Anorexia nervosa: a 63-year population-based survival study

As eating disorders attract increasing publicity, more affected individuals will seek medical attention. Many will have needs for life insurance. Due to selection bias, most of the literature on anorexia nervosa (AN) presents an unfavorable prognosis. Therefore, the impairment is considered an adverse life insurance risk. This review is from an unselected, community population. The demographics of the study population and its expected mortality are similar to a population purchasing life insurance products. Comparative experience over 63 years of follow-up reveals mortality ratios and excess death rates similar to those expected for the population. High-risk comorbid diagnoses of depression and alcoholism are discussed.     

More long-term care for better healthcare and vice versa: investigating the mortality effects of interactions between these public sectors

Public healthcare (HC) and long-term care (LTC) sectors coexist in several OECD countries. Economic interactions between these two sectors have been found to occur even in the absence of formal integrated care arrangements. We investigate whether and how interactions between the HC and LTC sectors impact mortality. We analyse data on English local authorities in 2014–15 and employ a sequence of cross-sectional econometric specifications based on instrumental variables to identify the effect that LTC expenditure has on mortality through its interactions with HC services, and vice versa. Our findings suggest that any effect of LTC expenditure on mortality is likely to run through the HC sector by allowing the latter to reallocate resources from less to more effective services. A 10 per cent increase in LTC expenditure per user can indirectly save, on average, about three lives per million individuals. In addition, on top of the known HC direct mortality effects, we find that investing an extra £42 million in the HC sector – equivalent to a 10 per cent increase in HC expenditure per capita for the average local authority – can decrease the use of LTC services, producing around £7.8 million of savings. These can generate mortality effects if invested in services having an impact on mortality.     

Comparison of mortality outcomes derived from survival curves calculated by the mean covariates and corrected group prognosis methods

As creators of mortality abstracts, we assume the mortality and survival curves from source articles have been created by the appropriate methodology. Two methods can be used to generate adjusted curves--the mean of covariates and the group prognosis methods. The use of the former, although simple to implement, may be mathematically problematic. A comparative mortality analysis is created from a study population using curves adjusted by both methods. For this cohort, utilizing data from direct measurement of enlarged survival curves produced no difference in mortality outcomes. Small differences in percent cumulative survival derived from each method do not translate into important differences in mortality ratios and excess deaths.     

Evaluation of survival in medically treated patients with homozygous beta thalassemia by the quick hit method

Articles published in medical journals often evaluate the survival and/or prognosis of a medical impairment. The conclusions of these articles can be very misleading if correct mortality methodology is not utilized. Authors evaluating survival in a cohort of individuals with Thalassemia Major concluded the prognosis was excellent. This was based solely on observed mortality. When the cohort is properly compared to the expected mortality of a similar nonimpaired population the result is quite different. Their survival is far from excellent. This article uses the quick hit method to evaluate the survival of this cohort having Thalassemia Major.     

Two-dimensional Hazard Estimation for Longevity Analysis

We investigate developments in Danish mortality based on data from 1974–1998 working in a two-dimensional model with chronological time and age as the two dimensions. The analyses are done with non-parametric kernel hazard estimation techniques. The only assumption is that the mortality surface is smooth. Cross-validation is applied for optimal bandwidth selection to ensure the proper amount of smoothing to help distinguishing between random and systematic variation in data. A bootstrap technique is used for construction of pointwise confidence bounds. We study the mortality profiles by slicing up the two-dimensional mortality surface. Furthermore we look at aggregated synthetic population metrics as ‘population life expectancy’ and ‘population survival probability’. For Danish women these metrics indicate decreasing mortality with respect to chronological time. The metrics can not directly be used for prediction purposes. However, we suggest that life insurance companies use the estimation technique and the cross-validation for bandwidth selection when analyzing their portfolio mortality. The non-parametric approach may give valuable information prior to developing more sophisticated prediction models for analysis of economic implications arising from mortality changes.     

Marfan syndrome: literature review of mortality studies

Marfan syndrome is an autosomal dominant heritable disorder of fibrous connective tissue due to mutation in the fibrillin-1 gene, located on chromosome 15. Early mortality from Marfan syndrome results from aortic dilatation. The medical literature contains long-term follow-up series of patients with Marfan syndrome accrued at major medical centers that address overall survival following surgical intervention, and prognosis in relation to certain risk factors such as family history and aortic root diameter. Mortality analyses based on these data are presented in this paper. Advances in surgical and medical therapy have improved mortality of affected individuals over the past 2-3 decades. However, significant mortality occurs, peaking in the third and fourth decades of life. Although surgery is successful treatment of aortic dissection, one cannot conclude that surgical repair confers a mortality advantage. Emergency surgery and history of aortic complications in first-degree relatives are associated with a higher mortality. Chronic beta-blocker therapy may slow the rate of aortic dilatation and may be associated with more favorable prognosis. Clinical research evaluating beta-blockade, echo assessment of the aortic root diameter progression, and gene mutation analysis may provide tools useful for future morality assessments.     

Screening potential elderly preferred markers: exploratory analysis of Cardiovascular Health Study (CHS) data

The Cardiovascular Health Study (CHS) analyzes risk factors for coronary heart disease and stroke in people age 65 and older. Since CHS is designed to comprehensively study cardiovascular risk factors in an elderly population, it provides a unique opportunity to study the association of risk factors with mortality, as well as morbidity risk. With the growth of the elderly as population and life insurance market segments, the need to more precisely stratify mortality within a standard risk group of the elderly has grown as well. This exploratory analysis assesses medical factors that could be used to improve mortality risk stratification within a "standard" mortality population, using the CHS public use data set. Participants with a personal history of cardiovascular disease, diabetes, or major electrocardiographic abnormalities were excluded from the analysis in order to mimic a standard life insurance selection process. Then, Cox proportional hazards regression was used to study 10 medical risk factors. This model suggested that forced vital capacity >80% predicted, serum creatinine <1.5 mg/dL (133 mcmol/L), hemoglobin >11 g/dL (110 g/L), and serum albumin >3.5 mg/L (35 mmol/ L) are significantly associated (p = 0.05) with favorable mortality. C-reactive protein <1 mg/L is associated with favorable mortality at borderline significance levels (p = 0.09). On the other hand, a family history of cardiovascular disease (MI and/or stroke) and low BMI (<26 kg/m2) are associated with unfavorable mortality in the analysis. Total to HDL cholesterol ratio of <6, presence of supine systolic blood pressure < or = 140 mmHg, and the presence of minor rest electrocardiographic findings were not statistically significant factors in the multivariate model. Further assessment of the predictive value of the "significant" medical factors identified is required in insured lives.     

Converting Clinical Literature to an Insured Population: A Comparison of Models Using Nhanes

Abstract

The use of clinical literature to set risk classification standards for life insurance underwriting stems from the need to set the most accurate standards using the best available information. A necessary hurdle in this process is converting any excess mortality observed in a clinical study to the appropriate rating for use in underwriting. A widely accepted model in the insurance industry, the Excess Death Rate model, treats the excess as additive to the conditional probability of death for an insurance company’s unimpaired class.

In this paper we test the validity of that model versus other common predictive models of excess mortality in an insured population. Applying these models to National Health and Nutrition Examination Survey (NHANES) data, we derive estimates for excess mortality from three commonly seen underwriting impairments in what could be considered a clinical population. These estimates are added to an estimate of an insurance company’s unimpaired mortality class and then used to predict deaths in an “insurable” subset of that clinical population.

The Excess Death Rate model performed the best of all models, having the smallest cumulative difference of actual to predicted deaths. The use of publicly available data, such as that in NHANES, could help bridge the gap between clinical literature and its application in insurance underwriting if insurable cohorts can be reliably identified from these generally healthy, ambulatory groups.     

A Bayesian non-parametric model for small population mortality

This paper proposes a Bayesian non-parametric mortality model for a small population, when a benchmark mortality table is also available and serves as part of the prior information. In particular, we extend the Poisson-gamma model of Hardy and Panjer to incorporate correlated and age-specific mortality coefficients. These coefficients, which measure the difference in mortality levels between the small and the benchmark population, follow an age-indexed autoregressive gamma process, and can be stochastically extrapolated to ages where the small population has no historical exposure. Our model substantially improves the computation efficiency of existing two-population Bayesian mortality models by allowing for closed form posterior mean and variance of the future number of deaths, and an efficient sampling algorithm for the entire posterior distribution. We illustrate the proposed model with a life insurance portfolio from a French insurance company.     

Lost Generations: Long-Term Effects of the COVID-19 Crisis on Job Losers and Labour Market Entrants,and Options for Policy*

This paper discusses the potential long-run effects of large-scale unemployment during the COVID-19 crisis in the labour market on vulnerable job losers and labour market entrants in the United States. The paper begins by contrasting measures of the scale of job loss during the crisis. These measures are paired with estimates from past recessions indicating that the costs of job loss and unemployment can reduce workers’ earnings and raise their mortality for several decades. Focusing only on a subset of vulnerable job losers, the potential lifetime earnings losses from job loss related to the COVID-19 pandemic are predicted to be up to $2 trillion. Related losses in employment could imply a lasting reduction in the overall employment–population ratio. For these workers, losses in potential life years could be up to 24 million. Even at the low range, the resulting estimates are substantially larger than losses in potential life years from deaths directly due to COVID-19. New labour market entrants are at risk to suffer long-term losses in earnings and mortality as well. Based partly on experiences in other countries, the paper discusses potential reforms to short-time compensation programmes and unemployment insurance, which could help limit the short- and long-term harm from layoffs going forward.     

Stroke--incidence, mortality, morbidity and risk

In the United States, 700,000 strokes, responsible for 165,000 deaths, occur each year. Worldwide, stroke is the 2nd leading cause of death. Stroke is a major health problem; and as the population ages, its significance will grow. This paper reviews the epidemiology of stroke, the identification of modifiable risk factors, and some of the options for intervention that can reduce stroke-related mortality and morbidity. Though the diagnosis and care of stroke patients has improved, mortality resultant from stroke remains significant, with only 50% 5-year survival in some clinical studies. The risk of stroke following a transient ischemic attack (TIA) or initial stroke is also significant-approximately 30% following either event. Stroke severity at onset and patient age are the most important factors for predicting prognosis. Stroke prevention focuses on management of the traditional cardiovascular risk factors especially control of blood pressure and smoking cessation. The role of diabetes and lipid control in stroke prevention continues to be studied. The optimum use of anticoagulation to reduce stroke risk has been explored by the Stroke in Patients with Atrial Fibrillation (SPAF) studies. Carotid endarterectomy is effective in stroke prevention for those with symptomatic carotid obstruction of 70%, but its role in other scenarios is less certain. Antiplatelet drugs continue to be an important therapy for the prevention of recurrent stroke. Centralized stroke centers that specialize in stroke diagnosis and care along with rapidly rendering appropriate treatment can improve mortality and morbidity of stroke by 20%.     

Summary of Results of Survey of Seminar Attendees

Abstract

The Society of Actuaries undertook a three-phase research project on mortality improvement in the three NAFTA countries: Canada, Mexico, and the U.S. Phase 1 consisted of a literature review of papers on projecting mortality levels in the future and a study of the trend in mortality improvement during this century. Phase 2 consisted of a discussion of different facets of modeling mortality rates at a seminar attended by 79 experts (actuaries, demographers, economists, and medical researchers) representing different countries. The last session of the seminar consisted of the completion of a survey by the attendees to obtain input for Phase 3, which would analyze the impact of mortality improvement on the social security system of each country. This paper summarizes the results of the survey.

The survey results illustrate the difficulty in forecasting mortality levels, because the effects of many factors that could have significant impact on mortality rates are unknown. This suggests the need for dynamic forecasting, which allows for the possibility of random shocks. A majority of the survey respondents believe that stochastic forecasting models, despite their complexity, have significant potential to add value. Respondents also believe that both historical data and cause-specific mortality forecasts are useful as input and also in validating forecasts of the aggregate levels of mortality. The challenge is to develop more sophisticated forecasting models to produce results that are relatively easy to interpret and to communicate these results to the desired audiences, including the public and policymakers.

The survey results suggest that the aggregate effect of lifestyle changes, medical advances, diseases, catastrophe, and physical environmental changes is an increase in life span. However, there is much uncertainty about the future. Respondents expect that beyond the year 2020 the mean annual rate of reduction in mortality for males age 65 and over will average about 0.58% for Canada, 0.76% for Mexico, and 0.67% for the U.S. The results for the female age 65 and over population are 0.64%, 0.83%, and 0.70%, respectively. The age 65 and over population is expected to see larger percentage reductions in mortality than the 0–14 and 15–64 populations. The reductions in male and female mortality will be ultimately the same, and the mortality levels in the three countries will ultimately converge, although differences may persist for decades.     

Analysis of hydrocarbon leaks and verification as an operational barrier

Prevention of hydrocarbon (HC) leaks is important; they are the most critical precursor events that may lead to major accidents, such as the Piper Alpha catastrophe in 1988. The number of HC leaks on offshore production installations on the Norwegian Continental Shelf peaked just after year 2000, with more than 40 leaks per year with initial rate above 0.1?kg/s. The Norwegian Oil and Gas Association carried out a reduction project from 2003 until 2007, which resulted in 10 HC leaks above 0.1?kg/s in 2007. The number of leaks increased in the years after 2007 and was on average 15 in the period 2008–2010, without any significant increase in the number of installations. A new initiative was launched early in 2011 in order to reduce the number of HC leaks further. A study performed by the project concludes that more than 50% of the leaks are associated with failure of operational barriers during manual intervention into the process systems. Human and organisational factors are dominating with respect to circumstances and root causes. The study has further demonstrated the high importance of verification as an operational barrier and has shown that many of the failures do not have multiple operational barriers in the form of several verifications and a leak test at the end. This finding is crucial in order to understand the criticality of performing the planned verifications, perform them in an independent manner according to the procedures and make sure that the focus is on detecting failures during the verification. This paper presents the analysis of HC leaks, with emphasis on operational barriers and importance of verification.     

Choice of measurement basis and discretionary valuation of real estate: Evidence from Dutch Social Housing Associations

In this study, I examine choice of measurement basis and managerial discretion in accounting for real estate, where I compare measurement on the basis of discounted cash flow (DCF) with measurement based on historical cost (HC). I exploit unique data in the setting of social housing associations (SHAs) in the Netherlands, using data from a supervisory agency which makes an independent assessment of the value of real estate based on comparable assumptions across all SHAs, allowing for a comparison with reported carrying amounts. In line with prior literature, I find that leverage is positively associated with using DCF as measurement basis. In addition, I find evidence that both in case of DCF and HC measurement, carrying amounts increase with leverage, suggesting opportunistic use of managerial discretion in measuring assets. While the degree of opportunism does not differ on average, I find that opportunistic measurement increases as entities switch from HC to DCF measurement. Finally, detailed data on the supervisor’s adjustments allow to investigate the assumptions SHAs use to adjust reported DCF carrying amounts. SHAs mostly use the timing of cash flows, the expected sales revenue, parameters such as inflation and the expected rent increases, and the assumed lifespan of real estate.     

Mortality outcome of surgically treated atrial septal defects

Comparative mortality in this abstract shows that surgical repair of an atrial septal defect (ASD) confers a survival advantage beyond that expected for the study population. Determinates of expected mortality and mean q' include the table selected, zero-time age and annual age, and sex distribution of the cohort. Each has an independent effect on mortality ratios and excess death rates. Confounding variables such as participant selection within the study cohort affect the outcome. Despite the multiple, methodologic variables in this abstract, individuals having surgical repair of an ASD appear to have low mortality.     

Pricing implications of trends in population mortality and underwriting effectiveness

Pricing actuaries try to anticipate insured lives mortality rates for decades into the future by considering historic relationships between population and insured lives mortality and trends in population mortality. The degree to which underwriting might decrease insured lives mortality relative to population mortality is of particular importance. A comparison of trends in population and insured mortality is presented to illustrate historic relationships. Two theories for future life expectancy trends are: 1) no foreseeable limit to life expectancy, and 2) life expectancy limited by biological forces. Factors that may increase or decrease the future effectiveness of underwriting are reviewed.     

Mortality among Swedish insured

In this paper, the mortality among the Swedish voluntarily insured is described. It is based on calculations of the mortality among the Swedish insured from 2001 to 2005, and in the total Swedish population. The total population data has been used to compute the mortality trend with the Lee–Carter model.     

Minimum Death Rates and Maximum Life Expectancy: The Role of Concordant Ages

Only five populations have achieved maximum life expectancy (or best practice population) more than occasionally since 1900. The aim of this article is to understand how maximum life expectancy is achieved in the context of mortality transition. We explore this aim using the concepts of potential life expectancy, based on minimum rates at each age among all high longevity populations, and concordant ages. Concordant ages are defined as ages at which the minimum death rate occurs in the population with the maximum life expectancy. The results show the extent to which maximum life expectancy could increase through the realization of demonstrably achievable minimum rates. Concordant ages are concentrated at increasingly older ages over time, but they have produced more than half of the change in maximum life expectancy in almost all periods since 1900. This finding is attributed to their quantity and position whereby concordant ages are concentrated at the ages that have the greatest impact on mortality decline in a particular period. Based on mortality forecasts, we expect that concordant ages will continue to lead increases in female maximum life expectancy, but that they will play a weaker role in male maximum life expectancy.     

“Economic Capital Allocation Derived from Risk Measures”, Eddy Van den Borre,January 2003

Abstract

The sustained reduction in mortality rates and its systematic underestimation has been attracting the significant interest of researchers in recent times because of its potential impact on population size and structure, social security systems, and (from an actuarial perspective) the life insurance and pensions industry worldwide. Despite the number of papers published in recent years, a comprehensive review has not yet been developed.

This paper attempts to be the starting point for that review, highlighting the importance of recently published research—most of the references cited span the last 10 years—and covering the main methodologies that have been applied to the projection of mortality rates in the United Kingdom and the United States. A comparative review of techniques used in official population projections, actuarial applications, and the most influential scientific approaches is provided. In the course of the review an attempt is made to identify common themes and similarities in methods and results.

In both official projections and actuarial applications there is some evidence of systematic overestimation of mortality rates. Models developed by academic researchers seem to reveal a trade-off between the plausibility of the projected age pattern and the ease of measuring the uncertainty involved. The Lee-Carter model is one approach that appears to solve this apparent dilemma.

There is a broad consensus across the resulting projections: (1) an approximately log-linear relationship between mortality rates and time, (2) decreasing improvements according to age, and (3) an increasing trend in the relative rate of mortality change over age. In addition, evidence suggests that excessive reliance on expert opinion—present to some extent in all methods—has led to systematic underestimation of mortality improvements.     

Reference mortality K2004 of personal life insurance policies in Finland

This article presents the reference mortality model K2004 approved by the Actuarial Society of Finland and the technique that was implemented in developing it. Initially, I will present the historical development of individual mortality rates in Finland. Then, the requirements posed for a modern mortality modelling will be presented. Reference mortality model K2004 is based on total population mortality rates, which were adjusted to correspond with that portion of the population that has a life insurance policy. First, the model presents a margin of the observed life insurance mortality rate in the total population with a Lee-Carter method together with a forecast, where the downward trend in mortality rates is expected to continue at the rate illustrated since the 1960s. Then, the mortality rate has been adjusted into life insurance mortality per age so that it corresponds to the differences observed between total population and the portion of population that has a life insurance during 1991–2001. Finally, a cohort and gender-specific functional margin will be presented to obtained data.