Journal of insurance medicine (New York, N.Y.)最新文献

Objectives.—: This study seeks to quantify the mortality effect of high levels of body mass index (BMI) on life insurance applicants and participants in the National Health and Nutrition Examination Survey (NHANES) in univariate models and in successive models controlling for BMI-related diseases and conditions.

Background.—: It is well established that a high BMI is associated with increased all-cause and cardiovascular mortality; however, the quantitative effect of controlling for related diseases and conditions is not well understood.

Methods.—: Data were collected from over 7 million life insurance applicants submitting samples to Clinical Reference Laboratories (CRL) and 23,486 NHANES participants with available BMI and mortality status. Cox models were utilized, treating BMI as both a continuous predictor and as a categorical variable within various age and sex groups. Six Cox models were constructed in each age-sex-data group: a univariate model controlled only for age, then 5 more successively controlling for disease status (hypertension, diabetes, and heart disease), liver function tests, blood pressure/renal function, and finally hemoglobin A1c.

Results.—: Overall, the effect of high BMI on mortality hazard was highest in the univariate model, and lower with successively controlled models. In the life insurance data, the residual effect of BMI in the final models was still significant above a BMI of about 35. In the NHANES data, the effect remained significant only above a BMI of about 40. In the continuous models, the hazard of BMI was persistently significant for both sexes in the CRL models, only for men in the final NHANES model.

Conclusion.—: Based on this study, the effect of high BMI on mortality is significantly blunted when accounting for diseases and conditions that are associated with high BMI.

Chronic myeloid leukemia (CML) is a myeloproliferative disorder in which there is a neoplastic proliferation of mature granulocytes. The cancer results from a reciprocal translocation of the breakpoint cluster region (BCR) on chromosome 22 and the ABL1 gene region on chromosome 9 - t (9;22). The result is an abnormal fusion gene on chromosome 22 known as the Philadelphia chromosome. It represents 15% to 20% of all leukemias in the United States with an estimated incidence rate of 1 to 2 cases per 100,000. About 50% of affected individuals are asymptomatic. Diagnosis depends on demonstrating the presence of the Philadelphia chromosome. CML occurs in 3 phases. The most common is the chronic phase characterized by an indolent course and <15% blast cells in the myeloid space. The remaining advanced phases are the accelerated (15%-30% blasts) and the blast phase (>30% blasts). Without treatment, progression is slow but relentless to the advanced stages and occurs over 3 to 5 years. Survival is markedly reduced once these latter stages are reached. The recognition that the BCR-ABL1 fusion gene was a key driver of the disease process led to the development of tyrosine kinase inhibitor (TKI) drugs that targeted the genetic basis for the cancer. The first of these was imatinib, which was released in 2001. Since then both second and third generations of the drug class have been approved. These medications have been demonstrated to reduce the ratio of abnormal to normal BCR:ABL1 transcripts. They are most effective if used in the chronic phase. The degree of this molecular response has been demonstrated to correlate with limitation of progression of disease and improvement, often marked, of survival. Most individuals who respond well require lifelong use of the medication. However, a subset of the responders may achieve treatment-free remission (TFR) without ongoing therapy. For those individuals who are in the advanced state of the disease, do not respond to the TKI drugs or cannot tolerate them, allogeneic hematopoietic stem cell transplantation (SCT) is an alternative therapy that can achieve long-term survival in some cases.

Background.—: Previously we have shown that, in theory, a prediction algorithm that incorporates methylation sensitive digital PCR (MSdPCR) assessments of smoking and drinking could predict mortality. But the potential impact of these findings was speculative because limitations of the generalizability and available data from the study cohort.

Objective.—: To directly demonstrate the potential financial impact of using an epigenetic mortality index to assess potential applicants based off actual MSdPCR and survival data from a nationally representative cohort.

Methods.—: Using actual MSdPCR and survival data from our recent study of the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial, we modeled the survival and financial impact of a 55-year-old male smoker at the 25th, 50th and 75th percentile of Alcohol T Score (ATS) values.

Results.—: The likelihood of survival to maturation of 20 years was 86.2%, 80.8% and 74.4%. Using a simplified financial modeling of a 20-year term policy with $500K face value, insuring a client at the 25th percentile, would result in an average of $38,749 and $85,833 more in average net revenue than insuring the individuals at the 50th and 75th percentile.

Conclusions.—: Epigenetic survival indices can make financially impactful predictions. Real life pilots of this technology in the underwriting space are in order.

Mental health disorders are harder to evaluate for life insurance because their diagnoses can be subjective. To make fair decisions, insurance medical directors use research from trusted sources to calculate risk based on survival data. This article reviews a study conducted on patients in the UK with a diagnosis of attention-deficit and hyperactivity disorder (ADHD).

In the United States, ovarian cancer is the second most common form of gynecologic cancer and the second leading cause of gynecologic cancer death. It is a heterogeneous disease with many different types and subtypes. The most common variety (70%-80%) is the high-grade serous epithelial tumor. A positive family history and/or the presence of susceptibility genes (BRCA1, BRCA2, and mismatch repair genes) increase the risk for developing the disease. Due to the lack of effective screening tools, even in those with known increased risk, most ovarian cancers are diagnosed at advanced stages. Diagnosis and accurate staging usually require tissue sampling and extensive debulking surgery performed by a surgeon who specializes in gynecologic oncology. Combination chemotherapy, before or after surgery, or as primary treatment for advanced disease is commonly needed. Mortality rates vary by stage, grade, and type of tumor. For the most common histotypes, due to the presence of advanced disease at presentation in most individuals, overall death rates remain high. Survival is better with some of the less common subtypes including sex cord stromal, germ cell and borderline epithelial ovarian tumors.

Objective.—: To compare the alcohol biomarkers phosphatidylethanol (PEth) and carbohydrate-deficient transferrin (CDT) in a convenience sample of life insurance applicants.

Background.—: PEth is a direct measure of alcohol consumption, which may have some advantages in the detection of problematic alcohol use when compared to CDT.

Methods.—: A total of 619 life insurance applicants were tested for both PEth and CDT. Linear models were constructed to assess the relationship between these two markers and other laboratory values. Classification and regression tree (CART) models were also constructed to identify clusters of individuals with high levels of either marker.

Results.—: The correlation between PEth and CDT was 0.52. PEth was positive in 23% of the sample at a threshold of 200 ng/ml, while CDT was positive in 11% at a threshold of 1.5%. CART models showed that GGT and AST were the most important predictors of PEth positivity, while HDL and AST were the most important predictors of CDT positivity.

Conclusion.—: PEth may be a more sensitive marker of alcohol intake than CDT, and may be useful as a reflex test from other laboratory values in both the clinical and life insurance setting.

Long Covid was first described in 2020. Five years later, progress in disease characterization has been considerable, and definitions continue to evolve. Several disease mechanisms are under study, and evidence for multiple endotypes is accumulating. No clinical biomarker has been identified, nor has an effective therapy been developed. Overlap with other post-infectious syndromes, particularly myalgic encephalomyelitis/chronic fatigue syndrome, is now more evident. For most individuals, symptoms of long Covid progressively disappear over time. Recurrent Covid-19 infections are now an important contributor to the pool of affected individuals. While symptoms limit activity in as many as 20%, inability to work is less common. The anticipated surge of disability claims from insured individuals has not materialized.

What is the survival of a life insurance applicant who is planning to or has previously donated a kidney? The medical director needs to assess short- and long term risk stratification in each scenario. For expectant and immediate post-donor applicants, a waiting period of 3 months is appropriate for insurability. Long-term post-donor applicants are, at best, standard risks due to the absence of renal reserve. For those with accompanying impairments such as hypertension and diabetes, which accelerate renal deterioration, adding debits to the basic rating is appropriate.

Objective.—: This article presents an analysis of mortality data in individuals with a diagnosis of adrenal insufficiency compared to a matched population from a United Kingdom database.

Background.—: Adrenal insufficiency is an easily treated disease, but if undiagnosed and/or glucocorticoid stress dosing is not appropriately implemented at times of illness, then death may occur.

Methods.—: Tabular data on patients with primary and secondary adrenal insufficiency relative to matched controls was generated using the pixel method on the all-cause mortality graph published in the Ngaosuwan et al study.

Results.—: Calculated annual mortality rates, excess death rates, and interval mortality rates were higher for both primary and secondary adrenal insufficiency compared to matched controls. And the increased mortality risk appeared to be greater in those with primary adrenal insufficiency compared to those with secondary adrenal insufficiency.

Conclusion.—: Those with primary and secondary adrenal insufficiency have increased mortality compared to their matched cohort, especially in the early years after their diagnosis.