Acute ischemia in an insurance applicant's electrocardiogram?

A life insurance applicant's electrocardiogram shows ST elevation and terminally negative T-waves suggestive of acute myocardial ischemia.

Using re-sampling methods in mortality studies

Traditional methods of computing standardized mortality ratios (SMR) in mortality studies rely upon a number of conventional statistical propositions to estimate confidence intervals for obtained values. Those propositions include a common but arbitrary choice of the confidence level and the assumption that observed number of deaths in the test sample is a purely random quantity. The latter assumption may not be fully justified for a series of periodic "overlapping" studies. We propose a new approach to evaluating the SMR, along with its confidence interval, based on a simple re-sampling technique. The proposed method is most straightforward and requires neither the use of above assumptions nor any rigorous technique, employed by modern re-sampling theory, for selection of a sample set. Instead, we include all possible samples that correspond to the specified time window of the study in the re-sampling analysis. As a result, directly obtained confidence intervals for repeated overlapping studies may be tighter than those yielded by conventional methods. The proposed method is illustrated by evaluating mortality due to a hypothetical risk factor in a life insurance cohort. With this method used, the SMR values can be forecast more precisely than when using the traditional approach. As a result, the appropriate risk assessment would have smaller uncertainties.

[Care continuity for patients with congenital hypothyroidism during transition from childhood to adulthood]

Since the nation-wide neonatal screening programs for congenital hypothyroidism(CH) had been implemented in 1979, the diagnosis and treatment of CH are now provided in the first 2-3 weeks of birth in Japan. The goals of treatment are to raise the serum T4 as rapidly as possible into the normal range, and maintain normal growth and development while avoiding overtreatment. Because transient hypothyroidism may occur frequently, a reevaluation after 3 years is needed in such patients. Patients with CH had normal growth in general, suggesting that the neonatal screening system is being performed efficiently from detection to treatment of the disease in Japan. Pediatric and adult thyroidologists are engaging in processes to promote the continuity of care for patients with CH.

[Phenylketonuria--toward a better carry-over care]

Issues pertinent to patients with phenylketonuria(PKU) in adulthood are presented. Nutritional management policy that is optimal to prevent such nutritional complications as osteoporosis and possible vitamin B12 deficiency in each age group should be considered. Adolescent girls with PKU and their guardians should be informed of the issue of maternal PKU to prevent the condition. Socioeconomical issues also remain to be solved. Most adult patients have felt that medical expense to continue dietary therapy is a significant economical burden, which often leads to withdrawal from the therapy. Buying life insurance may be refused by insurance companies simply because the patients have PKU. Current knowledge on health status of well-controlled PKU patients should be provided to insurance companies.

Invigorating the content in social embeddedness: an ethnography of life insurance transactions in China

Based on more than 14 months' ethnographic research in China, this article brings in culture and symbolic interactionism to understand the social embeddedness of economic transactions. First, an analytic frame linking tie strengths to defining principles, relational properties, and interactions is constructed and applied to changes in life insurance transactions in China. The data suggest that strong tie transactions were common until the economic gains of the sellers were made public. The author argues that the ethical-affective principle that defines strong ties and the high intensity of trust, affection, and asymmetric obligation that constitute these ties make them a double-edged sword for economic transactions. Instead, ties with midrange or weak strength are more effective because of their relational complementarity (although direct economic exchanges may take place among strong ties under extreme institutional or contingency conditions). The author also reveals that dramaturgical interactions, through which economic actors exercise their agency, are an integral part of embedded transactions.

Mortality risk prediction by an insurance company and long-term follow-up of 62,000 men

Background

Insurance companies use medical information to classify the mortality risk of applicants. Adding genetic tests to this assessment is currently being debated. This debate would be more meaningful, if results of present-day risk prediction were known. Therefore, we compared the predicted with the observed mortality of men who applied for life insurance, and determined the prognostic value of the risk assessment.

Methods

Long-term follow-up was available for 62,334 male applicants whose mortality risk was predicted with medical evaluation and they were assigned to five groups with increasing risk from 1 to 5. We calculated all cause standardized mortality ratios relative to the Dutch population and compared groups with Cox's regression. We compared the discriminative ability of risk assessments as indicated by a concordance index (c).

Results

In 844,815 person years we observed 3,433 deaths. The standardized mortality relative to the Dutch male population was 0.76 (95 percent confidence interval, 0.73 to 0.78). The standardized mortality ratios ranged from 0.54 in risk group 1 to 2.37 in group 5. A large number of risk factors and diseases were significantly associated with increased mortality. The algorithm of prediction was significantly, but only slightly better than summation of the number of disorders and risk factors (c-index, 0.64 versus 0.60, P<0.001).

Conclusions

Men applying for insurance clearly had better survival relative to the general population. Readily available medical evaluation enabled accurate prediction of the mortality risk of large groups, but the deceased men could not have been identified with the applied prediction method.

Securing your financial future

Securing one's financial future requires dedication and planning. A clear plan must be implemented and continually re-examined to assure an individual remains on track to achieve this security. True success of the plan will be dependent upon taking the appropriate steps to protecting one's assets against unfortunate events along with building assets with a clear end goal in mind. This article will cover the fundamental steps an individual can take to secure their financial future.

Insurance: a dynamic process

From graduation to retirement, insurance plays an important part of a dentist's professional and personal life. The intent of this article is to offer an overview of the needs and solutions for obtaining coverage. This article is not advice for a practitioner's personal choice of insurance purchases but is only a discussion. The framework of the discussion will be the four stages of dentistry: beginning a career, starting a practice, enriching a career, and preparing for retirement.

Diastolic dysfunction--a case of trouble relaxing

In this issue of the Journal of Insurance Medicine, Dr. Clifford S. Hale reviews a frequent and important condition that we frequently come across during medical underwriting. The term "diastolic dysfunction" is often noted in echocardiography reports and this term gives rise to a lot of uncertainty in terms of how much emphasis we should put on it and how much rating that it should carry.

Atherogenic dyslipidemia--a medical underwriter's iceberg

Life insurance medical underwriters assess cardiovascular risk by applying versions of cholesterol guidelines that were written in the early 1980s, when people were not obese, triglyceride levels were lower, and the low-density lipoprotein particles carried 95% of the cholesterol ester. Today in 2010, 30% of the population is obese, triglyceride levels are higher, HDL-C levels are lower, and LDL-P may carry as little as 60% of the circulating cholesterol ester. Applicants with cardiometabolic risk have an atherogenic dyslipidemia, which is characterized by a normal LDL-C, numerous small LDL-particles, mildly elevated triglycerides, and a depressed level of HDL--and a markedly increased risk of coronary artery disease. New and alternative lipid tests are available to help insurers better underwrite this new risk.

Use of carotid intima-media thickness in an insurance context

Measurement of carotid intima-media thickness (CIMI) with B-mode ultrasound is a non invasive technique for identifying subclinical vascular disease and estimating risk of future cardiovascular disease (CVD), such as myocardial infarction (MI), stroke, and death from coronary heart disease (CHD). Although the optimal use of CIMT has not been determined, the prevailing opinion is that it improves clinical risk prediction beyond the benefits of using only the traditional cardiovascular risk factors. The reason is because CIMT can detect early subclinical disease, and thus it's both a risk factor and a marker of CVD risk. CIMT thus has the potential to increase the accuracy of risk classification. The problem from both a clinical and an insurance perspective is the absence of reliable data that relate CIMT measurements to CVD incidence rates.

Association of cholesterol, LDL, HDL, cholesterol/ HDL and triglyceride with all-cause mortality in life insurance applicants

OBJECTIVE

Determine the relationship between various lipid tests and all-cause mortality in life insurance applicants stratified by age and sex.

METHOD

By use of the Social Security Death Master File, mortality was determined in 1,488,572 life insurance applicants from whom blood samples were submitted to Clinical Reference Laboratory. There were 41,020 deaths observed in this healthy adult population during a median follow-up of 12 years (range 10 to 14 years). Results were stratified by 4 age-sex subpopulations: females, ages 20 to 59 or 60+; and males, ages 20 to 59 or 60+. Those with serum albumin < 3.6 mg/dL or fructosamine > or = 2.1 mmol/L were excluded. The middle 50% of lipid values specific to each of these 4 age-sex subpopulations was used as the reference band. The mortality rates in bands representing other percentiles of lipid values were compared with the mortality rate in the reference band within each age-sex subpopulation.

RESULTS

In contrast to some published findings from general populations, lipid test results are only moderately predictive of all-cause mortality risk in a life insurance applicant population and that risk is dependent on age and sex. At ages below 60, HDL values are associated with a "J" shaped mortality curve and at ages 60+, total cholesterol is associated with a "U" shaped curve. The total cholesterol/HDL ratio may serve as a useful single measure to predict mortality risk, but only if stratified by age and sex, and only if high HDL values at younger ages and lower total cholesterol values at ages 60+ are recognized as being associated with increased risk as well. Using LDL or non-HDL cholesterol instead of total cholesterol does not improve mortality risk discrimination; neither does using total cholesterol or triglyceride values in addition to the total cholesterol/HDL ratio.

CONCLUSION

The total cholesterol/HDL ratio is the best single measure of all-cause mortality risk among the various lipid tests but is useful only if viewed on an age- and sex-specific basis and is only a modest risk predictor.

Relative survival in dilated cardiomyopathy: a stratification study of long-term outcome to evaluate life insurance cover

OBJECTIVES

The aim of this study was to compare mortality of dilated cardiomyopathy (DCM) patients with the mortality in the background Italian population, taking into account demographic characteristics and clinical stratification of long-term outcome, ie, "reverse remodelling" within the first 2 years of follow-up.

BACKGROUND

DCM is a myocardial disease, characterized by left and/or right ventricular dilation and dysfunction and poor outcome. Evidence-based treatment with ACE inhibitors, beta-blockers and, in the last decade, implantable cardioverter defibrillators have been demonstrated to improve significantly heart failure symptoms and prognosis. At present, DCM patients are unlikely to be accepted for life insurance.

METHODS

A cohort of 577 DCM patients consecutively enrolled from 1988 to 2004 in the Heart Muscle Disease Registry of Trieste, Italy, was matched by sex, age and registry data entry with the mortality data of the Italian population. Relative survival has been estimated by means of Kaplan-Meier technique, and mortality ratios (MR) with corresponding 95% confidence intervals have been computed.

RESULTS

DCM patients who showed a significant reverse remodelling within the first 2 years of treatment showed comparable survival with respect to the control population, and therefore could be taken into consideration for life insurance coverage, at least for a short or medium-term of years.

CONCLUSIONS

The data illustrate that survival probability strongly depend on the individual treatment and evolution of the disease and could be easily measured within the first 2 years of follow-up. If this information is collected at the time of evaluation of an applicant for life cover, the insurance company could possibly improve its risk stratification.

Insurance planning for dentists and dental practices

There are a myriad of insurance products available for the dentist and his dental practice. Care must be taken to ensure that all risks have been reviewed and the appropriate risks covered with an insurance plan. Taking the time to solidify your base helps to ensure a strong financial plan for years to come.

[Diabetes mellitus: an epidemic rise?]

Diabetes mellitus is becoming an increasingly important issue in insurance medicine. Given the rising numbers of overweight applicants, an important question is wether the number of diabetic applicants is also rising, and if so, by how much. The media talks of an epidemic of obese poeple. Is the same true of diabetes mellitus? And what can wo do? Higher loadings? Nothings? Let us take a closer look at the prevalence and incidence rates. Hopefully, this will shed some light on this problem.

South Africa: the new world of disability

Over the past 10 years, unique business imperatives in South Africa have led to innovative risk product design, some of which are still unfamiliar to the rest of the world. The main drivers are: the unique mix of first- and third-world societies in our country, and an energetic marketing force operating in an already highly saturated insurance market. As a result, new product design has become one of the most effective ways to grow new business volumes in this competitive environment. This article reviews some of the unique products available and their advantages, target markets and disadvantages. The products that are discussed include lump sum total and permanent disability benefits, extended critical illness products, cover for impairment of function as well as risk products for people living with HIV/AIDS.

Using liver enzymes as screening tests to predict mortality risk

OBJECTIVE

Determine the relationship between liver function test results (GGT, alkaline phosphatase, AST, and ALT) and all-cause mortality in life insurance applicants.

METHOD

By use of the Social Security Master Death File, mortality was examined in 1,905,664 insurance applicants for whom blood samples were submitted to the Clinical Reference Laboratory. There were 50,174 deaths observed in this study population. Results were stratified by 3 age/sex groups: females, age <60; males, age <60; and all, age 60+. Liver function test values were grouped using percentiles of their distribution in these 3 age/sex groups, as well as ranges of actual values.

RESULTS

Using the risk of the middle 50% of the population by distribution as a reference, relative mortality observed for GGT and alkaline phosphatase was linear with a steep slope from very low to relatively high values. Relative mortality was increased at lower values for both AST and ALT. ALT did not predict mortality for values above the middle 50% of its distribution.

CONCLUSION

GGT and alkaline phosphatase are significant predictors of mortality risk for all values. ALT is still useful for triggering further testing for hepatitis, but AST should be used instead to assess mortality risk linked with transaminases.

Diagnostic pitfalls in a scanned electrocardiogram

Diagnostic accuracy in electrocardiogram (ECG) interpretation is important for medical directors. Both confirming and discarding the diagnosis of a specific abnormality may greatly influence the assessment of an applicant's mortality risk. In the insurance industry, an additional challenge for ECG interpretation is the increasing use of scanned images. This case study illustrates some of the pitfalls in the electrocardiographic interpretation of a common prognostically important ECG abnormality.

Smoking habit and mortality: a meta-analysis

Cigarette smoking leads to excess mortality risk. Although it is well known that the risk increases with the number of pack-years of smoking--that is, how much a person smokes, or "habit"--there is apparently no published studies that organize and synthesize the evidence on this topic. This paper provides a meta-analysis of the latest published findings relating to cigarette smoking habit and excess mortality. A combined estimate of the relative risk (RR) of death for smokers, stratified by habit (light, medium, or heavy smoking), compared with non-smokers is provided.

Abnormal electrocardiogram in a professional athlete

Highly trained athletes occasionally present with abnormal electrocardiogram (ECG) patterns. Such abnormal ECGs in apparently healthy athletes raise several important underwriting questions: are these changes benign expressions of athletic training or do such patterns represent the initial and subtle expression of cardiovascular disease (especially genetic disorders with delayed phenotypic appearance and potentially adverse consequences)? What is the reliability of the ECG in the various conditions that are known to cause sudden cardiac death in athletes? How does the type of sport, position played and the individual's race and ethnic background influence these changes? This ECG case study addresses these questions.

Comparative mortality in asymptomatic men issued standard insurance with routine ECG classified as normal or with minor T wave changes

METHODS

From a prospective electrocardiogram (ECG) study file at the New England Mutual Life Insurance Company, cases were selected on the basis of men issued standard insurance, without symptoms, but with a routine ECG interpreted as normal or with minor low amplitude T wave (+0.5 mm to +1.0 mm). There were 1460 men so classified, with interpretations made between May 1, 1954, and December 31, 1966, and cases followed to July 1, 1970.

RESULTS

In a mean follow-up (FU) of 7.6 years, there were 50 deaths in 12,043 person-years of exposure, with a mean annual mortality rate of 4.4 per 1000 per year, lower than the 4.9 expected from company age/sex/duration-matched rates. However, the annual excess death rate (EDR) of the 12% of men with minor low T waves was +3.1 per 1000 per year, significantly higher than the EDR of -0.9 in the 88% of men with T waves of normal amplitude (+1.0 mm or higher).

CONCLUSION

When a routine ECG is classified as satisfactory for standard issue (normal or with minor low T wave), the mortality is lower than for all standard issues on male applicants of all ages (mostly without any ECG for review). Nevertheless, in the 12% of men with minor low T wave amplitude as defined for this study, there was significant excess mortality observed, with a mortality ratio (MR) of 188% and an EDR of +4.0 per 1000 per year, when compared with mortality of the men with completely normal T Waves.

Insurability of living organ donors: a systematic review

Being an organ donor may affect one's ability to obtain life, disability and health insurance. We conducted a systematic review to determine if insurability is affected by living organ donation, and if concern about insurability affects donor decision making. We searched MEDLINE, EMBASE, SCI, EconLit and Cochrane databases for articles in any language, and reviewed reference lists from 1966 until June 2006. All studies discussing the insurability of living organ donors or its impact on donor decision making were included. Data were independently abstracted by two authors, and the methodological quality appraised. Twenty-three studies, from 1972 to 2006, provided data on 2067 living organ donors, 385 potential donors and 239 responses from insurance companies. Almost all companies would provide life and health insurance to living organ donors, usually with no higher premiums. However, concern about insurability was still expressed by 2%-14% of living organ donors in follow-up studies, and 3%-11% of donors actually encountered difficulties with their insurance. In one study, donors whose insurance premiums increased were less likely to reaffirm their decision to donate. Based on available evidence, some living organ donors had difficulties with insurance despite companies reporting otherwise. If better understood, this potential barrier to donation could be corrected through fair health and underwriting policies.

Genetics, insurance and participation: how a Citizens' Jury reached its verdict

Access to life insurance is subject to health discrimination. Whether this discrimination should take into account the results of predictive genetic tests is a topic of public debate. This paper draws from the deliberations of the Edinburgh (Scotland) Citizens' Jury on Genetic Test Results and Life Insurance to evaluate the capacity of one participatory research method to inform debates on genetics and insurance. We show that through a process of knowledge-building, cross-examination and deliberation, 'lay' jurors are able to assimilate complex information, engage in subtle argument and arrive at well-reasoned, clearly warranted conclusions. The Citizens' Jury approach has a further key advantage: it embraces the formation and articulation of normative ideas. It brings public understandings of how things ought to be into an arena dominated by 'expert' opinion. These normative indicators, which in this case relate to fairness and trust, are often overlooked by policy makers. However, they are key to democratic decision-taking and relevant for health promotion.

Compelled authorizations for disclosure of health records: magnitude and implications

Each year individuals are required to execute millions of authorizations for the release of their health records as a condition of employment, applying for various types of insurance, and submitting claims for benefits. Generally, there are no restrictions on the scope of information released pursuant to these compelled authorizations, and the development of a nationwide system of interoperable electronic health records will increase the amount of health information released. After quantifying the extent of these disclosures, this article discusses why it is important to limit disclosures of health information for nonmedical purposes as well as how it may be possible to do so.

Pivot tables for mortality analysis, or who needs life tables anyway?

Actuarial life-table analysis has long been used by life insurance medical directors for mortality abstraction from clinical studies. Ironically, today's life actuary instead uses pivot tables to analyze mortality. Pivot tables (a feature/function in MS Excel) collapse various dimensions of data that were previously arranged in an "experience study" format. Summary statistics such as actual deaths, actual and expected mortality (usually measured in dollars), and calculated results such as actual to expected ratios, are then displayed in a 2-dimensional grid. The same analytic process, excluding the dollar focus, can be used for clinical mortality studies. For raw survival data, especially large datasets, this combination of experience study data and pivot tables has clear advantages over life-table analysis in both accuracy and flexibility. Using the SEER breast cancer data, we compare the results of life-table analysis and pivot-table analysis.

Increased mortality associated with elevated carcinoembryonic antigen in insurance applicants

OBJECTIVE

Determine the relationship between the carcinoembryonic antigen (CEA) value and all-cause mortality in life insurance applicants aged 50 years and over.

METHOD

By use of the Social Security Master Death Index, mortality was examined in 115,590 insurance applicants aged 50 and up for whom blood samples for CEA were submitted to the Clinical Reference Laboratory. Results were stratified by CEA value (<5 ng/mL, 5 to 9.9 ng/mL, 10+ ng/mL), smoking status, and age groups (50-59 years, 60-69 years, and 70 years and up).

RESULTS

Relative mortality is increased at CEA values between 5 and 9.9 ng/mL and further increased at 10+ ng/mL for all age groups, with the most dramatic increase at the youngest ages. Excess mortality appears to last at least 3 to 4 years after the elevated result. Five-year all-cause mortality in applicants with CEA values of 10+ ng/mL is 25.2% with a mortality ratio relative to those with a CEA <5 ng/mL of 1156%.

CONCLUSION

This study shows that CEA can detect the risk of early excess mortality in life insurance applicants; CEA levels of 5 ng/mL and over may be of concern. CEA testing beginning at age 50 years for life insurance applicants could capture 4.6% of early mortality if the threshold for further evaluation was set at 10 ng/mL. Only 0.4% of all applicants aged 50 and over have CEA values at or above this threshold.

Relationship of hemoglobin A1c to mortality in nonsmoking insurance applicants

OBJECTIVE

Determine the relationship between hemoglobin A1c value and 5-year, all-cause mortality in nonsmoking life insurance applicants.

METHOD

By use of the Social Security Master Death Index, mortality was examined in 286,443 non-smoking insurance applicants aged 40 and up for whom blood samples for hemoglobin A1c were submitted to the Clinical Reference Laboratory. Results were stratified by hemoglobin A1c value, gender and age bands 40 to 59, 60 to 69 and 70 and up.

RESULTS

Increased mortality is apparent at hemoglobin A1c values of 6% and above, is linear, and on a percentage basis decreases with age. Hemoglobin A1c values less than 5% also are associated with increased mortality. Absolute mortality rates for females with elevated hemoglobin A1c are generally lower than rates for males, although mortality relative to the gender-specific reference group with hemoglobin A1c of 5% to 5.9% is generally the same for both.

CONCLUSION

The importance of even small elevations of hemoglobin A1c above 5.9% is apparent. For screening, it is the degree of blood sugar elevation as measured by hemoglobin A1c rather than any diagnostic label that is critical in risk assessment.

Mortality in co-morbidity (I)--Analysis of the results in the Multiple Medical impairment Study for impairments with elevated blood pressure as the second or co-morbid impairment

BACKGROUND

In life insurance medicine as in general medicine, it has long been recognized that chronic medical conditions often occur in persons, not as a single impairment or risk factor, but as multiple co-morbid conditions. Nevertheless, it was not until 1999 that the first intercompany Multiple Medical Impairment Study (MMIS) was completed by Harry A. Woodman, FSA. Prior intercompany mortality studies from 1903 to 1983 had been almost 100% devoted to single impairments excluding all comorbid impairments except minor ones with a mortality ratio (MR) of 125% or less. However, abundant co-morbid mortality data have been presented in other clinical and single company studies. Examples are in the studies on diabetes mellitus abstracted in the 1976 Medical Risks monograph and two more recent studies. In this article, we analyze overall mortality and mortality for most of the individual impairments with elevated blood pressure (EBP) as the co-morbid impairment, provided that exposures and deaths were sufficient in number to utilize.

METHODS

From the standardized results page for the impairments published in the MMIS, we have extracted 3 tables of aggregate mortality experience on groups with a single impairment, 2 impairments, and 3 impairments. Then we prepared a similar table from the substandard experience of the 1979 Blood Pressure Study. Weighted mean age was calculated, for all groups, and excess death rates (EDRs) in the group with EBP were adjusted to the mean age of the 2-impairment group. Next a subsidiary table was prepared of data from 57 impairments in Section III of the MMIS. The data included the name of the impairment, exposures, observed and expected deaths (d and d'), overall EDR as a multiple and as a single impairment, and as a co-morbid impairment with EBP as the second impairment. The age-adjusted EDR for EBP alone was added to the EDR as a single impairment, and the sum was compared with the co-morbid EDR for the impairment and EBP. The 57 impairments were then divided into 3 groups (Tables 4-6), depending on whether the comorbid EDR exceeded the sum of the separate EDRs, was less than the sum, or approximately equal to the sum.

RESULTS

EDR rose with decennial age group in each of the 4 groups shown in Table 1. Mean annual EDR, all ages combined, increased from 2.6 per 1000 for a single impairment to 5.2 for 2 impairments to 9.2 for 3 impairments. In males in the 1979 Blood Pressure Study, the mean EDR, all rated policies combined, was 5.0 per 1000, and the mean rate of increase per decennial age group was 2.77 per 1000, aged 20-29 to 60-69. In 18 of 57 comparisons, the co-morbid EDR exceeded the sum of the separate EDRs by 1.0 or more; in 20 the 2 EDR values were approximately equal, within +/- 0.9; and in 19 the co-morbid EDR was less than the sum of the separate EDRs by 1.0 or more. In Table 4, we listed the 18 impairments whose co-morbid EDR exceeded the sum of the separate EDRs, entering the overall co-morbid mortality data (combined impairment and EBP), and the comparison EDRs. The mean co-morbid EDR was 11.3 per 1000 per year, with a range from 6.8 to 17.7; the mean sum of EDRs was 8.3 per 1000 (range 5.6 to 12.5). The mean excess EDR was +2.8, with a range from +1.2 to +9.2. Results are shown in Tables 5 and 6 for the groups in which the co-morbid EDR was less than or approximately equal to the sum of the separate EDRs.

CONCLUSION

In 18 of 57 comparisons made in MMIS, there was a synergistic excess mortality when the co-morbid EDR (impairment with EBP as second impairment) was compared with the summated EDR of the impairment alone and the EDR for EBP alone. In the remaining 68% of the impairments, the co-morbid EDR was approximately equal to or less than the sum of the separate EDRs.