Download Underwriting Diabetes - philippine society of insurance medicine

New Concepts in Underwriting
Diabetes
September 2002 - Manila, Philippines
By Dr. Philip Smalley MD FRCPC
Vice President and Medical Director
RGA International
Toronto
Objectives
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Diabetes definitions and epidemiology
Discuss diabetic complications
Demonstrate new therapies in diabetes
Diabetes mortality and prognostic indicators
Underwriting diabetes:
• How to place the good risks and avoid the early
death claims.
Diabetes Classifications
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Type 1 Diabetes (10 – 15% of all diabetics)
Type 2 Diabetes
Maturity-onset Diabetes of Youth (MODY)
Maternally Inherited Diabetes and Deafness
Secondary Diabetes
• Pancreatic disease
• Hemochromatosis
• Medication Induced
 Impaired Glucose Tolerance
 Gestational Diabetes
Global Prevalence of Diabetes
 135 million diabetics in the world
 300 million by year 2025
• More diabetics in developed countries
• More increase in diabetes prevalence in under-developed
countries
 Impaired Glucose
Tolerance more common
 1/3 – 1/2 of diabetics
are undiagnosed
H. King et al, Diabetes Care 1998 Sep;21(9):1414-31
H. King et al, Diabetes Care 1993 Jan;16(1):157-77
Ali O et al, Diabetes Care 1993 Jan;16(1):68-75
Diabetes Across the Globe
Population
World
US Whites
Mortality
Rate per
100,000
Prevalence
Male DM
Female DM
*******1.5%
*****19%
US Japanese
Japan Japanese
**9.9%
Philippines
*9.8%
Both Sexes DM
4%
12%
14%
20%
16%
5%
4%
****7.8%
******10.9%
***4%
Asian Indians in
Tanzania
40%
Africans
0.3%
Philippine Health Statistics – Department of Health, 1995; SEAMIC Health Statistics 1999 – http://www.seamic-imfj.or.jp/PDF/1999SHS/1-3.pdf
SEAMIC Health Statistics 1999 - http://www.seamic-imfj.or.jp/PDF/1999SHS/1-3.pdf
Fernando RE, Indian J Pediatr 1989 Nov – Dec;56 Suppl 1:S67-70
National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Statistics fact sheet: general information and national estimates on diabetes in the United
States, 2000. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, 2002.
http://www.niddk.nih.gov/health/diabetes/pubs/dmstats/dmstats.htm#7
***** World Health Organization: Themes and Focuses http://www.wpro.who.int/themes_focuses/ Theme2/focus4/t2f4pub_50dia.asp
****** Diabetes.com http://www.niddk.nih.gov/health/diabetes/pubs/dmstats/dmstats.htm#12
******* WHO: The Global Burden of Disease 2000 project: aims, methods and data sources. Global Programme on Evidence for Health Policy Discussion Paper No. Annex Table 8
summarizes GBD 2000 Version 1 estimates of death by cause, age and sex… http://www3.who.int/whosis/burden/papers/Discussion%20Paper%2036%20Revised.doc
*
**
***
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New Criteria for Diagnosis of DM
 Canadian and American Diabetes Association’s
NEW Definition of Diabetes 1998
• FBS >125 mg/dl (7.0 mmol/l)
• In past, diagnosis with glucose > 140 mg/dl (7.8 mmol/l)
• Random glucose >200 mg/dl (11.1 mmol/l) and
symptoms
• IGT FBS 110 - 124 mg/dl
• Normal FBS < 100 mg/dl
 Oral Glucose Tolerance Tests
 Glycosuria is poor marker of diabetes
• Poor sensitivity and specificity
The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus,, Diabetes
Care Volume 22 Supplement 1, American Diabetes Association: Clinical Practice
Recommendations 1999.
Measures of Control
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Urine dipstick (poor indicator)
Blood glucometer readings
Hb A1c (reflects 12 - 15 weeks of control)
Fructosamine (reflects 2 week control)
Diabetes is a Serious Disease
 Acute onset ketoacidosis or hyperosmotic coma can be
lethal
 Treatment induced hypoglycemia can be lethal
 Microvascular Complications
• nephropathy, retinopathy, and neuropathy
 Macrovascular Complications
• heart disease, stroke, peripheral vascular disease, diabetic
ulcers
 Premature Death
• Diabetics live about 8 years less than non-diabetics
 Yearly mortality in diabetics is 2.9% in meta-analysis of
27 international studies
Kanters SD et al, Vasc Med 1999; 4(2): 67-75
Type 2 Versus Heart Disease Mortality
Non DM, no MI
DM but no MI
Non DM with MI
DM with MI
Figure 1: Kaplan-Meier Estimates of the Probability of Death from Coronary Heart Disease
in 1059 Subjects with Type 2 Diabetes and 1378 Nondiabetic Subjects with and without Prior
Myocardial Infarction.
Figure from Haffner SM et al, NEJM July 23, 1998 Vol. 339, No. 4
Determinants of All Cause
Mortality in Diabetics
 Type 1 higher rates than Type 2
• Type 1 Risk Ratios of 3 to 15
• Type 2 Risk Ratios of 1.4 to 3.7
Effect of Gender
 Standardized mortality ratios higher for women
than men in both Type 1 and Type 2
• 21,447 diabetics followed for 26 years
• Male Standardized Mortality Ratio 1.44 - 1.74
• Female Standardized Mortality Ratio 1.73 - 2.42
 Diabetes causes the loss of the usual protective
effect of female hormones on the heart
Kessler II, Am J Med 1971 Dec;51(6):715-24
Mortality Ratio Falls with Age of Patient
Type 1
M
Type 2
F
M
F
Figure from Muller WA,, J Insur Med 1998;30(1):17-27, Published erratum appears in J Insur
Med 1998;30(2):129.
Effect of Duration of Diabetes
Type 1
Type 2
Risk of nephropathy declines if no proteinuria after 15 years of
diabetes history
Figure from Muller WA,, J Insur Med 1998;30(1):17-27, Published erratum appears in J Insur
Med 1998;30(2):129.
Complications of Diabetes
Heart Disease
 Major cause of death in diabetics
 Krolewski reported 2 fold risk of CAD
mortality in males and 4 fold in females
 Occurs at younger ages than non-diabetics
 More atypical presentations of CHD
 Prognosis is worse in CHD with underlying
diabetes
Autonomic Neuropathy
 72% five year survival
with autonomic
neuropathy
 92% five year survival
without neuropathy
Figure from Muller WA,, J Insur Med 1998;30(1):17-27,
Published erratum appears in J Insur Med 1998;30(2):129.
Nephropathy
 Prevalence
• 30 - 40% of Type 1 DM
• 20% of Type 2 DM
 Proteinuria to renal failure in 5 to 23 years
 Improved prognosis of nephropathy recently with
more BP therapy, better DM control and ACE
Inhibitor therapy
Nephropathy in Type 1
____ Solid line 1971
……. Fine dot 1983
. . . . . Dotted 1985
- - - - Slashed 1989
 Also improved end stage
kidney disease therapies
and transplant mortality
Figure from Muller WA,, J Insur Med 1998;30(1):17-27,
Published erratum appears in J Insur Med 1998;30(2):129.
Microalbuminuria (MAU)
 Confusing Name
• “Small amounts of proteinuria”
• 0.03 - 0.3 g/ day (30 - 200 ug / min)
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Use microalbumin / urine creatinine ratio
Best to have repeated results
Less MAU if diastolic BP is below 75 mmHg
Becoming standard of care to check MAU yearly
and treat with ACE Inhibitor to lower MAU
Microalbuminuria (MAU)
 Marker of nephropathy in Type 1 diabetics
 Marker of heart disease in Type 2 diabetics
 Dinneen SF 1997
• Analyzed 11 studies of Type 2 and MAU
• 20% to 36% of Type 2 had MAU
• Odds ratio for death was 2.4
Dinneen SF, et al Arch Intern Med 1997 Jul 14;157(13):1413-8
Stroke
 Diabetics have 4 times more strokes than
non-diabetics
Treatment of Diabetes
 12 year follow up of 6956 men with glucose
intolerance
 Diet and exercise improved mortality
• 6.5 / 1000 person-years with intervention
• 14.0 / 1000 person-years without the intervention
• 6.2 / 1000 person-yrs in normal glucose tolerance
controls
Eriksson KF et al, Diabetologia 1998 Sep;41(9):1010-6
Inhaled Insulin
Cefalu WT et al, Inhaled Human Insulin Treatment in Patients with Type 2 Diabetes Mellitus,
Annals of Internal Medicine 6 February 2001;134: 203-207
Newer Diabetes Therapies
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Combination therapies
Agents to increase insulin sensitivity
Drugs to delay glucose load from bowel
Inhaled Insulin
Pancreatic cell transplants
Gene therapy
30
http://www.unos.org/Newsroom/critdata_main.htm
31
Gene Therapy for Diabetes
 Insert gene for insulin into intestine cells
 Diabetic mice have normal glucose levels
http://news.bbc.co.uk/hi/english/sci/tech/newsid_1059000/1059925.stm
Control of Diabetes
 Diabetes Control and Complication Trial
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10 year study of 1,441 Type 1 DM
Intensive group had better control
76% less retinopathy
60% less neuropathy
56% less nephropathy
3 times more hypoglycemia
The DCCT Research Group, NEJM Sept 30, 1993 Vol. 329, No. 14
UK Prospective Diabetes Study (UKPDS)
 Multi-center study of Type 2 diabetics
 3055 Type 2 patients with median follow
up of 7.9 years
Turner RC et al, BMJ 1998; 316:823-828 (14 March)
Baldeweg SE et al, Prim Care 1999 Dec;26(4):809-27
Nasr CE et al, Cleve Clin J Med 1999 Apr;66(4):247-53
Turner RC, Diabetes Care 1998 Dec;21 Suppl 3:C35-8
Turner RC et al, BMJ 1998; 316:823-828 (14 March)
What to look for in Underwriting
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Diagnosis
Duration
Treatment
Control
Follow up
Complications
Other cardiac risk factor profile
Case 1
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35 year old Type 1 Diabetic for 15 years on:
1) 30 units of insulin once per day
or
2) 10 units of insulin 4 times per day with
rare mild hypoglycemic episodes following
glucometer readings carefully
Case 2
 55 year old Type 2 Diabetic
 1) On oral pills glyberide 10 mg bid and
metformin 1g tid with HbA1c 11.5
 or
 2) On insulin 10 units daily with HbA1c 5.5
Case 3
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55 year old male
Type 2 diabetic
HbA1c 7.2
BP 150/90
Cholesterol 7.0
Ex-smoker for 5 yrs
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55 year old male
Type 2 diabetic
HbA1c 9.2
BP 120/80
Cholesterol 4.9
Never smoked
Case 4
 22 year old Type 1 diabetic for 12 years.
Urine microalbumin/urine Cr ratio is
elevated. Proliferative retinopathy and BP is
170/95
Case 5
 62 year old male with increased BMI at 28. Sees
his MD frequently and had a normal blood tests 1
year ago. His stress test is normal.
• a) Family Doctor recently found and started treatment
for a FBS of 170 mg/dl (9.4 mmol/l) and HbA1c
elevated to 7.0
• b) Insurance blood profile currently shows FBS of 170
mg/dl (9.4 mmol/l) and HbA1c is elevated at 7.0
Summary of Diabetes
 High risk if other risk factors or end organ damage
especially Type 1 Diabetics
 Improved trends in therapy and case fatality rate
 Better risk in older ages
 Credit for cardiac work up, good control and follow
up
 Urine microalbumin can stratify risks but has
marketing issues
 Look at full risk factor profile
Thank you !