abcd The 2004 Healthcare Conference 26-27 April 2004 Scarman House, The University of Warwick Session B1 / D3 Richard Morris, Hamish Galloway, Sue Elliott Critical Illness Trends Research Group
What impact might screening for bowel cancer have ? Richard Morris The interaction between trends in CABG, angioplasty, angina and heart attacks The importance of trends in non-CI deaths Hamish Galloway Pulling it all together - a framework for assessing the outlook on CI risk costs Sue Elliott Trends in Critical Illness Risk CostsFurther Lessons from Population DataAn update from the 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 Critical Illness Trends Research Group
Heart AttackMS, TPD,Cancer& Strokenon-CI morty & overall proj’n Actuaries Azim Dinani Scott Reid Sue Elliott Richard Morris Joanne Wells Hamish Galloway Neil Robjohns (Chair)Scott Reid Medical Experts Professor Rubens Richard Croxson Consultant Oncologist Consultant Cardiologist Links : Actuaries Panel on Medical Advances CMIB CI experience investigation ABI CI definitions group Group Members and our Current Focus
The Actuarial Profession making financial sense of the future The Impact of Screen for Bowel Cancer - Richard Morris
Screening for Colo-rectal Cancer • (Prostate - quick update) • Background on the disease • Plans for screening • Trends to date • Modelling screening
Prostate Cancer Screening Update • PSA Test: • Not specific enough - false positives • Not sensitive enough - false negatives • Not standardised • No evidence that screening reduces mortality • Cancer Research UK briefing to MPs (Sep 03): “Population screening of men displaying no symptoms is not recommended.”
Statistics • 3rd most common cancer in men • 2nd most common cancer in women • Over 35,500 new cases per annum • Male incidence (ages 40-59) increasing at 1% p.a. • Female incidence trend is level • 90% of cases occur over age 50
Risk Factors Unclear but could include: • High-fat diet • Lack of dietary fibre • Sedentary lifestyle • Obesity • Alcohol • Family history • Age • History of bowel disease (inflammation, Crohn’s disease, …) • Lack of melatonin (night-shift workers)
Histology • Normal cells • Abnormal gland cells in the lining of the bowel wall • Adenomatous Polyp • (20-25% prevalence at age 50) • Cancer localised within the bowel wall (Duke’s Stage A) • Cancer which penetrates the bowel (Duke’s Stage B) • Cancer spread to lymph nodes (Duke’s Stage C) • Cancer with distant metastases (Duke’s Stage D / Stage 4)
Histology • Normal cells • Abnormal cells • Adenomatous Polyp • (20-25% prevalence at age 50) • Cancer localised within the bowel wall (Duke’s Stage A) • Cancer which penetrates the bowel (Duke’s Stage B) • Cancer spread to lymph nodes (Duke’s Stage C) • Cancer with distant metastases (Duke’s Stage D / Stage 4) DETECTION?
Screening Methods • Faecal Occult Blood Test (FOBT) • Double Contrast Barium Enema • Flexible sigmoidoscopy • Colonoscopy • CT Colonography • DNA in stools
Plans for screening • UK clinical trials: population screening over age 50 using FOBT: • 15% reduction in mortality. • Two pilots (Coventry and Fife) set up in spring 2000 for a 2-year period. • 50-69 year olds invited for FOBT screen. • Evaluated by National Screening Committee and DofH • Second round of screening in pilot sites. • Separate UK trial of flexible sigmoidoscopy screening.
Screening Pilot Conclusions • “Our recommendation to the Department of Health is that FOBT screening should be part of new national strategies targeting colorectal cancer.” • “Findings … suggest that population-based FOBT screening is feasible.” • “adverse effects of screening … were low” • “The UK Pilot has demonstrated that mortality reductions demonstrated in randomised studies of FOBT screening can be repeated in the models of screening used in the UK pilot.”
Cancer Screening Model H ULRP DLRP UHRP DHRP LCA LCB LCC LCD DCA DCB DCC DCD Cured From Cancer Dead From Cancer
Screening Studies • National Screening Committee UK • Pilot study data • “Cost-effectiveness of screening for colorectal cancer in the general population” - Frazier et al (Journal of the American Medical Association – October 2000) • : “One of the most robust modelling studies reported to date.” National Screening Committee report • Both focus on mortality reduction.
Model Assumptions Medical data Transition rates: • Low-risk polyp to high-risk polyp • High-risk polyp to cancer (stage A) • Transition between cancer stages Population data • Cancer incidence rate • Incidence rate by Duke’s stage Unknown • Risk of developing low-risk polyp
Screening: Conclusions for Insurers We’re all doomed! Don’t panic!
The Actuarial Profession making financial sense of the future Interaction in Trends between Heart Attack, CABG and Angioplasty- Hamish Galloway
Should Trends in Heart Conditions be Modelled Together? • Drivers of trends • Risk factors • Medical intervention • Review of trends in incidence • heart attack, coronary artery bypass, angioplasty 2+ • Correlation • by age • by calendar year
Risk Factors for Coronary Heart Disease Source: Britton and McPherson (2000). National Heart Forum
Medical Intervention • Drug treatments • Surgical intervention (e.g. CABS and Angioplasty) • Limited by resource • could also be driven by resource
Trends in Population Incidence RatesHeart Attack (First and Subsequent) Age 35-64
Trends in Population Incidence RatesCoronary Artery Bypass Graft Age 35-64
Percentage Change p.a. in Incidence Rates1989-2000 Non-smoker modelHA, CABG and Angioplasty 2+ Males
Percentage Change p.a. in Incidence Rates1989-2000 Non-smoker modelHA, CABG and Angioplasty 2+ Females
Summary Trends 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
Heart procedure rates versus 1st ever heart attack rates35 up to age 65. 1996-2000 data combined. Age Age Age
Heart procedure rates versus 1st ever heart attack rates.From age 65. 1996-2000 data combined. Age Age Age
Heart procedure rates versus all heart attacks rates By HES year 1989 to 2000. Ages 35-64 combined Years Years Years
Effectiveness of CABS and Angioplasty • Randomised controlled trials of revascularisation against medical treatment show: • for CABS • a reduction in mortality • no reduction in the subsequent risk of non fatal vascular events • For angioplasty • improved symptoms in patients with angina • no improvements in survival • no prevention of subsequent myocardial infarction
Heart procedure rates versus angina ratesby HES year 1989 to 2000. Ages 35-64 combined Years Years Years
Ratio of heart procedures to first ever heart attack by calendar year for England and Wales, Ages 35-64 combined
Ratio of heart procedures to angina rates by calendar year for England and Wales, Ages 35-64 combined
Summary on Correlation • Trends in diet and smoking will impact all of HA, CABS, and angioplasty as well as angina but… • the impact does not appear to be the same due to medical intervention • Correlation by calendar year of CABS and angioplasty is stronger with angina than heart attack • Increases in the number of CABS and angioplasty are not acting to reduce the rate of heart attack • Greatest potential for increase in operations is at ages over 65 • International comparisons show considerable scope for the rate of angioplasty operations to increase. • Heart attack, needs to be modelled separately from CABS and angioplasty.
The Actuarial Profession making financial sense of the future Trends in non-CI Mortality- Hamish Galloway
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 • Biggest Single Component of Male ACI to Age 50 • 2nd Biggest Single Component of Female ACI throughout