Superior vena cava syndrome

Approximately 15,000 cases of superior vena cava (SVC) obstruction are diagnosed in the United States annually. Malignancies (primarily lung cancer) are the underlying cause of 80-85% of cases, leaving 15-20% caused by various benign conditions, including sclerosing mediastinitis (the diagnosis in our case). Thrombolytic therapy and major advances in vascular techniques in recent years have improved the outcome and lessened the morbidity of SVC obstruction. However, even though a benign condition, sclerosing mediastitinis is a dynamic, ongoing fibrotic condition that seldom can be totally removed surgically. It frequently causes recurrent episodes of SVC obstruction, requiring further repetitive vascular procedures that can result in major morbidity and even mortality.     

Gene-environment interactions and the complexity of human genetic diseases

In the assessment of mortality and morbidity risk, the ability of family history and genetic test results to predict the age of occurrence, severity, and long-term prognosis of 'genetic' diseases is important. An increasing number of gene-gene and gene-environment interactions have been demonstrated in a number of monogenic Mendelian diseases. These interactions can significantly modify the clinical presentation (disease phenotype) of diseases previously regarded purely as 'genetic.' As a result, 'genetic' diseases can be positioned in a continuum between classic Mendelian and complex disease where the extremes, pure genetic or solely non-genetic, do not exist. The position of any given disease in this continuum is defined by three components: the major gene(s) contributing to the phenotype, the variability added by modifier genes and the significance of environmental factors influencing the phenotype. As the predictive value of genetic test results can be significantly influenced by additional genetic and environmental risk factors, a better understanding of these factors may influence the quantification of mortality and morbidity risk.     

Sarcoidosis: a review

Sarcoidosis is a systemic inflammatory disorder characterized by non-caseating granulomas found in the lung, lymphatic systems, and potentially in a host of other tissues and organs. Despite intriguing hints of infectious or environmental etiology, causation remains a mystery. The diagnosis, therefore, requires demonstration of granulomatous inflammation in more than one organ and exclusion of any of the known causes of granulomatous disease or local sarcoid reaction. Clinicians and underwriters alike frequently forget the latter requirement. For this reason, the other causes of granulomatous inflammation will be included in this treatise. Although the vast majority of applicants with sarcoidosis exhibit limited or remitting disease, the remaining applicants represent increased risk of both morbidity and mortality. This paper reviews the relevant clinical, radiographic, and laboratory findings that may help identify those applicants with increased or prohibitive risk for life or disability insurance.     

Coronary heart disease and life insurance

Coronary heart disease morbidity and mortality are dynamic issues. Outcomes from medical and surgical treatments are having dramatic effects. For the life insurer it is vital to follow closely the changing history of the disease.     

Ankle/arm blood pressure index: an insurance perspective

Recent studies conclude that the ankle/arm blood pressure index (AAI) is a useful clinical tool for refining cardiovascular risk classification in the elderly. A reduction in the AAI to 0.9 or less is associated with increased risk for both coronary heart disease and total cardiovascular disease morbidity and mortality, as well as all-cause mortality. This relationship persists after adjusting for traditional risk factors and known cardiovascular disease. AAI will appear more common in attending physician's statements, prompting a need to educate underwriters about this technology. AAI may be of particular interest to insurers dealing in the elderly market, to those with strong physician examiner systems, and in markets where blood or urine tests are not commonly used in underwriting.     

Compression of Morbidity and Mortality: New Perspectives

Compression of morbidity is a reduction over time in the total lifetime days of chronic disability, reflecting a balance between (1) morbidity incidence rates and (2) case-continuance rates, generated by case-fatality and case-recovery rates. Chronic disability includes limitations in activities of daily living and cognitive impairment, which can be covered by long-term-care insurance. Morbidity improvement can lead to a compression of morbidity if the reductions in age-specific prevalence rates are sufficiently large to overcome the increases in lifetime disability due to concurrent mortality improvements and progressively higher disability prevalence rates with increasing age. Compression of mortality is a reduction over time in the variance of age at death. Such reductions are generally accompanied by increases in the mean age at death; otherwise, for the variances to decrease, the death rates above the mean age at death would need to increase, and this has rarely been the case. Mortality improvement is a reduction over time in the age-specific death rates and a corresponding increase in the cumulative survival probabilities and age-specific residual life expectancies. Mortality improvement does not necessarily imply concurrent compression of mortality. This article reviews these concepts, describes how they are related, shows how they apply to changes in mortality over the past century and to changes in morbidity over the past 30 years, and discusses their implications for future changes in the United States. The major findings of the empirical analyses are the substantial slowdowns in the degree of mortality compression over the past half century and the unexpectedly large degree of morbidity compression that occurred over the morbidity/disability study period 1984–2004; evidence from other published sources suggests that morbidity compression may be continuing.     

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.     

Chronic eosinophilic pneumonia

Chronic eosinophilic pneumonia is one form of eosinophilic lung disease that includes both idiopathic and known etiological cases. Chronic eosinophilic pneumonia has a characteristic clinical picture, along with a characteristic pattern on CT imaging. It is readily treatable with oral steroids, and although response is prompt with excellent resolution of the symptoms, chronic steroids are often necessary. The mortality from this disease is negligible.     

Population-based mortality outcome of rheumatoid arthritis in females

Rheumatoid arthritis (RA) is a systemic disease whose morbidity exceeds its mortality. This abstract quantifies the mortality of RA in a general population over a 30-year period in females. The generic, across the spectrum of disease, mortality ratio is 136%; the excess death rate is 12. The mortality impact on males is minimal; the source publication noted a mortality ratio of 107%. Many selected cases of RA can be underwritten very favorably. PURPOSE: To quantify the excess mortality in females diagnosed with rheumatoid arthritis (RA) between 1955 to 1985. SUBJECTS AND METHODS: Medical records of all residents age 35 and over of Rochester, Minnesota, who met the American College of Rheumatology 1987 diagnostic criteria for RA were reviewed. Based on the comprehensive statistical base for residents in Rochester, virtually complete ascertainment of all clinically recognized cases of RA were identified. An incidence cohort identifying the same residents with new cases of RA occurring between January 1, 1955, and January 1, 1985, was created. Three, 10-year prevalence cohorts were assembled as of July 1, 1965, 1975 and 1985. Patients in each cohort were followed longitudinally until death or migration from Rochester. Data of disease characteristics, course, co-morbidity and death were collected. During the follow-up period, 6.9% moved out of the county, and 5.1% moved into the county after the diagnosis of RA had been made elsewhere. Expected survival was based on age and sex adjusted survival from the same community in the same time period. Mortality was described using the Kaplan-Meier product-limit method. Cox proportional hazards modeling was used to examine the effects of age, sex and rheumatoid factor on survival. DATA: In the 1965, 1975 and 1985 prevalence cohorts, there were 163, 235 and 272 cases of RA, respectively. Some individuals were present in more than one. Deaths in each cohort were 54, 93 and 111, respectively. Median follow-up was 12.7 years for the entire group with the earlier groups being longer. Mean follow-up was 15.1 years. Seventy-three percent of patients were females. The average age at diagnosis was 60.2 years.     

Underwriting lethal genetic diseases

There are thousands of single gene deposits that cause increased morbidity or mortality risks. Few have complete penetrance leading to certain death. Most can be underwritten with affordable increases in premium; many at standard rates. As we learn more about penetrance for specific mutations we can learn to be more aggressive in underwriting inherited risks. I have described approaches to underwriting untested applicants to Huntington disease, and tested applicants who carry dominant mutations leading to breast, ovarian and colon cancer.     

Metabolic syndrome

This paper reviews current diagnostic criteria for Metabolic Syndrome, and provides in-depth discussion of the component abnormalities. A cluster of abnormalities defines Metabolic Syndrome including insulin resistance, hypertension, obesity, hypertriglyceridemia, and low HDL cholesterol. Evidence that inflammation is another component of Metabolic Syndrome raises the possibility that this is an additional process that links Metabolic Syndrome to cardiovascular disease (CVD) risk. Population studies strongly suggest the existence of a relationship between the metabolic abnormalities associated with Metabolic Syndrome and the development of diabetes and cardiovascular disease. It appears that lifestyle modifications can contribute to the prevention of progression to diabetes and the reduction of individual CVD risk factors. Whether use of insulin sensitizing drugs can significantly delay or prevent the progression to diabetes is under investigation. Because of its contribution to the growing prevalence of type 2 diabetes, and the associated increased CVD risk, the recognition of Metabolic Syndrome and its consequences are critical in the course of morbidity and mortality risk assessment.     

Radical prostatectomy versus watchful waiting in early prostate cancer

Prostate cancer continues to be a significant factor in morbidity and mortality. Due to high prevalence (most common cancer in U.S. males) and mortality (second most common cause of cancer deaths in males), prostate cancer is one of the most crucial health problems in men. The discussion of managing early prostate cancer is not only common, but also complicated. Treatment decisions involve scant survival data and quality of life issues such as impotence and urinary incontinence. Watchful waiting has also had to fight the paradigm of surgery curing cancer.     

Effect of increasing body weight on morbidity and mortality in South Korea

The number of overweight and obese people in South Korea is increasing due to changes in exercise and dietary habits. The World Health Organization estimated that 45% of Korean men and 54% of women were overweight in 2005, and the percentages are expected to increase to 66% and 67%, respectively, by 2015. Studies have also found that more than 10% of Korean children and adolescents are now obese. These trends are important from both a public health and an insurance perspective because weight gain increases the likelihood of diabetes, cardiovascular disease, cancer, and other disorders that affect morbidity and mortality.     

Mortality in rheumatoid disease

This paper provides an overview of rheumatoid disease from the perspective of its impact on mortality. The term, rheumatoid arthritis, may promote the misconception that this disease is relatively trivial and easily managed; therefore, "rheumatoid disease" is preferred. Numerous long-term studies in many settings have established that significant excess mortality is associated with rheumatoid disease, and that this excess mortality is related to cardiovascular disease deaths. Inflammation in rheumatoid and cardiovascular diseases shares the same biologic mechanisms. Severity of extraarticular disease, decline in functional level, and level of inflammatory activity are associated with increased risk of mortality. Detection and measurement of novel inflammatory biomarkers may provide tools to assess prognosis and to monitor therapy. Close attention to the management of traditional cardiovascular risk factors is essential in these patients. Whether disease modifying antirheumatic drug (DMARD) therapy will reduce all-cause and cardiovascular disease mortality in rheumatoid disease is the subject of ongoing studies.     

Particulate matter air pollution control programs in Japan — an analysis of health risks in the absence of future remediation

The objective of this case study was to assess potential health risks and productivity loss in the absence of future additional environmental control of particulate matter (PM) in Japan. Assuming a 10% decline in PM, the estimates of the numbers of possible cases of premature mortality and morbidity that could be prevented in the year 2010 were (1) 8700 long term deaths, (2) 12,000 cases of chronic bronchitis, (3) 24,000 cases of cardiovascular disease, (4) 10,000 cases of pneumonia, (5) 18,000 asthma attacks, and (6) 12,000 cases of acute bronchitis during a one year period. The best estimate of medical costs plus lost productivity in adults and children was $56 billion USD. When compared to a separately derived estimate of $31 billion USD in avoided pollution control costs, the health risk to no‐control benefit ratio of 1.8 suggests that additional future pollution control policies would successfully prevent a large expense to the society in medical care and lost productivity while imposing a lesser cost to the private sector in control equipment, to government in oversight expenses and to society in opportunity costs.     

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%.     

The Metabolic Syndrome and All-Cause Mortality in an Insured Lives Population

Abstract

Metabolic syndrome and its association with mortality have not been studied in insured lives populations. The Swiss Re Study evaluated metabolic syndrome prevalence and associated mortality from all causes and circulatory disease in a cohort of 35,470 predominantly healthy individuals, aged 18–83 years, who were issued life insurance policies between 1986 and 1997. Metabolic syndrome was defined using the National Cholesterol Education Program (NCEP) Expert Panel Adult Treatment Panel (ATP) III guidelines. The NCEP obesity criteria were modified with a prediction equation using body mass index, gender, and age substituted for waist circumference. Adjustments also were made for nonfasting triglyceride and blood glucose values. Risk ratios for policyholders identified with metabolic syndrome were 1.16 (P = .156) for mortality from all causes and 1.45 (P = .080) for mortality from circulatory disease compared with individuals without the syndrome. Risk was proportional to the number of components, or score, of the metabolic syndrome present. Risk ratios for metabolic syndrome score were 1.14 (P < .001) for mortality from all causes and 1.38 (P < .001) for mortality from circulatory disease compared with individuals without metabolic syndrome factors. In both all-cause and circulatory death models, relative risk was highest for the blood pressure risk factor. Based on a modified NCEP definition, increased mortality risk is associated with metabolic syndrome in an insured lives cohort and has life insurance mortality pricing implications.     

Bicuspid aortic valve

Bicuspid aortic valve is the most common congenital cardiac malformation and may be responsible for more mortality and morbidity than the combined effects of all the other congenital heart defects.     

Obstructive sleep apnea and cardiovascular disease and mortality: the argument for causality

There is solid evidence linking obstructive sleep apnea (OSA) to cardiovascular mortality. Although it has yet to be scientifically proven that OSA causes cardiovascular disease, many investigators consider it an independent cardiovascular risk factor. Its impact on the cardiovascular mortality risk of a given applicant varies depending upon the severity of the condition, compliance with treatment, and the applicant's specific cardiovascular milieu. This review is aimed at making mortality risk assessment more accurate by describing what is known of the physiologic mechanisms by which OSA may influence cardiovascular mortality and providing an appreciation for the magnitude of this risk. In doing so, an argument supporting OSA as a cause for cardiovascular disease and mortality emerges.     

Benefits analysis of particulate matter control programs – a case study of Tokyo

The objective of this case study was to assess economic benefits of past environmental policies of particulate matter (PM) in Tokyo by comparing observed pre‐control PM levels in 1975 and post‐control levels in 1998. The point estimates of the numbers of additional cases of avoided premature mortality and morbidity due to PM pollution control were (1) 3900 long‐term deaths in adults aged 30 years and older (population 5?098?000), (2) 4700 cases of chronic bronchitis in adults aged 30 years and older, (3) 7800 cases of in‐patient cardiovascular disease in adults aged 65 and older (population 1?281?942), (4) 3100 cases of in‐patient pneumonia in adults aged 65 and older, (5) 2500 cases of in‐patient chronic obstructive pulmonary disease in adults aged 65 and older, (6) 390?000 asthma attacks in asthmatics (population 450?000), and (7) 4500 cases of acute bronchitis in children aged 8–12 (population 300?300) during a one‐year period. The point estimate of medical costs in adults and children plus the cost of lost wages was a purchasing power parity‐adjusted $38 billion USD. Overall these results appear more likely to be underestimates than overestimates due to several unquantified benefits. The calculations of avoided health and productivity impacts suggest that pollution control policies successfully prevented a large expense to the society in extra medical care and lost work time.