docPlenary 4: Painting Pictures of the Brain by Numbers
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Plenary 4: Painting Pictures of the Brain by Numbers
24/11/2014 Painting pictures of the brain with numbers Neurology for Insurers Dr Ian Cox & Adele Groyer Gen Re PowerPoint presentations lette B88 Overview 71 B22 0 B184 • Critical Illness Product Background B72 palette B72 63 B42 en B82 n 9 B162 B200 79 B225 – Why should we be interested in neurology? • Consult our doctor – How your brain works (assuming it does) – White matter and grey matter (and whether it matters) – How we can we look at the Central Nervous System – Changes in the way doctors diagnose and manage Stroke, MS and Alzheimer's Disease 18 B207 0 B147 • Critical Illness Pricing implications 9 B140 0 B69 16 29 1 24/11/2014 PowerPoint presentations lette B88 71 B22 Critical Illness Neurological cause of claim Strokes, Multiple Sclerosis and Benign Brain Tumours are important causes of claim in this UK sub-population Gen Re Dread Disease Survey 2004 - 2008 0 B184 B72 palette B72 63 B42 en B82 n 9 B162 B200 79 B225 18 B207 0 B147 9 B140 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% Major head trauma Coma Motor Neurone Disease Parkinson’s Disease Benign brain tumour Multiple sclerosis Stroke UK males Australia males China males 0 B69 3 16 29 PowerPoint presentations lette B88 71 B22 Critical Illness Neurological cause of claim … and these are important for females too Gen Re Dread Disease Survey 2004 - 2008 0 B184 B72 palette B72 63 B42 en B82 n 9 B162 B200 79 B225 18 B207 0 B147 9 B140 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% Major head trauma Coma Motor Neurone Disease Parkinson’s Disease Benign brain tumour Multiple sclerosis UK females Australia females China females Stroke 0 B69 16 29 4 2 24/11/2014 PowerPoint presentations lette B88 71 B22 2012/2013 Claims statistics - a similar picture Neurological causes still account for around 15% of CI claims Sample of recently published CI claims statistics 0 B184 B72 palette B72 63 B42 en B82 n 9 B162 B200 79 B225 (excluding death & terminal illness) 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% Parkinson’s Disease Benign brain tumour Multiple sclerosis Stroke 18 B207 0 B147 9 B140 0 B69 16 29 5 Zurich reported only on a few top causes of claim What matters………… The Brain [Presentation Title] | [Name of Presenter ] | [MM/DD/YYYY] Proprietary and Confidential Reinsurance Corporation | © General 6 3 24/11/2014 PowerPoint presentations lette B88 Neurons and other cells 71 B22 0 B184 B72 palette • Basic functional unit of the nervous system • 100 Billion cells in the brain B72 63 B42 en B82 n 9 B162 • 100 trillion synapses or connections • Other supporting cells – Glial cells – Called astrocytes, oligodendrocytes B200 79 B225 18 B207 0 B147 9 B140 0 B69 7 16 29 PowerPoint presentations lette B88 71 B22 Neurons Axons and dendrites - transport electrical and chemical messages 0 B184 B72 Axons covered by segment like myelin sheath palette B72 This assists speed of conduction 63 B42 en B82 Connects brain to muscles (motor) and to sensory cells n 9 B162 B200 79 B225 18 B207 0 B147 9 B140 0 B69 16 29 http://kvhs.nbed.nb.ca/gallant/biology/neuron_str ucture.html 8 4 24/11/2014 PowerPoint presentations lette B88 Brain appearance 71 B22 0 B184 B72 palette B72 63 B42 en B82 n 9 B162 B200 79 B225 18 B207 0 B147 9 B140 http://snowbrains.com/13-facts-about-the-human-brain-you-didnt-know/ http://www.psychologytoday.com/blog/the-athletes-way/201209/toward-new-split-brain-model-brain-down-brain 0 B69 9 16 29 PowerPoint presentations lette B88 Grey Matter, White Matter 71 B22 0 B184 B72 palette B72 63 B42 en B82 n 9 B162 B200 79 B225 18 B207 0 B147 9 B140 0 B69 16 29 http://www.humanconnectomeproject.org/gallery/ 10 5 24/11/2014 PowerPoint presentations lette B88 71 B22 0 B184 B72 palette B72 How can we look at the Nervous System? • Symptoms – reported • Clinical Examination of individual • Test transmission of nerves – Nerve conduction 63 B42 en B82 n 9 B162 B200 – Visual evoked responses • Imaging – X-Ray 79 B225 – CT 18 B207 – MRI 0 B147 – Functional imaging 9 B140 0 B69 11 16 29 PowerPoint presentations lette B88 CT or MRI ? 71 B22 CT MRI 0 B184 • Was more available • Now more available • Quicker • Longer process • Cheaper • More expensive • Possible with metal in body • Claustrophobia in most machines B72 palette B72 63 B42 en B82 n 9 B162 B200 • Not possible with metal in body • But radiation • Different images possible (not just ‘MRI’) 79 B225 18 B207 • No radiation 0 B147 9 B140 0 B69 16 29 12 6 24/11/2014 PowerPoint presentations lette B88 71 B22 MS diagnosis MacDonald Criteria 0 B184 B72 palette B72 63 B42 en B82 n 9 B162 B200 79 B225 18 B207 0 B147 9 B140 0 B69 13 16 29 PowerPoint presentations lette B88 71 B22 MS diagnosis • Disseminated in time and space 0 B184 B72 palette • Evidenced by clinical examination – More than one clinical lesion B72 63 B42 en B82 • Evidenced by more than one lesion on MRI – Different lesions in position and/or duration n 9 B162 B200 79 B225 18 B207 0 B147 9 B140 0 B69 16 29 14 http://www.radiologyassistant.nl/en/p4556dea65db62/multiple-sclerosis.html#i459798814a5eb 7 24/11/2014 PowerPoint presentations lette B88 MS lesions on MRI over one year 71 B22 MS attacks cause early inflammation – swelling and leakage of immune cells into area. Leaving scars - gliosis 0 B184 B72 palette B72 63 B42 en B82 n 9 B162 B200 79 B225 18 B207 0 B147 9 B140 0 B69 15 16 29 PowerPoint presentations lette B88 Blood supply in the brain 71 B22 0 B184 B72 palette B72 63 B42 en B82 n 9 B162 Stroke • Haemorrhage or Infarct • Infarct when blood vessel is blocked – thrombosis or embolus • Treatment with clot busting drugs if infarct • New concept of ‘Brain Attack’ B200 79 B225 http://www.wellcomecollection.org/fullimage.aspx?page=3586&image=cast-of-blood-vessels 18 B207 0 B147 9 B140 0 B69 16 29 8 24/11/2014 PowerPoint presentations lette B88 Stroke Vs Transient Ischaemic Attack (TIA) 71 B22 • TIA: Change diagnosis to ‘tissue based’ diagnosis 0 B184 • No time – 24 hrs no longer relevant B72 palette • Scans vital B72 • CT : available 24 hours a day and is the gold standard for haemorrhage 63 B42 en B82 n 9 B162 • On CT 60% of infarcts are seen within 3-6 hrs and virtually all are seen in 24 hours. The overall sensitivity of CT to diagnose stroke is 64% and the specificity is 85% • 30% to 50% of classically defined TIAs show brain injury on diffusion-weighted magnetic resonance (MR) imaging (MRI). B200 79 B225 • ‘TIA patients should undergo neuroimaging evaluation within 24 hours of symptom onset, preferably with magnetic resonance imaging’ 18 B207 0 B147 9 B140 0 B69 17 16 29 PowerPoint presentations lette B88 Acute CT scans (top row) 1.5 hours and MRI diffusion-weighted images (DWI) obtained 3.5 and 36 hours after stroke onset in a woman with left hemiparesis 71 B22 0 B184 B72 palette B72 63 B42 en B82 n 9 B162 B200 79 B225 18 B207 0 B147 9 B140 Lansberg M G et al. Neurology 2000;54:1557-1561 0 B69 16 29 © 2013 American Academy of Neurology 9 24/11/2014 PowerPoint presentations lette B88 71 B22 Sensitivity Specificity CT and MRI acute stroke 0 B184 B72 palette B72 63 B42 en B82 n 9 B162 B200 79 B225 18 B207 0 B147 9 B140 Lancet. Jan 27, 2007; 369(9558): 293–298. doi: 10.1016/S0140-6736(07)60151-2 0 B69 19 16 29 PowerPoint presentations lette B88 Stroke 71 B22 0 B184 B72 palette B72 63 B42 en B82 n 9 B162 • 55 year old man with weakness • CT to rule out haemorrhage • MRI next • Angiogram B200 79 B225 18 B207 0 B147 9 B140 0 B69 16 29 20 10 24/11/2014 PowerPoint presentations lette B88 71 B22 0 B184 B72 palette B72 63 B42 Cerebral aneurysm & Subarachnoid Haemorrhage Dilatation of a blood vessel Risk is that this may: burst – causing haemorrhage cause pressure on surrounding brain tissue en B82 n 9 B162 B200 79 B225 18 B207 0 B147 9 B140 0 B69 16 29 PowerPoint presentations lette B88 71 B22 0 B184 Clipping of cerebral aneurysm Aneurysm B72 palette B72 63 B42 en B82 n 9 B162 B200 79 B225 18 B207 0 B147 9 B140 0 B69 16 29 22 11 24/11/2014 PowerPoint presentations lette B88 71 B22 Coiling of aneurysm 0 B184 B72 palette B72 63 B42 en B82 n 9 B162 B200 79 B225 18 B207 0 B147 9 B140 0 B69 23 16 29 PowerPoint presentations lette B88 71 B22 Brain covering layers – meninges - BBT No classification of Benign Vs Malignant!! 0 B184 http://iheartautopsy.com/?p=1175 B72 palette B72 63 B42 en B82 n 9 B162 B200 79 B225 18 B207 0 B147 9 B140 http://www.wellcomecollection.org/whats-on/exhibitions/brains/image-galleries/cutting-andtreating.aspx?view=brain-surgery http://www.neuro chirurgiaire.it/eng/58_Meningioma.s html 0 B69 16 29 24 12 24/11/2014 PowerPoint presentations lette B88 Dementia 71 B22 0 B184 B72 palette B72 63 B42 en B82 n 9 B162 B200 79 B225 18 B207 • Continuum of increasing memory loss • Diagnostic criteria not objective – rely on impairment of everyday functioning and questions answered by patient (clinical medicine) • Where does mild cognitive impairment end and dementia start? 0 B147 9 B140 0 B69 25 16 29 PowerPoint presentations lette B88 71 B22 0 B184 Dementia • Scans not diagnostic although supportive B72 palette B72 • Clinical diagnosis • Blood tests ? for early diagnosis 63 B42 en B82 • Screening suggested - targets n 9 B162 B200 79 B225 18 B207 0 B147 9 B140 0 B69 16 29 26 13 24/11/2014 PowerPoint presentations lette B88 Incidental Findings on Brain MRI. Incidental MRI findings 71 B22 0 B184 B72 palette B72 63 B42 en B82 n 9 B162 B200 79 B225 18 B207 0 B147 9 B140 0 B69 Vernooij MW et al. N Engl J Med 2007;357:1821-1828. 16 29 PowerPoint presentations lette B88 71 B22 White matter lesions on scan 0 B184 B72 palette B72 63 B42 en B82 n 9 B162 B200 79 B225 18 B207 0 B147 9 B140 0 B69 16 29 14 24/11/2014 PowerPoint presentations lette B88 Future changes in neurological imaging 7T vs 1.5T MRI scan 71 B22 0 B184 B72 palette B72 63 B42 en B82 n 9 B162 B200 79 B225 18 B207 0 B147 9 B140 0 B69 16 29 PowerPoint presentations lette B88 71 B22 0 B184 Positron Emission Tomography (PET) Scanning with Florbetapir in possible Alzheimer’s Disease B72 palette Detects β-amyloid deposition in brain B72 63 B42 en B82 n 9 B162 B200 79 B225 18 B207 0 B147 http://www.radiology.ucsf.edu/patientcare/services/specialty-imaging/alzheimer 9 B140 0 B69 16 29 30 15 24/11/2014 PowerPoint presentations lette B88 Blood markers 71 B22 0 B184 B72 palette • ‘Holy grail’ of pharma/biomarker industry • Massive investment ongoing B72 63 B42 en B82 n 9 B162 B200 79 B225 • Looking at: – Stroke – Dementia – MS – Huntington’s 18 B207 0 B147 9 B140 0 B69 31 16 29 Implications for insurance [Presentation Title] | [Name of Presenter ] | [MM/DD/YYYY] Proprietary and Confidential Reinsurance Corporation | © General 3 2 16 24/11/2014 PowerPoint presentations lette B88 71 B22 0 B184 Neurological CI claims triggers (typically 100% pay) The list is long and includes many similar illnesses ABI/ABI+ B72 palette B72 Non-standard full benefits Stroke Devic’s Disease Multiple sclerosis Benign Spinal Cord Tumour Benign Brain Tumour Progressive Supranuclear Palsy Parkinson’s Disease Multiple System Atrophy Alzheimer’s Disease Dementia Motor Neurone Disease Bacterial Meningitis Coma Encephalitis Traumatic head injury Creutzfeldt-Jakob Disease 63 B42 en B82 n 9 B162 B200 79 B225 18 B207 0 B147 9 B140 0 B69 33 16 29 PowerPoint presentations lette B88 Definite diagnosis by a Consultant Neurologist PLUS Permanent Neurological Deficit or specific form of permanent impairment 71 B22 0 B184 ABI/ABI+ B72 Devic’s Disease palette B72 Non-standard full benefits Multiple sclerosis 63 B42 en B82 n 9 B162 Progressive Supranuclear Palsy Parkinson’s Disease Multiple System Atrophy Alzheimer’s Disease Dementia Motor Neurone Disease Bacterial Meningitis B200 79 B225 18 B207 0 B147 Encephalitis 9 B140 0 B69 16 29 34 17 24/11/2014 PowerPoint presentations lette B88 Definite diagnosis by a suitable / specified medical professional PLUS specific form of permanent impairment 71 B22 0 B184 ABI/ABI+ Non-standard full benefits B72 palette B72 Benign Spinal Cord Tumour + 63 B42 en B82 n 9 B162 B200 Alzheimer’s Disease Dementia 79 B225 18 B207 0 B147 9 B140 Creutzfeldt-Jakob Disease * 0 B69 16 29 PowerPoint presentations lette B88 + Just “diagnosis” + PND * Some definitions are diagnosis only 35 No specification of who makes the diagnosis 71 B22 0 B184 ABI/ABI+ B72 palette Stroke + B72 * Permanent neurological deficit with persisting clinical symptoms 63 B42 en B82 + permanent symptoms (ABI standard) temporary / no symptoms (ABI+) Benign Brain Tumour + n 9 B162 B200 Two of the most common causes of neurological CI claim have the loosest definitions! 79 B225 18 B207 0 B147 Coma* 9 B140 0 B69 16 29 Traumatic head injury* 36 18 24/11/2014 PowerPoint presentations lette B88 71 B22 Neurological CI claims triggers Does not specify who makes the diagnosis but requires specific surgery or procedure 0 B184 B72 palette B72 Additional payments 63 B42 en B82 Arteriovenous Malformation of the brain n 9 B162 B200 Carotid Artery Stenosis 79 B225 18 B207 0 B147 Cerebral Aneurysm 9 B140 0 B69 37 16 29 PowerPoint presentations lette B88 How representative is the past data we see? 71 B22 0 B184 B72 palette B72 63 B42 en B82 n 9 B162 B200 What constitutes “Definite Diagnosis” and how protective is this requirement? 79 B225 18 B207 0 B147 9 B140 Currently undiagnosed / asymptomatic cases • Prevalence detectable by MRI • Use of MRI • Robustness of exclusion “abnormality seen on scans without definite related clinical symptoms” 0 B69 16 29 38 19 24/11/2014 Incidental MRI findings Do the statistics suggest an Illness headache? [Presentation Title] PowerPoint presentations lette B88 71 B22 | [Name of Presenter ] | [MM/DD/YYYY] Proprietary and Confidential Reinsurance Corporation | © General 3 9 Context Some rough tools to estimate impact of increased neurological claim rates on total Accelerated Illness cost 0 B184 B72 palette B72 63 B42 en B82 n 9 B162 • Probability of death or CI claim by age 69 for someone aged 50 – Male non-smoker: 23% – Female non-smoker: 16% B200 79 B225 18 B207 CMI AC04 tables (Working Paper 50) Based on UK insured lives experience 2003-2006 0 B147 9 B140 0 B69 16 29 20 24/11/2014 PowerPoint presentations lette B88 71 B22 MRI findings Morris Z et al, “Incidental findings on brain magnetic resonance imaging: systematic review and meta-analysis”, BMJ 2009;339:b3016 doi:10.1136/bmj.b3016 0 B184 B72 palette B72 63 B42 en B82 n 9 B162 B200 79 B225 18 B207 0 B147 9 B140 0 B69 41 16 29 PowerPoint presentations lette B88 71 B22 MRI findings: Silent stroke Morris Z el at, “Incidental findings on brain magnetic resonance imaging: systematic review and meta-analysis”, BMJ 2009;339:b3016 doi:10.1136/bmj.b3016 Silent stroke prevalence ages 50 - 69: 2% 0 B184 B72 palette UK population stroke diagnoses ages 55 - 69* - 0.1% p.a. incidence - 1.1% prevalence B72 63 B42 en B82 5% of Accelerated Illness claims are for stroke n 9 B162 20% probability of Accelerated Illness claim aged 50 - 69 B200 79 B225 18 B207 Worst case scenario could add 10% to total risk cost 0 B147 more of an issue at older ages 9 B140 0 B69 16 29 * Lee S. et al, UK stroke incidence, mortality and cardiovascular risk management 1999–2008: time-trend analysis from the General Practice Research Database, BMJ Open2011;1:e000269 42 21 24/11/2014 PowerPoint presentations lette B88 Do patients “fully recover” after stroke? 71 B22 0 B184 B72 palette • 19% of stroke survivors aged 50 – 69 were classified as “fully recovered” 6 months after stroke adjusted for unknown statuses B72 Source: International Stroke Trial database US and UK statistics Trial was conducted in the 1990s 63 B42 en B82 n 9 B162 B200 79 B225 18 B207 • Changes from reclassification of some TIAs as strokes more recently • “fully recovered” label has been modified and incidental findings have been associated with poorer cognitive performance 0 B147 9 B140 0 B69 43 16 29 PowerPoint presentations lette B88 71 B22 MRI findings: Benign Brain Tumours Morris Z et al, “Incidental findings on brain magnetic resonance imaging: systematic review and meta-analysis”, BMJ 2009;339:b3016 doi:10.1136/bmj.b3016 0 B184 B72 Neoplastic incidental findings: 1% palette B72 approx. 50% of which are meningiomas (paid as BBT) 63 B42 Next most common are pituitary gland tumours en B82 n 9 B162 B200 79 B225 2% of claims are currently for benign brain tumour 20% probability of Accelerated Illness claim aged 50 - 69 18 B207 0 B147 Worst case scenario could add 2.5% to total risk cost 9 B140 0 B69 16 29 44 22 24/11/2014 PowerPoint presentations lette B88 71 B22 MRI findings: aneurysms and AVMs in the brain Morris Z et al, “Incidental findings on brain magnetic resonance imaging: systematic review and meta-analysis”, BMJ 2009;339:b3016 doi:10.1136/bmj.b3016 0 B184 B72 palette B72 63 B42 en B82 n 9 B162 B200 79 B225 18 B207 0 B147 Prevalence of incidental findings aged 50 - 69: 2% ~20% of these are aneurysms or AVMs Additional payment definition requires surgery. 20% probability of Accelerated Illness claim aged 50 - 69 Worst case scenario could add less than 1% to risk cost 9 B140 0 B69 45 16 29 PowerPoint presentations lette B88 71 B22 MRI findings: white matter hyperintensities Morris Z et al, “Incidental findings on brain magnetic resonance imaging: systematic review and meta-analysis”, BMJ 2009;339:b3016 doi:10.1136/bmj.b3016 0 B184 B72 palette B72 These findings are common and increase further at ages 70+ 63 B42 en B82 n 9 B162 B200 79 B225 18 B207 They are not directly associated with an Illness definition at present. Indicate 2 to 3x increase risk of dementia, stroke & death 0 B147 9 B140 0 B69 16 29 46 23 24/11/2014 PowerPoint presentations lette B88 MRI scans are being done more often 71 B22 0 B184 palette Average cost per scan in the NHS MRI exams per 1,000 population B72 OECD Health Statistics 2013 120 CT: £54 to £268 MRI: £84 to £472 B72 63 B42 en B82 n 9 B162 100 National audit office 2008-09 80 UK (in-hospital only) USA 60 Australia B200 Belgium 40 Ireland (in-hospital only) 79 B225 20 18 B207 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 9 B140 0 2000 0 B147 0 B69 16 29 47 PowerPoint presentations lette B88 71 B22 Insufficient evidence to justify asymptomatic screening 0 B184 B72 palette B72 63 B42 en B82 n 9 B162 B200 79 B225 18 B207 0 B147 9 B140 0 B69 16 29 48 24 24/11/2014 PowerPoint presentations lette B88 71 B22 0 B184 Concluding thoughts • Neurological CI definitions are complicated – Information sharing between disciplines helps B72 palette B72 63 B42 en B82 n 9 B162 • Diagnostic criteria and technology in the clinical setting continue to change – Screening is a possibility but is not clearly beneficial now – Insurers need to remain vigilant and participate regularly in industry discussions B200 79 B225 18 B207 0 B147 9 B140 0 B69 • There is some risk attached to the existing definitions – Especially the “diagnosis only” variety – But worst case scenarios appear less catastrophic than other triggers 49 16 29 PowerPoint presentations lette B88 71 B22 0 B184 B72 Questions Comments palette B72 63 B42 en B82 n 9 B162 B200 79 B225 18 B207 Expressions of individual views by members of the Institute and Faculty of Actuaries and its staff are encouraged. The views expressed in this presentation are those of the presenter. 0 B147 9 B140 0 B69 16 29 50 25
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