Long-term morbidity and mortality in Chinese insurance applicants infected with the hepatitis B virus

BACKGROUND

Worldwide, there are approximately 350 million carriers of the hepatitis B virus (HBV). The protracted course of HBV infection makes it difficult to estimate morbidity and mortality risk in an insured lives population that is chronically infected with HBV because most studies on this topic have been based on older patients with advanced disease who were treated at tertiary centers that specialize in care of patients with liver disease. Data from these reports bias risk estimates toward severe cases and are not appropriate indicators of what might be expected in an insurance context. This article discusses use of a Markov model to estimate long-term morbidity and mortality risk associated with chronic HBV infection in otherwise healthy Chinese insurance applicants.

RESULTS

The model was validated by comparing results to population data published in Taiwan, Hong Kong, Shanghai, Singapore, and Korea. For males, mortality ratios were in the range of 150-175% for underwriting ages 20, 30, and 40 and slightly lower for age 50. For females, mortality ratios were in the range of 125-150% and slightly higher for age 50. Higher mortality ratios in males were related to the fourfold higher hepatocellular carcinoma (HCC) incidence rate. Mortality ratios varied with the extent of the underwriting evaluation. Liver-related morbidity incidence increased with age at underwriting for males and females. HBeAg (hepatitis B "e" antigen)/anti-HBe status was not a major factor for differentiating risk in an insurance context.

CONCLUSION

Morbidity and mortality are within the insurable range for the majority of HBV-infected Chinese applicants. Risk varies with the extent of the underwriting evaluation and the percentage of applicants with significant liver fibrosis or early cirrhosis that are detected during the underwriting process. HBeAg/anti-HBe status is not a major factor for differentiating risk in an insurance context. Morbidity and mortality estimates provided by the model can be generalized to other populations and individuals where HBV infection occurs at birth or during early childhood, although some modification in insurance risk might be required in non-Asian markets.

Long-term morbidity and mortality risk in Japanese insurance applicants with chronic hepatitis C virus infection

BACKGROUND

Japan has the highest rate of liver cancer of any industrialized country in the world, and research indicates that hepatitis C virus (HCV) is responsible for 50-76% of these cases. The natural history of chronic HCV infection is difficult to determine because the initial bout of acute infection is usually not recognized and serious complications generally do not develop for at least 3 decades. This article discusses use of a Markov model to estimate long-term morbidity and mortality risk associated with chronic HCV infection in otherwise healthy Japanese insurance applicants. A range of risk estimates is derived based on different assumptions of disease progression.

RESULTS

Data for this analysis were based on prospective and combined retrospective-prospective studies of populations infected at different ages and followed for durations of up to 25 years. Estimated mortality ratios varied with assumptions regarding rate of progression from active HCV infection to cirrhosis. For males, peak mortality ratios decreased with advancing age at underwriting, from a high of 253% (age 20) to a low of 144% (age 60). A similar age-related pattern was seen for females, from a peak mortality ratio of 222% (age 20) to a low of 156% (age 60). In contrast to the pattern of decreasing relative mortality at older ages, morbidity increased with age at underwriting. Sensitivity analysis indicated that calculations in the model were sensitive to different transition rates from active HCV infection to cirrhosis and from cirrhosis to HCC, but were not sensitive to treatment frequency and success or the percentage of people treated prior to application. A review of the literature also suggested that a favorable prognosis was likely in applicants with persistently normal ALT levels, but prognosis was less certain for those with intermittent or persistent elevation of liver enzymes.

CONCLUSION

Morbidity and mortality are within the insurable range for the majority of HCV-infected persons. Risk varies with gender, age at infection, and other variables discussed in the article.

Long-term survival after repair of tetralogy of Fallot

BACKGROUND

Tetralogy of Fallot (TOF) is the most common cause of cyanotic congenital heart disease. Long-term survival has improved because of lower operative mortality and surgical repair in infancy or early childhood prior to the development of cardiac compromise from chronic hypoxia. Thus, more people with repaired TOF will survive to adulthood and will be interested in insurance coverage.

RESULTS

This paper reported 36-year follow-up of 490 patients observed for a mean duration of 25 years after surgical repair of TOF; 42 deaths occurred, 62% of which were due to cardiac causes, principally sudden cardiac death and congestive cardiac failure. Mortality ratios were generally highest for the first 10 years of follow-up, ranging from 309% (ages < 10 years) to 714% (ages 20-39 years). By age, mortality ratios were stable and relatively similar for ages to 19 years and variable at older ages due to the small exposure. Most patients were actively at work (70.8%), homemakers (20.1%), or retired (6.1%); 3% were unable to work.

CONCLUSION

For patients < 10 years of age and 10-19 years of age at the time of surgery who were alive after 1 year after the repair of the TOF, excess mortality persisted at least 30 years after surgery and did not vary a great deal with duration of the follow-up. Based on limited data, excess mortality for age group 20-39 years was higher compared with those in a younger age group during the first 10 years after surgery and decreased thereafter. Survival rates similar to those of the general population were attained in subjects who did not require treatment with a right ventricular outflow patch and who had normal hematocrit levels prior to surgery. Elevated morbidity risk was manifest by cardiac symptoms, arrhythmias, subsequent heart surgery, and disability in 3% of patients.

Long-term insured lives morbidity and mortality risk associated with chronic hepatitis C virus infection

BACKGROUND

Hepatitis C virus (HCV) infects 170 million people worldwide. Some medical experts have suggested that progression to end-stage liver disease is inevitable; others have concluded that progression is restricted to a limited percentage of those who are infected. These opposing views have added to the uncertainty faced by underwriters who must assess risk in applicants infected with HCV. This article discusses use of a Markov model to estimate risk associated with chronic HCV infection in otherwise healthy applicants for life and critical illness insurance.

RESULTS

Estimated mortality ratios varied with assumptions regarding rate of progression from active HCV infection to cirrhosis. For males, peak mortality ratios decreased with advancing age at underwriting from a high of 209% (age 20) to a low of 122% (age 60). A similar age-related pattern was seen for females, from a peak mortality ratio of 184% (age 20) to a low of 128% (age 60). In contrast to the pattern of decreasing relative mortality at older ages, morbidity increased with age at underwriting. Sensitivity analysis indicated that calculations in the model were sensitive to different transition rates from active HCV infection to cirrhosis and from cirrhosis to hepatocellular carcinoma (HCC) but not sensitive to treatment frequency and success. A review of the literature also suggested that a favorable prognosis was likely in applicants with persistently normal alanine aminotransferase (ALT) levels, but prognosis was less certain for those with intermittent or persistent elevation of liver enzymes.

CONCLUSION

Morbidity and mortality are within the insurable range for the majority of HCV-infected persons. Risk varies with gender, age at infection, and other variables discussed in the article.

5-year survival after bone marrow transplantation for aplastic anemia

The International Bone Marrow Transplant Registry reported experience from 179 transplant teams worldwide on patients treated with bone marrow transplantation for severe aplastic anemia. The cohort consisted of 470 patients (283 male, 187 female), mean age 20 years, who received an HLA-identical sibling bone marrow transplant for aplastic anemia between 1988 and 1992. The etiology of aplastic anemia was usually idiopathic, with a small number of cases caused by hepatitis or toxin exposure. Congenital aplastic anemia was not considered. Expected mortality was based on the United States 1992 Total Population Mortality Table. Additional data were obtained from the author.

Mortality risk in patients with coronary artery disease and depression

Investigators at Duke University Medical Center studied the impact of depression on long-term mortality risk in patients with significant coronary artery disease (CAD), defined as > or = 75% narrowing of > or = 1 coronary artery. Participants were classified after testing into nondepressed, mildly depressed and moderately to severely depressed groups. From 5-10 years after the first cardiac catheterization, the mortality ratios were progressively high for the more depressed cohort.

Influence of age on survival of patients treated surgically for lower limb ischemia

BACKGROUND

Investigators in Norway reported long-term survival experience in patients treated surgically for lower leg occlusive atherosclerotic disease over the period 1974 to 1993.

RESULTS

Ten-year survival data were provided for seven age groups. Average annual mortality ratios decreased with age at time of surgery from a high of 460% in the 50-54 year-old age group to a low of 212% in patients > 80 years of age.

CONCLUSIONS

Excess mortality was related to age. This same mortality pattern is observed with most impairments, i.e., mortality ratios are usually highest at younger ages, intermediate in the middle-aged people, and lower in the very elderly.

Long-term survival of patients with infective endocarditis

BACKGROUND

Investigators in Lyon, France reported long-term outcome of 330 patients with infective endocarditis (IE). This article compares experience of the cohort to what would be expected in the general population.

RESULTS

Excess mortality persisted for many years following IE. Average annual mortality ratios were highest in the first and second years (4050% and 662%, respectively) and decreased gradually thereafter to a low of 219% during duration 10-12 years. Morbidity risk following IE would also be increased because of greater likelihood of recurrent IE, heart failure, embolism, valve thrombosis, additional valve surgery, complications of anticoagulant therapy, and stroke.

CONCLUSIONS

Morbidity and mortality risk remain elevated for many years following recovery from IE.

Effect of peripheral vascular disease on long-term mortality after coronary artery bypass graft surgery

BACKGROUND

The Northern New England Cardiovascular Disease Study Group examined the effect of cerebrovascular disease (CVD) and lower extremity disease (LED) on long-term outcome following coronary artery bypass graft (CABG) surgery in patients with coronary heart disease (CHD). This article uses data provided by the authors to quantify the mortality implications of progressively more extensive atherosclerosis.

RESULTS

After successful CABG surgery, mortality ratios for patients with CHD + CVD (107%), CHD + LED (171%), and CHD + CVD + LED (195%), respectively, were 1.6 times, 2.5 times, and 2.8 times higher than mortality ratios for patients with CHD only (69%).

CONCLUSIONS

The extent of peripheral vascular disease predicted mortality experience even after successful myocardial revascularization.

Insurance underwriting in the genetic era

Genetic technology is assuming a greater role in the practice of medicine. Insurers have a vested interest because individually underwritten insurance cannot be sold without risk classification, and much of the medical information needed to classify risks will have a genetic component. This paper reviews recent genetic advances and their potential impact on life, disability income, long-term care, and critical illness insurance. Alzheimer disease is chosen to illustrate the effect of an organized effort to withhold medical information from insurance companies. Consumers will not support a private insurance mechanism with extensive cross-subsidization among policyholders and where medical information becomes inviolate simply because it is genetic. A framework for deliberations with the medical community is proposed.

Outcome of patients treated with a St. Jude prosthetic heart valve

BACKGROUND

Long-term outcome of patients treated with a St. Jude prosthetic heart valve was reported by investigators in Lausanne, Switzerland. This article quantifies the mortality and morbidity implications of single or multiple heart valve replacement.

RESULTS

After hospital discharge, mortality ratios were highest for duration 5-10 years, roughly comparable in patients who received a single valve, and generally higher in those who received both an aortic and a mitral valve prosthesis. Outcome varied with preoperative myocardial function, but there was no survival difference among subjects with a history of stenotic, regurgitant, or mixed lesions. Postoperative complications included embolism, anticoagulant-related hemorrhage, stroke, prosthesis thrombosis, endocarditis, prosthesis dysfunction, hemolytic anemia, and reoperation.

CONCLUSIONS

This study indicated that overall mortality experience was fairly comparable in patients who received a single St. Jude prosthetic heart valve and less favorable in those who received multiple valves. Long-term morbidity rates following insertion of a St. Jude prosthetic heart valve were high.

Long-term survival experience of patients with multiple sclerosis

BACKGROUND

Long-term survival of patients with multiple sclerosis is not well characterized because this disorder is relatively uncommon and subjects must be followed for decades after onset of symptoms. This paper reports comparative mortality experience of the world's largest series on an unselected cohort with multiple sclerosis.

RESULTS

Excess mortality varied with age, gender, duration since onset and diagnosis, calender year of onset, and clinical severity.

CONCLUSIONS

Compared to the general population in Denmark, patients with multiple sclerosis had less favorable survival experience during long-term follow-up.

Morbidity and mortality associated with intracranial aneurysms

Subarachnoid hemorrhage (SAH) is bleeding into the subarachnoid space. It may result from a rupture of an intracranial aneurysm, bleeding from an arteriovenous malformation, hypertensive intracerebral hemorrhage with extension into the subarachnoid space, hemorrhage from an intracranial tumor, trauma, and hematologic disorders. If trauma is eliminated as a cause of SAH, more than 80% of SAHs are due to rupture of an intracranial aneurysm. This paper will focus on morbidity and mortality associated with ruptured and unruptured intracranial aneurysms.

Effect of age on mortality experience in patients with hypertrophic cardiomyopathy

Medical authors typically combine all patient groups to increase the amount of data available for analysis. Use of this statistical methodology generally conceals higher mortality ratios at younger ages and masks survival differences related to disease severity and comorbid impairments. This paper discusses the effects of age and clinical characteristics on mortality experience in patients with hypertrophic cardiomyopathy. Limited data suggest the mortality pattern associated with this impairment is similar to that observed with most disorders: excess mortality (compared to the general population) that is high at younger ages, intermediate in middle-aged people, and minimal in the very elderly. Optimism regarding generally favorable mortality at older ages must be tempered with caution since studies report much poorer experience in certain subgroups of elderly patients with this impairment.

Morbidity and mortality associated with transient ischemic attack (TIA)

Transient ischemic attack (TIA) is defined as "an episode of focal loss of brain function attributed to ischemia that lasts less than 24 hours, is localized to a portion of the brain supplied by one vascular system, has no persistent deficit, and is not attributable to any other cause." Most TIAs are caused by small thromboemboli that originate in atheromatous areas in neck vessels or the heart. Other mechanisms include nonatherosclerotic vascular diseases, mitral valve prolapse, hematologic diseases, and abnormal blood pressure fluctuations. Even in series of fully investigated cases, there remains a group in which no cause can be found. The great majority of TIAs are extremely brief. In one series, 24% ended within 5 minutes, 39% in 15 minutes, 50% in 30 minutes, and 60% in 1 hour.

Genetic information and life insurance

Genetic testing will become the future standard of medical care. Life insurers will also need access to genetic information if the insurance industry is to survive intact and if cover is to remain affordable.

Ankle/arm blood pressure index: an insurance perspective

Recent studies conclude that the ankle/arm blood pressure index (AAI) is a useful clinical tool for refining cardiovascular risk classification in the elderly. A reduction in the AAI to 0.9 or less is associated with increased risk for both coronary heart disease and total cardiovascular disease morbidity and mortality, as well as all-cause mortality. This relationship persists after adjusting for traditional risk factors and known cardiovascular disease. AAI will appear more common in attending physician's statements, prompting a need to educate underwriters about this technology. AAI may be of particular interest to insurers dealing in the elderly market, to those with strong physician examiner systems, and in markets where blood or urine tests are not commonly used in underwriting.