1. abcd 2001 Healthcare Conference Keeping Health on Track 21-23 October 2001 Scarman House

2. Session B1 : Critical Illness n Trends in Incidence Rates n Working Party / Research Group Progress Report n Neil Robjohns

3. Critical Illness Trends Working Party Our Aims : nTo examine underlying trends in the factors influencing UK Insured Critical Illness claim rates, and from these, to assess : nThe historic trend in incidence and death rates for the major CI’s nAny pointers for future trends in Standalone CI, Mortality and hence Accelerated CI. nFormed in March 2001

4. Group Members and our Initial Focus CancerHeart Attack nActuaries Azim DinaniScott Reid Richard MorrisJoanne Wells Neil Robjohns nMedical Experts Professor RubensRichard Croxson Consultant OncologistConsultant Cardiologist nLinks : nActuaries Panel on Medical Advances nCMIB CI experience investigation (via Dave Grimshaw) nABI CI definitions group (also via Dave Grimshaw)

5. Cancer Trends nData sources nOverall trends nPossible reasons behind observed trends nIllustrate by examples nRevisit overall picture nSome thoughts looking into the future

6. Cancer Data Sources nIncidence nCancer Registrations - England & Wales nFirst ever incidences nSelected behaviour codes nMortality nONS nBy cause - England & Wales nYears covered : 1971 - 97

7. Cancer Incidence and Mortality Rates, 1971 - 97 All Ages

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

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

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

11. Summary of Trends in Cancer Incidence and Mortality Rates Crude Rates of Change, % pa, over 1971 - 97 Female Male rate of Age RangeIncidenceMortalityIncidenceMortality Under 200.8%-2.4%0.7%-3.0% 20 - 291.4%-1.5%1.0%-2.6% 30 - 391.0%-1.1%0.8%-2.1% 40 - 490.3%-1.6%-0.2%-1.7% 50 - 591.1%-0.9%-0.1%-1.4% 60 - 591.2%0.1%0.3%-1.0% 70 - 791.6%0.7%0.9%-0.3% 80 & over1.3%0.6%1.5%0.9% All ages1.2%0.1%0.7%-0.4% Key Insurance Ages0.8%-1.1%0.0%-1.5%

12. Possible Reasons Behind Observed Trends nIssues with Data Recording nCancer Screening Initiatives nBehavioural changes nTreatment nof Cancer nof other illnesses nAwareness nOther ?

13. Cancer Screening Initiatives nBreast Cancer nCervical Cancer nProstate Cancer

14. Breast Cancer Changes in Incidence Rates, by age band, over 1971 - 97

15. Cervical Cancer Changes in Incidence Rates, by age band, over 1971 - 97

16. Prostate Cancer Changes in Incidence Rates, by age band, over 1971 - 97

17. Behavioural Changes nLung Cancer nMalignant Melanoma

18. Lung Cancer Changes in Incidence Rates, by age band, over 1971 - 97

19. Malignant Melanoma Changes in Incidence Rates for Males, by age band, over 1971 - 97

20. Treatments / Medical Advances nLung Cancer nImprovements in treatment of other smoker-related illnesses nBreast Cancer nStomach Cancer nTreatment of other stomach conditions

21. Breast Cancer Changes in Mortality Rates, by age band, over 1971 - 97

22. Stomach Cancer Changes in Incidence Rates for Males, by age band, over 1971 - 97

23. Awareness nBreast Cancer nTesticular Cancer nMalignant melanoma

24. Testicular Cancer Changes in Incidence Rates, by age band, over 1971 - 97

25. Some Other Possible Factors nDiet ? nExercise ? nSocio-Economic Differences ? nClimate ? nPollution ?

26. Cancer Incidence Rates by Site of Cancer Females, 1997

27. Cancer Incidence Rates by Site of Cancer Males, 1997

28. Contribution to Overall Change in Cancer Incidence Selected Cancer Sites for Females, by Age Band, over 1971 - 97 All Cancers 29% 21% 39%

29. Contribution to Overall Change in Cancer Incidence Selected Cancer Sites for Males, by Age Band, over 1971 - 97 All Cancers 22% -3% 22%

30. Contribution to Overall Change in Cancer Mortality Selected Cancer Sites for Females, by Age Band, over 1971 - 97 All Cancers -25% -23% 12%

31. Contribution to Overall Change in Cancer Mortality Selected Cancer Sites for Males, by Age Band, over 1971 - 97 All Cancers -42% -30% -5%

32. Summary of Contribution to Overall Change Females, by Age Band, over 1971 - 97 20 - 3940 - 5960 +20 - 3940 - 5960 + Stomach-1% -5%-2%-3%-7% Lung, etc-1%0%10%-3%-5%4% Malignant Melanoma8%3%2%-1%0%1% Breast9%20%10%-7%-6%1% Cervix6%-5%-1%2%-5%-1% Other7%4%23%-14%-5%15% All Cancers29%21%39%-25%-23%12% Cancer IncidenceCancer Mortality

33. Summary of Contribution to Overall Change Males, by Age Band, over 1971 - 97 20 - 3940 - 5960 +20 - 3940 - 5960 + Stomach-1%-4% -3%-7%-6% Lung, etc-6%-19%-7%-11%-31%-20% Malignant Melanoma7%3%1%0%1%0% Prostate0%4%13%0% 4% Testis18%1%0%-9%0% Other4%12%18%-20%6%17% All Cancers22%-3%22%-42%-30%-5% Cancer IncidenceCancer Mortality

34. Summary of Trends in Cancer Incidence and Mortality Average 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.

35. Summary of Trends in Cancer Incidence and Mortality Average 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.

36. Some Thoughts Looking Forwards nGovernment Targets / Initiatives nMore Screening ? nMedical Advances nCancer Treatment nEarlier Detection nOther Illnesses nLatent Cancer nCI definitions nProstate Cancer nBut how long until the next change is “forced” ?

37. Some Thoughts Looking Forwards nTentative Initial Views : nCancer Mortality : n“Good News” ? n“Continuing Reductions, at least for ages below 65” ? nCancer Incidence : n“Bad News” ? n“Underlying, steady increase, plus jumps up” ? !

38. Group Members and our Initial Focus CancerHeart Attack nActuaries Azim DinaniScott Reid Richard MorrisJoanne Wells Neil Robjohns nMedical Experts Professor RubensRichard Croxson Consultant OncologistConsultant Cardiologist nLinks : nActuaries Panel on Medical Advances nCMIB CI experience investigation (via Dave Grimshaw) nABI CI definitions group (also via Dave Grimshaw)

39. Overview Mortality and morbidity –Scotland –England Risk factors Reasons for historical change The Future

40. Overview Mortality and morbidity –Scotland –England Risk factors Reasons for historical change The Future

41. 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

42. Own figures: source Registrar General Scotland

43. Own figures: source Scottish Health Statistics

45. 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 1980198219841986198819901992199419961998 year proportion of smokers English men Scottish men own figures: General Household Survey 1998

46. Own figures: source Registrar General Scotland

47. Own figures: source Scottish Health Statistics

49. Own figures: General Household Survey 1998 Prevalence of female cigarette smoking in Scotland and England: 1980 to 1998 20 25 30 35 40 45 1980198219841986198819901992199419961998 year proportion of smokers English women Scottish women own figures: General Household Survey 1994

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

52. Overview Mortality and morbidity –Scotland –England Risk factors Reasons for historical change The Future

53. 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

60. Overall Improvements from AMI in England - 1989-1997 Own Figures - Data from HES and ONS

61. Overview Mortality and morbidity –Scotland –England Risk factors Reasons for historical change The Future

62. Coronary Heart Disease - Risk Factors Source: Britton and McPherson (2000). National Heart Forum

63. Overview Mortality and morbidity –Scotland –England Risk factors Reasons for historical change The Future

64. Reason for historical changes Reduction in the prevalence of smoking Improvements in diet Social-economic wellbeing Awareness of Cardiovascular risk

65. Reason for historical changes Medical advances –thrombolytic therapy –ACE (Angiotensinconverting enzyme) inhibitors –Statins –aspirin –beta-blockers –Angioplasty –CABG

66. Reason for historical changes Medical advances –thrombolytic therapy –ACE (Angiotensinconverting enzyme) inhibitors –Statins –aspirin –beta-blockers –Angioplasty –CABG

67. Reason for historical changes 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!

68. Reason for historical changes PCI Rates per million population (UK) Source: BCIS returns 1999

69. Reason for historical changes

70. Overview Mortality and morbidity –Scotland –England Risk factors Reasons for historical change The Future

71. Life style factors –Awareness of cardiovascular risk Smoking Diet Environment Exercise Government targets –Availability of treatments Definition of heart attack –Troponin

72. Session B1 : Critical Illness n Trends in Incidence Rates n Comments / Questions. n Suggestions for future focus of our work.