1 / 39

New Concepts in Underwriting Diabetes

New Concepts in Underwriting Diabetes. September 2002 - Manila, Philippines By Dr. Philip Smalley MD FRCPC Vice President and Medical Director RGA International. Toronto. Objectives. Diabetes definitions and epidemiology Discuss diabetic complications

jeri
Download Presentation

New Concepts in Underwriting Diabetes

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. New Concepts in Underwriting Diabetes September 2002 - Manila, Philippines By Dr. Philip Smalley MD FRCPC Vice President and Medical Director RGA International

  2. Toronto

  3. Objectives • 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.

  4. Diabetes Classifications • 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

  5. 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

  6. Diabetes Across the Globe • * 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

  7. 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.

  8. Measures of Control • Urine dipstick (poor indicator) • Blood glucometer readings • Hb A1c (reflects 12 - 15 weeks of control) • Fructosamine (reflects 2 week control)

  9. 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

  10. Non DM, no MI DM but no MI Non DM with MI DM with MI Type 2 Versus Heart Disease Mortality 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

  11. 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

  12. 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 Med1971 Dec;51(6):715-24

  13. Type 1 Type 2 M F M F Mortality Ratio Falls with Age of Patient Figure from Muller WA,, J Insur Med 1998;30(1):17-27, Published erratum appears in J Insur Med 1998;30(2):129.

  14. 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.

  15. Complications of Diabetes

  16. 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

  17. 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.

  18. 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

  19. 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.

  20. Microalbuminuria (MAU) • Confusing Name • “Small amounts of proteinuria” • 0.03 - 0.3 g/ day (30 - 200 ug / min) • 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

  21. 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

  22. Stroke • Diabetics have 4 times more strokes than non-diabetics

  23. 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, Diabetologia1998 Sep;41(9):1010-6

  24. 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

  25. Newer Diabetes Therapies • Combination therapies • Agents to increase insulin sensitivity • Drugs to delay glucose load from bowel • Inhaled Insulin • Pancreatic cell transplants • Gene therapy

  26. 30 http://www.unos.org/Newsroom/critdata_main.htm

  27. 31

  28. 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

  29. Control of Diabetes • Diabetes Control and Complication Trial • 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

  30. 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):809-27Nasr CE et al, Cleve Clin J Med 1999 Apr;66(4):247-53 Turner RC, Diabetes Care 1998 Dec;21 Suppl 3:C35-8

  31. Turner RC et al, BMJ 1998; 316:823-828 (14 March)

  32. What to look for in Underwriting • Diagnosis • Duration • Treatment • Control • Follow up • Complications • Other cardiac risk factor profile

  33. Case 1 • 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

  34. 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

  35. 55 year old male Type 2 diabetic HbA1c 7.2 BP 150/90 Cholesterol 7.0 Ex-smoker for 5 yrs 55 year old male Type 2 diabetic HbA1c 9.2 BP 120/80 Cholesterol 4.9 Never smoked Case 3

  36. 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

  37. 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

  38. 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

  39. Thank you !

More Related