Abcd 2001 Healthcare Conference Keeping Health on Track 21-23 October 2001 Scarman House

2001 Healthcare Conference Keeping Health on Track

21-23 October 2001

Scarman House

Session B1 : Critical Illness

Trends in Incidence Rates

Working Party / Research Group Progress Report

Neil Robjohns

Critical Illness Trends Working Party

Our Aims : To examine underlying trends in the factors

influencing UK Insured Critical Illness claim rates, and from these, to assess : The historic trend in incidence and death rates for the major

CI’s Any pointers for future trends in Standalone CI, Mortality and

hence Accelerated CI.

Formed in March 2001

Group Members and our Initial Focus

Cancer Heart Attack Actuaries

Azim Dinani Scott Reid

Richard Morris Joanne Wells

Neil Robjohns

Medical Experts

Professor RubensRichard Croxson

Consultant Oncologist Consultant Cardiologist

Links : Actuaries Panel on Medical Advances CMIB CI experience investigation (via Dave Grimshaw) ABI CI definitions group (also via Dave Grimshaw)

Cancer Trends

Data sources Overall trends Possible reasons behind observed trends Illustrate by examples Revisit overall picture Some thoughts looking into the future

Cancer Data Sources

Incidence Cancer Registrations - England & Wales First ever incidences Selected behaviour codes

Mortality ONS By cause - England & Wales

Years covered : 1971 - 97

Cancer Incidence and Mortality Rates, 1971 - 97All Ages

0

100

200

300

400

500

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

Ra

tes

pe

r 1

00

,00

0

Male Incidence Female Incidence

Male Mortality Female Mortality

Cancer Incidence and Mortality Rates, 1971 - 97"Key Insurance Ages"

0

100

200

300

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

Ra

tes

pe

r 1

00

,00

0

Male Incidence Female Incidence

Male Mortality Female Mortality

Trends in Cancer Incidence Rates over 1971 - 97Average Rate of Change, by Sex and Age Band

-0.4%

0.0%

0.4%

0.8%

1.2%

1.6%

Under 20 20's 30's 40's 50's 60's 70's 80 +

Ave

rag

e C

han

ge,

% p

a

Males Females

Trends in Cancer Incidence and Mortality RatesAverage Rate of Change, by Sex and Age Band, over 1971 - 97

-3.0%

-2.0%

-1.0%

0.0%

1.0%

2.0%

Under 20 20's 30's 40's 50's 60's 70's 80 +

Ave

rag

e C

han

ge,

% p

a

Male Incidence Female Incidence Male Mortality Female Mortality

Summary of Trends in Cancer Incidence and Mortality RatesCrude Rates of Change, % pa, over 1971 - 97

Female Female Male Malerate of rate of rate of rate of

Age Range Incidence Mortality Incidence Mortality

Under 20 0.8% -2.4% 0.7% -3.0%20 - 29 1.4% -1.5% 1.0% -2.6%30 - 39 1.0% -1.1% 0.8% -2.1%40 - 49 0.3% -1.6% -0.2% -1.7%50 - 59 1.1% -0.9% -0.1% -1.4%60 - 59 1.2% 0.1% 0.3% -1.0%70 - 79 1.6% 0.7% 0.9% -0.3%80 & over 1.3% 0.6% 1.5% 0.9%

All ages 1.2% 0.1% 0.7% -0.4%Key Insurance Ages 0.8% -1.1% 0.0% -1.5%

Possible Reasons Behind Observed Trends

Issues with Data Recording Cancer Screening Initiatives Behavioural changes Treatment

of Cancer of other illnesses

Awareness Other ?

Cancer Screening Initiatives

Breast Cancer

Cervical Cancer

Prostate Cancer

Breast CancerChanges in Incidence Rates, by age band, over 1971 - 97

0

50

100

150

200

250

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

45-49 50-54 55-59 60-64 65-69

Cervical CancerChanges in Incidence Rates, by age band, over 1971 - 97

0

50

100

150

200

250

300

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

20-24 25-29 30-34 35-39 40-44

Prostate CancerChanges in Incidence Rates, by age band, over 1971 - 97

0

50

100

150

200

250

300

350

400

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

Behavioural Changes

Lung Cancer

Malignant Melanoma

Lung CancerChanges in Incidence Rates, by age band, over 1971 - 97

Males

-

100

200

300

1971 1975 1979 1983 1987 1991 1995

35-39 45-49 55-59

65-69 75-79 85+

Females

-

100

200

300

1971 1975 1979 1983 1987 1991 1995

35-39 45-49 55-59

65-69 75-79 85+

Malignant MelanomaChanges in Incidence Rates for Males, by age band, over 1971 - 97

0

100

200

300

400

500

600

700

800

900

1000

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

35-39 45-49 55-59 65-69 75-79 85+

Treatments / Medical Advances

Lung Cancer Improvements in treatment of other smoker-related illnesses

Breast Cancer

Stomach Cancer Treatment of other stomach conditions

Breast CancerChanges in Mortality Rates, by age band, over 1971 - 97

0

20

40

60

80

100

120

140

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

35-39 40-44 45-49 50-54 55-59 60-64

Stomach CancerChanges in Incidence Rates for Males, by age band, over 1971 - 97

0

20

40

60

80

100

120

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

45-49 50-54 55-59 60-64 65-69

Awareness

Breast Cancer

Testicular Cancer

Malignant melanoma

Testicular CancerChanges in Incidence Rates, by age band, over 1971 - 97

0

50

100

150

200

250

300

1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997

20-24 25-29 30-34 35-39 40-44

Some Other Possible Factors

Diet ?

Exercise ?

Socio-Economic Differences ?

Climate ?

Pollution ?

Cancer Incidence Rates by Site of CancerFemales, 1997

Key Insured Ages

Breast47%

Colorectal6%

Lung6%

Uterus4%

Cervix5%

Ovary6%

Stomach1%

NHL3%

Bladder & Pancreas

2%

Malignant melanoma

4%Other16%

All Ages

Breast29%

Colorectal12%

Lung11%

Uterus4%

Cervix2%

Ovary5%

Stomach3%

NHL3%

Bladder & Pancreas

6%

Malignant Melanoma

3%

Other22%

Cancer Incidence Rates by Site of CancerMales, 1997

All Ages

Lung19%

Prostate17%

Colorectal14%

Bladder & Pancreas

9%

Stomach5%

NHL3%

Mouth & Oesophagus

5%

Kidney3%

Testis1%

Leukaemia3%

Malignant Melanoma

2% Other19%

Key Insured Ages

Lung15%

Prostate6%

Colorectal13%

Bladder & Pancreas8%

Stomach4%

NHL6%

Mouth & Oesophagus

8%

Kidney4%

Testis5%

Leukaemia3%

Malignant melanoma5%

Other23%

Contribution to Overall Change in Cancer IncidenceSelected Cancer Sites for Females, by Age Band, over 1971 - 97

All Cancers 29% 21% 39%

-5%

5%

15%

25%

20 - 39 40 - 59 60 +

Imp

act

on

Ove

rall

Can

cer

Inci

den

ce

Stomach Lung, etc Malignant Melanoma Breast Cervix Other

Contribution to Overall Change in Cancer IncidenceSelected Cancer Sites for Males, by Age Band, over 1971 - 97

All Cancers 22% -3% 22%

-20%

-10%

0%

10%

20%

20 - 39 40 - 59 60 +

Imp

ac

t o

n O

ve

rall

Ca

nc

er

Inc

ide

nc

e

Stomach Lung, etc Malignant Melanoma Prostate Testis Other

Contribution to Overall Change in Cancer MortalitySelected Cancer Sites for Females, by Age Band, over 1971 - 97

All Cancers -25% -23% 12%

-20%

-10%

0%

10%

20%

20 - 39 40 - 59 60 +

Imp

ac

t o

n O

ve

rall

Ca

nc

er

Mo

rta

lity

Stomach Lung, etc Malignant Melanoma Breast Cervix Other

Contribution to Overall Change in Cancer MortalitySelected Cancer Sites for Males, by Age Band, over 1971 - 97

All Cancers -42% -30% -5%

-40%

-30%

-20%

-10%

0%

10%

20%

20 - 39 40 - 59 60 +

Impa

ct o

n O

vera

ll C

ance

r M

orta

lity

Stomach Lung, etc Malignant Melanoma Prostate Testis Other

Summary of Contribution to Overall ChangeFemales, by Age Band, over 1971 - 97

20 - 39 40 - 59 60 + 20 - 39 40 - 59 60 +

Stomach -1% -1% -5% -2% -3% -7%Lung, etc -1% 0% 10% -3% -5% 4%Malignant Melanoma 8% 3% 2% -1% 0% 1%Breast 9% 20% 10% -7% -6% 1%Cervix 6% -5% -1% 2% -5% -1%Other 7% 4% 23% -14% -5% 15%

All Cancers 29% 21% 39% -25% -23% 12%

Cancer Incidence Cancer Mortality

Summary of Contribution to Overall ChangeMales, by Age Band, over 1971 - 97

20 - 39 40 - 59 60 + 20 - 39 40 - 59 60 +

Stomach -1% -4% -4% -3% -7% -6%Lung, etc -6% -19% -7% -11% -31% -20%Malignant Melanoma 7% 3% 1% 0% 1% 0%Prostate 0% 4% 13% 0% 0% 4%Testis 18% 1% 0% -9% 0% 0%Other 4% 12% 18% -20% 6% 17%

All Cancers 22% -3% 22% -42% -30% -5%

Cancer Incidence Cancer Mortality

Summary of Trends in Cancer Incidence and MortalityAverage Change % pa, for Females, aged 40 - 59, over 1971 - 97

Size of Balls Indicates Relative Importance of Cancer Site, measured by Incidence Rates in 1997.

-6.0%

-4.0%

-2.0%

0.0%

2.0%

4.0%

6.0%

-6.0% -4.0% -2.0% 0.0% 2.0% 4.0%

Change in Mortality, %pa

Ch

ang

e in

In

cid

ence

, %

pa

Breast

Other

Uterus & Ovary

Colorectal

Lung

Cervix

Malignant melanoma

NHL

Pancreas & Bladder

Mouth & Oesophagus

Kidney

Stomach

Summary of Trends in Cancer Incidence and MortalityAverage Change % pa, for Males, aged 40 - 59, over 1971 - 97

Size of Balls Indicates Relative Importance of Cancer Site, measured by Incidence Rates in 1997.

-6.0%

-4.0%

-2.0%

0.0%

2.0%

4.0%

6.0%

-6.0% -4.0% -2.0% 0.0% 2.0% 4.0%

Change in Mortality, %pa

Ch

ang

e in

In

cid

ence

, %

pa

Other

Lung

Colorectal

Pancreas & Bladder

Mouth & Oesophagus

Prostate

NHL

Stomach

Kidney

Malignant melanoma

Testis

Some Thoughts Looking Forwards

Government Targets / Initiatives More Screening ?

Medical Advances Cancer Treatment Earlier Detection Other Illnesses Latent Cancer

CI definitions Prostate Cancer But how long until the next change is “forced” ?

Some Thoughts Looking Forwards

Tentative Initial Views :

Cancer Mortality : “Good News” ? “Continuing Reductions, at least for ages below 65” ?

Cancer Incidence : “Bad News” ? “Underlying, steady increase, plus jumps up” ? !

Group Members and our Initial Focus

Cancer Heart Attack Actuaries

Azim Dinani Scott Reid

Richard Morris Joanne Wells

Neil Robjohns

Medical Experts

Professor RubensRichard Croxson

Consultant Oncologist Consultant Cardiologist

Links : Actuaries Panel on Medical Advances CMIB CI experience investigation (via Dave Grimshaw) ABI CI definitions group (also via Dave Grimshaw)

Overview

• Mortality and morbidity– Scotland– England

• Risk factors• Reasons for historical change• The Future

Overview



Scotland - why use Scottish data?

• Scottish Morbidity Record Database• Good Quality

– Patient based– Linked to all Scottish Mortality data

• Detailed Medical studies on trends– Trends in case fatalities with AMI– Gender and survival studies

• Check on the English HES data• Understanding trends in UK

Trends in mortality in AMI - males - Scotland - 1981 to 1999

20%

40%

60%

80%

100%

120%

140%

1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

year

mo

rta

lity

ra

te a

s a

% o

f 1

98

1

0-39

40-64

65+

Own figures: source Registrar General Scotland

Trends in incidence rates in AMI - males - Scotland - 1981 to 1999

50%

60%

70%

80%

90%

100%

110%

1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

year

inc

ide

nc

e r

ate

as

a %

of

19

81

va

lue

0-39

40-64

65+

Own figures: source Scottish Health Statistics

Trends in the rate of incidence in AMI - males aged 45 to 59 in Scotland and England - 1989 to 1997

0

100

200

300

400

500

600

700

1989 1990 1991 1992 1993 1994 1995 1996 1997

year

rate

of i

ncid

ence

per

100

,000

of p

opul

atio

n

Scottish Male

English Male


Own figures: General Household Survey 1998

Prevalence of male cigarette smoking in Scotland and England: 1980 to 1998

20

25

30

35

40

45

50

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998

year

pro

po

rtio

n o

f sm

oke

rs

English men

Scottish men

own figures: General Household Survey 1998

Trends in mortality in AMI - females in Scotland - 1981 to 1999

20%

40%

60%

80%

100%

120%

140%

1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

year

mo

rta

lity

ra

te a

s a

% o

f 19

81

0-39

40-64

65+

Own figures: source Registrar General Scotland

Trends in incidence in AMI - females in Scotland - 1981 to 1999

40%

60%

80%

100%

120%

140%

160%

180%

1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

year

inci

de

nce

ra

te a

s a

% o

f 19

81

0-39

40-64

65+


Trends in the rate of incidence in AMI - females aged 45 to 59 in Scotland and England - 1989 to

1997

80

100

120

140

160

180

200

220

240

1989 1990 1991 1992 1993 1994 1995 1996 1997

year

rate

of

inci

de

nce

pe

r 10

0,00

0 o

f p

op

ula

tio

n

Scottish Female

English Female


Own figures: General Household Survey 1998

Prevalence of female cigarette smoking in Scotland and England: 1980 to 1998

20

25

30

35

40

45

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998

year

pro

po

rtio

n o

f sm

oke

rs

English women

Scottish women

own figures: General Household Survey 1994

Summary of overall improvements from AMI in Scotland - crude rates of improvement per annum 1981 to 1999

Male Male Female Femalerate of rate of rate of rate of

Age Range Mortality Incidence Mortality Incidence

0-39 3.6% 1.8% 3.8% -1.4%40-44 5.5% 2.6% 5.1% 2.6%45-49 7.1% 2.7% 5.2% 1.9%50-54 5.9% 3.6% 5.8% 3.4%55-59 5.6% 4.0% 4.9% 3.5%60-64 5.2% 2.9% 5.2% 3.2%65+ 3.4% 2.7% 2.3% 1.8%

All ages 3.9% 2.6% 2.4% 2.0%own figures-data source Scottish Health Statistic and Registrar General Scotland

Summary of overall improvements from AMI in Scotland - crude rates of improvement per annum 1981 to 1999

Male Male Female Femalerate of rate of rate of rate of

Age Range Mortality Incidence Mortality Incidence

0-39 3.6% 1.8% 3.8% -1.4%40-44 5.5% 2.6% 5.1% 2.6%45-49 7.1% 2.7% 5.2% 1.9%50-54 5.9% 3.6% 5.8% 3.4%55-59 5.6% 4.0% 4.9% 3.5%60-64 5.2% 2.9% 5.2% 3.2%65+ 3.4% 2.7% 2.3% 1.8%

All ages 3.9% 2.6% 2.4% 2.0%own figures-data source Scottish Health Statistic and Registrar General Scotland

Overview


• Risk factors• Reasons for historical change • The Future

England - The Data

• Hospital Episode Statistics (HES)– Complex– Essential to understand the coding system

• Years 1989/90 to 1997/98• Code change between 1994/95 and 1995/96

– Myocardial infarction – ICD9 410 – ICD10 I21 and I22

Males Trends Incidence of AMI

0%

20%

40%

60%

80%

100%

120%19

89

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

Source: HES

0-34 incidence

35-59 incidence

60+ incidence

Males Trends in Mortality and Incidence of AMI

0%

20%

40%

60%

80%

100%

120%19

89

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

Source: ONS and HES

35-59 deaths

35-59 incidence

Females Trends in Incidence of AMI

40%

60%

80%

100%

120%

140%19

89

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

Source: HES

0-34 incidence

35-59 incidence

60+ incidence

Females Trends Mortality and Incidence of AMI

40%

60%

80%

100%

120%

140%

160%19

89

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

Source: ONS and HES

35-59 deaths

35-59 incidence

Trend in Incidence Rates AMI

60%

70%

80%

90%

100%

110%19

89/9

0

1990

/91

1991

/92

1992

/93

1993

/94

1994

/95

1995

/96

1996

/97

1997

/98

Source: HES

35-59 Males

Trend in Incidence Rates AMI

60%

70%

80%

90%

100%

110%19

89/9

0

1990

/91

1991

/92

1992

/93

1993

/94

1994

/95

1995

/96

1996

/97

1997

/98

Source: HES

35-59 Males

35-59 Females

Overall Improvements from AMI in England - 1989-1997

AgeRange

MaleIncidence

MaleMortality

FemaleIncidence

FemaleMortality

30-34 1.8% 0.7% -3.7% 0.4%35-39 2.5% 8.7% 2.5% 1.3%40-44 1.9% 4.9% 1.0% 3.9%45-49 3.1% 7.2% 1.7% 4.8%50-54 3.5% 8.0% 2.9% 8.0%55-59 2.6% 7.3% 2.2% 7.6%60-64 2.6% 7.3% 2.5% 7.1%65-69 2.0% 6.4% 1.5% 6.7%70-74 2.0% 5.9% 1.7% 6.5%

All Ages 1.7% 5.1% 1.5% 4.9%

Own Figures - Data from HES and ONS

Overview



Coronary Heart Disease - Risk Factors

Source: Britton and McPherson (2000). National Heart Forum

Overview



Reason for historical changes

• Reduction in the prevalence of smoking• Improvements in diet• Social-economic wellbeing• Awareness of Cardiovascular risk


• Medical advances– thrombolytic therapy– ACE (Angiotensinconverting enzyme) inhibitors– Statins– aspirin– beta-blockers– Angioplasty– CABG


• Medical advances– thrombolytic therapy– ACE (Angiotensinconverting enzyme) inhibitors– Statins– aspirin– beta-blockers– Angioplasty– CABG


• Medical advances– thrombolytic therapy– ACE (Angiotensinconverting enzyme) inhibitors– Statins– aspirin– beta-blockers– Angioplasty- not so good for CI insurers!– CABG - not so good for CI insurers!


0

50

100

150

200

250

300

350

400

450

500'8

5

'88

'90

'92

'94

'96

'98

PCI Rates per million population (UK)

Source: BCIS returns 1999


United Kingdom Cardiac Surgical Register Trends in Cardiac Surgery 1977-1999

0

5

10

15

20

25

30

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

-94

1994

-95

1995

-96

1996

-97

1997

-98

1998

-99

year

Th

ou

san

ds

of

pro

ced

ure

s

Isolated CABG

Overview



The Future

• Life style factors– Awareness of cardiovascular risk

• Smoking

• Diet

• Environment

• Exercise

• Government targets– Availability of treatments

• Definition of heart attack– Troponin

Session B1 : Critical Illness

Trends in Incidence Rates

Comments / Questions.

Suggestions for future focus of our work.

Documents

Abcd 2001 Healthcare Conference Keeping Health on Track 21-23 October 2001 Scarman House