

140/75 30

120/75

Very high >4%High 3-4%Moderate 2-3%Mild 1-2%Low .5-1%Very low <0.5%

Total Chol:HDL-CholNonsmoker Smoker

Men - no diabetes

Risk levelPercent chance of a CV event per

annum

4 5 6 7 8 4 5 6 7 8

180/105

160/95 AGE

140/75 70

120/75

180/105

160/95 AGE

140/75 60

120/75

180/105

160/95 AGE

140/75 50

120/75

180/105

160/95 AGE

140/75 40

120/75

180/105

160/95 AGE

140/75 30

120/75

Very high >4%High 3-4%Moderate 2-3%Mild 1-2%Low .5-1%Very low <0.5%

Total Chol:HDL-CholSmokerNonsmoker

Women - no diabetes

Risk levelPercent chance of a CV event per annum

Screening

Guidelines AHA, BCS

Concept of the “Polypill”

Cover note

                                                             

      A pill to prevent 80% of heart attacks

Polypill

Statin, Aspirin, Folic Acid,

3 Anti hypertensives (half dose);

Thiazide, Betablocker, ACE Inhibitor

Everyone age 55 and over

Everyone with existing cardiovascular disease

Polypill

4 Risk Factors: LDL C

Intervened BP

Platelets

HomocysteineOutcome measures 88% heart attack

Reduction in 80% Stokes

1 in 3 Benefit Gaining 11/12 years life

without heart attack / stroke

Evaluations

Evidence Based Medicine (EBM)Meta-AnalysesDatabase – Cochrane LibraryGuidelines – NICE, NSF, SIGN, BCS, AHAAudit, Peer Review, RevalidationContinuing Professional Development.

Trends in Critical Illness Risk CostsAn update from the Critical Illness Trends Research Group

Update and analysis of cancer trends Cancer screening

Recent and future developments in cardiovascular medicine

Update and analysis of trends in heart attack, coronary artery bypass grafts and angioplasty

Trends in non-Critical-Illness mortality

Heart Related Conditions

Update on trends in incidence

heart attack

coronary artery bypass

angioplasty (1 and more or 2 and more vessels)

Breaking down trends

by age

different time periods

Trends in Population Incidence RatesHeart Attack (First and Subsequent) Age 35-64

60%

65%

70%

75%

80%

85%

90%

95%

100%

105%

89/89 90/89 91/89 92/89 93/89 94/89 95/89 96/89 97/89 98/89 99/89 00/89

Female

Male

Trends in Population Incidence RatesCoronary Artery Bypass Graft Age 35-64

60%

80%

100%

120%

140%

160%

180%

200%

89/89 90/89 91/89 92/89 93/89 94/89 95/89 96/89 97/89 98/89 99/89 00/89

Female

Male

Trends in Population Incidence RatesAngioplasty 2+Vessels Age 35-64

60%

110%

160%

210%

260%

310%

360%

410%

89/89 90/89 91/89 92/89 93/89 94/89 95/89 96/89 97/89 98/89 99/89 00/89

Female

Male

Trends in Population Incidence RatesAngioplasty 1+Vessels Age 35-64

60%

110%

160%

210%

260%

310%

360%

89/89 90/89 91/89 92/89 93/89 94/89 95/89 96/89 97/89 98/89 99/89 00/89

Female

Male

Trends in Population Incidence RatesCABG and Angioplasty 2+ Age 35-64

60%

80%

100%

120%

140%

160%

180%

200%

89/89 90/89 91/89 92/89 93/89 94/89 95/89 96/89 97/89 98/89 99/89 00/89

Female

Male

Trends in Population Incidence RatesCABG and Angioplasty 1+Vessels Age 35-64

60%

80%

100%

120%

140%

160%

180%

200%

89/89 90/89 91/89 92/89 93/89 94/89 95/89 96/89 97/89 98/89 99/89 00/89

Female

Male

Trends in Population Incidence RatesHA, CABG, Stroke and Angioplasty 2+ Age 35-64

70%

75%

80%

85%

90%

95%

100%

105%

110%

89/89 90/89 91/89 92/89 93/89 94/89 95/89 96/89 97/89 98/89 99/89 00/89

Female

Male

MalesHA

Angio2plus

CABG

Stroke

FemalesHA

Angio2plus

CABG

Stroke

Percentage Change p.a. in Incidence Rates1989-2000 Non-smoker model

Coronary Artery Bypass Graft Males

-20.00%

-10.00%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

25

_2

9

30

_3

4

35

_3

9

40

_4

4

45

_4

9

50

_5

4

55

_5

9

60

_6

4

65

_6

9

70

_7

4

75

_7

9

80

_8

4

85

_8

9

p.a % change

LCI

UCI

Percentage Change p.a. in Incidence Rates1989-2000 Non-smoker model

Coronary Artery Bypass Graft Females

-10.00%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

30_34

35_39

40_44

45_49

50_54

55_59

60_64

65_69

70_74

75_79

80_84

85_89

p.a % change

LCI

UCI

Percentage Change p.a. in Incidence Rates1989-2000 Non-smoker model

HA, CABG and Angioplasty 2+ Males

-6.00%

-4.00%

-2.00%

0.00%

2.00%

4.00%

6.00%

8.00%

25

_2

9

30

_3

4

35

_3

9

40

_4

4

45

_4

9

50

_5

4

55

_5

9

60

_6

4

65

_6

9

70

_7

4

75

_7

9

80

_8

4

85

_8

9

p.a % change

LCI

UCI

Percentage Change p.a. in Incidence Rates1995-2000 Non-smoker model

HA, CABG and Angioplasty 2+ Males

-6.00%

-4.00%

-2.00%

0.00%

2.00%

4.00%

6.00%

8.00%

25

_2

9

30

_3

4

35

_3

9

40

_4

4

45

_4

9

50

_5

4

55

_5

9

60

_6

4

65

_6

9

70

_7

4

75

_7

9

80

_8

4

85

_8

9

p.a % change

LCI

UCI

Percentage Change p.a. in Incidence Rates1989-2000 Non-smoker model

HA, CABG and Angioplasty 2+ Females

-6.00%

-4.00%

-2.00%

0.00%

2.00%

4.00%

6.00%

8.00%

30_34

35_39

40_44

45_49

50_54

55_59

60_64

65_69

70_74

75_79

80_84

85_89

p.a % change

LCI

UCI

Percentage Change p.a. in Incidence Rates1995-2000 Non-smoker model

HA, CABG and Angioplasty 2+ Females

-6.00%

-4.00%

-2.00%

0.00%

2.00%

4.00%

6.00%

8.00%

30_34

35_39

40_44

45_49

50_54

55_59

60_64

65_69

70_74

75_79

80_84

85_89

p.a % change

LCI

UCI

Summary Heart Related Conditions

Heart attack incidence is no longer reducing at historical rates Potentially explained by the use of troponin to assist in the diagnosis

of heart attacks Full impact of troponin not yet in data

Operations CABG

stabilising/reducing less 60 increasing over 60

Angioplasty operations increasing at all ages

Combined effect Flat incidence at younger ages Increases in incidence at older ages Before troponin and other medical advances

Trends in Critical Illness Risk CostsAn update from the Critical Illness Trends Research Group

Update and analysis of cancer trends Cancer screening

Recent and future developments in cardiovascular medicine

Update and analysis of trends in heart attack, coronary artery bypass grafts and angioplasty

Trends in non-Critical-Illness mortality

Importance of Non-CI Mortality

Accelerated CI Incidence Rate Formula ix + (1-kx)qx or ix + q’x where q’x represents non-CI related

mortality Non CI Mortality as a %age of CIBT93

Age 25 Age 55Male 54.7% 24.6%Female 27.4% 13.4%

Biggest Single Component of Male ACI to Age 502nd Biggest Single Component of Female ACI throughout

Age 15-39 Age 40-64 Age 65+All Mortality Male 0.30% 2.70% 1.70%

Female 1.10% 2.10% 1.20%

Cancer, HA and Stroke Male 3.30% 3.70% 2.20%Female 2.20% 2.40% 1.80%

Non CI Mortality Male -0.40% 1.10% 1.10%Female 0.30% 1.50% 0.60%

Population Mortality Improvements 1979-2000

Deaths by Cause, Males 15-39

0

0.00005

0.0001

0.00015

0.0002

0.00025

0.0003

0.00035

0.000419

79

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

Dea

th R

ate

AccidentsVehicular AccidentsCancer (CI)Cardio (Non-CI)Heart Attack CIMental / NervousEverything else

Deaths by Cause - Males 40-64

0

0.0005

0.001

0.0015

0.002

0.0025

0.003

0.0035

Dea

th R

ate

Cancer (CI)

Heart Attack CI

Cardio (Non-CI)

Respiratory

Stroke CI

Accidents

Everything Else

Deaths by Cause - Males 65+

00.0020.0040.0060.0080.01

0.0120.0140.0160.0180.02

Dea

th R

ate

Cancer (CI)

Cardio (Non-CI)

Heart Attack CI

Respiratory

Stroke CI

Everything Else

Deaths by Cause - Female ages 15-39

0

0.00005

0.0001

0.00015

0.0002

0.00025

0.0003

Dea

th R

ate

Cancer (CI)

Accidents

Vehicular Accidents

Mental Nervous

Respiratory

Cardio (Non-CI)

Stroke CI

Everything Else

Death by Cause - Females 40-64

0

0.0005

0.001

0.0015

0.002

0.0025

0.00319

79

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

Dea

th R

ate

Cancer (CI)

Cardio (Non-CI)

Heart Attack CI

Stroke CI

Respiratory

Everything Else

Death by Cause - Females 65+

00.0010.0020.0030.0040.0050.0060.0070.0080.009

0.01

De

ath

Ra

te

Cardio (Non-CI)Cancer (CI)RespiratoryStroke CIHeart Attack CIEverything Else

Further Work and Application to Insured Lives

Need to understand non-CI cardio

CMI cause of Death survey discontinued 1994

Link to deprivation codes

Workshop Session A1 :

Trends in Critical Illness Risk Costs

Research Group Progress Report

Neil Robjohns Dr Richard Croxson Joanne Wells

Questions and Discussion Any proposals for further research ?