cardiovascular disease and older age underwriting
DESCRIPTION
Cardiovascular disease and Older Age Underwriting. Mike Fulks, M.D. and Robert L. Stout, Ph.D. Life’s tough; you work hard. If you are lucky, you get old and you die. Dr. Bob. Changes in our view of cardiovascular disease. - PowerPoint PPT PresentationTRANSCRIPT
Cardiovascular disease and Older Age Underwriting
Mike Fulks, M.D. and Robert L. Stout, Ph.D.
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Life’s tough; you work hard.
If you are lucky, you get old and you die.
Dr. Bob
Changes in our view of cardiovascular disease
• Cholesterol and obstructive disease.• Soft vulnerable vs stable calcified? plaque.• Networks of inflammation, Senescence
and chronic illness.• Genetic regulation of CVD risk.
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normal senescent
youthadaptablity
cytokineschemokines
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• Immune surveillance• Detect• Remove
• Remodel
youth
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What makes older ageunderwriting different?• Initial (first year) underwriting impact on
mortality is much greater at older age– 81% reduction in (select) risk at age 72– 63% reduction in (select) risk at age 32
• BUT Ultimate (at 16 years) impact is much smaller at older age– 19% mortality reduction at age 72– 35% mortality reduction at age 32
1975-80 Select and Ultimate male tables,
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Why so different?
• The young have risk factors for future disease rather than current and more behavioral risk leading to traumatic death
• The older ages already have current diseases that need detection and much more limited risk of traumatic death.
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Prevalence of diseaseby age
20-39 40-59 60-69 70>0.000
0.050
0.100
0.150
0.200
0.250
0.300
0.350
0.400
0.450
0.500
Self-reported disease
heart disease
high bp
diabetes
PR
EV
AL
EN
CE
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What age is “old“?
• Based on current industry Select and Ultimate data, that transition is around age 60
• Based on CRL research on laboratory studies, BP and build mortality we come to the same conclusion- age 60
• If you are going to have a different approach is terms of testing or handling based on age- do it at age 60, not age 65 or 70!
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Major Mortal diseases of old age.• Vascular and Renal disease
– Heart, especially early heart failure (not presence of CAD)
– Stroke, including unrecognized events accounting for a portion of dementia
• Cancer, pre-diagnosis– Now as common a cause of mortality as Heart
• Cognitive impairment and Dementia– Non-vascular and Vascular
• Frailty
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CRL research
• 10’s of millions of applicant records including all laboratory studies
– Duration of follow-up to 15 years– Include BP and Ht/Wt for past 9 years
• Able to link those records with the Social Security Death Master File to obtain all-cause mortality
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CRL results
• Generated an ongoing series of articles in JIM and OTR as well as other reports on the actual impact of test results on mortality in an age- and sex-specific manner
• These results supplemented by other recent published works from clinical and general population studies
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Specific Findings - Cardiovascular
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Cholesterol/HDL mortality
Excess Risk as a % relative to middle 50% band of values
Chol/HDLFemales
<60Males
<60Female
60+Male
60+
2.1-2.5 - - - +25
3.1-4.6 - - - -
4.7-5.2 +50 - - -
5.3-5.8 +50 - - -
6.5-7 +100 +25 +25 -
>9 +150 +75 +50 +25
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Cholesterol HDL ratio
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Blood Pressure
Systolic BP is a potent predictor of cardiovascular and cerebro-vascular risk
SYSTOLIC BP
< 130 130 - 134 135 - 139 140 - 149 150+
F 20-59 -25 0 50 100 200
M 20-59 -25 0 50 75 100
All 60+ -25 0 25 75 100
Excess mortality based on insurance exam BP’s
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NT-ProBNP
1-100 (ref)
101-200
201-300
301-1000
1001+
100%
300%
500%
700%
900%
1100%
1300%
1500%
1700%
1900%
Age 60-69
NT-ProBNP
Mo
rtal
ity
Rat
io
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Specific Findings - Kidney• Value of creatinine, eGFR and cystatin C
– Cystain C is good reflex marker when serum creatinine is high.
– Must stratify eGFR, creatinine and cystatin C by age as eGFR falls normally the other two increase with aging
– When age and proteinuria are properly accounted for, eGFR minimally predictive except at very low values.• Those eGFR values are in the 40s for 70+
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Proteinuria
• Mild proteinuria has 50% increase in CV disease and mortality, while heavy has >100% increase.
• In contrast, eGFR from >60 ml/min compared to <50 ml/min had minimal impact (Hemmelgarn BR. JAMA 2010;303:423-429.)
• CRL research also shows proteinuria as measured by the protein/creatinine ratio is a potent risk predictor at much lower levels than previously recognized
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Proteinuria contd.
<= 0.10 0.11 - 0.20 0.21 - 1.00 1.01+50%
100%
150%
200%
250%
300%
350%
Mortality excluding diabetes and low eGFR, age 60+
Protein/Creatinine Ratio gram/gram
Mo
rta
lity
Ra
tio
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Specific Findings - Cancer
• PSA?
• CEA
• Age and sex-specific evaluation of a wide range of tests including LFTs, cholesterol, albumin, etc
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PSA for Age 60-69
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PSA for Age 80>
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Prevalence of PSA in the insurance population
PSA LEVEL
<4.0 4-9.9 10-20 >20
50-59 97.5 2.2 0.21 0.05
60-69 92.3 6.8 0.73 0.15
70-79 86.2 11.8 1.55 0.38
80> 82.0 14.3 2.63 1.00
The USPSTF draft statement says: “This recommendation applies to men in the U.S. population that do not have symptoms that are highly suspicious for prostate cancer, regardless of age, race, or family history.”
U.S. Preventive Services Task Force October 2011
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CEA for Older Age
• How predictive ages 60+ for NS– CEA 5 to 9.9 rel. risk = 200 to 250%– CEA 10+ = 550 to 1000%
• How Common age 60-69 for NS– CEA 5 to 9.9 = 3%– CEA 10+ = 0.5%
• How much risk avoided if take action at 10?– Eliminate 3.2% of early deaths but only 0.4% of applicants
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Specific Findings - Dementia
• Alzheimer’s disease is responsible for over half of dementia but ischemic disease affects 60-90% of those with Alzheimer’s with major infarctions present in 1/3 (Querfurth HW, NEJM 2010;362:329)
• DM and BP associated with AD risk, the rest less certain (Duron E. Vasc Health Risk Manag 2008;4:363)
• Vascular dementia accounts for a significant minority of dementia cases. However, lab testing likely only provides limited value here.
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Specific Findings – Frailty and unrecognized conditions
• Albumin
• Total Cholesterol
• Combination of other labs and measurements
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Albumin and mortality
Lower albumin
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T. Cholesterol and Mortality
<133
133
145
155
167
187
100%
110%
120%
130%
140%
150%
160%
170%
180%
Mortality Ratio for males age 60+
Cholesterol level from lowest to average
Mo
rta
lity
ra
tio
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A surprise: Age, Alcohol & Mortality
0
50
100
150
200
250
20-29 30-39 40-49 50-59 60-69
DE
AT
HS
DECADE AGE
DEATHS/1000 APPLICANTS
0-10
10.1-50
50.1-100
>100
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Can testing identify an older age preferred risk?
• “Yes”, as we will show on the next slide.• Need to use all lab, BP and build as well
as including any special testing (NT-ProBNP, Hemoglobin)– No magic single test– Age and sex-specific use of lab based on
actual mortality, not “normal” ranges
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<=-40
-39 to -20
-19 to 0
1 to 40
41 to 100
101 to 125
126 to 150
151 to 175
176 to 250
>250
0%
50%
100%
150%
200%
250%
300%
350%
CRL Applicants Tested 1993 to 2005, Followed to 2010
M 20 to 39M 40 to 49M 50 to 59M 60 to 69M 70 to 79M 80 to 89
Mo
rta
lity
Ra
tio
CRL Scoring
Preferred
Standard Substd
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Summary• Older age begins at 60
• Lab panel can predict older age risk but must be used with age-specific risk-based ranges
• Some additional testing such as NT-ProBNP improves risk discrimination
• Using a combined scoring approach most successful especially for preferred risks
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