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Critical questions

A conference at the Royal College of Pathologists last week hosted by General Cologne Life Re UK brought experts together to address current critical-illness standard definitions and how these could change in the future. Experts from institutions around the UK discussed five critical-illness conditions -cancer-solid tumours, leukemia, myocardial infarction (heart attacks), stroke and multiple sclerosis – and how medical advances will shape the way insurers will deal with them.

Cancer

heart attack

stroke

Imperial College professor of cancer Karol Sik-ora assessed the likely implications of technology and risk assessment on the current definitions of cancer. He says there are certain anomalies in the current ABI definition. For example, 95 per cent of testicular cancers can be cured and yet they are not excluded by the current definitions, whereas other forms of cancer have far lower cure rates and are excluded.

Sikora says cancer will become more and more exp-ensive to treat and he predicts that in 10 years, cancer will take up a huge percentage of the financial resources of the National Health Service.

As 73 per cent of the cost of cancer drugs is spent in the year before cancer death, Sikora predicts that new partnerships will emerge, with the NHS franchising out cancer services.

With the benefits of technology, he says Cancer could be seen in the future as a disease such as diabetes – controllable by a life-time commitment to drugs which should in time be reflected in definitions.

Leukemia is a genetic disease but must not be confused with inherited conditions, according to Imperial College Prof-essor of haematology John Goldman.

Almost 50 per cent of leukemia patients do not have any symptoms of leukemia. The cost of hospitalisation, treatment and drugs for leukemia are all expensive.

Diagnosis of leukemia is based initially on examination of blood and then backed by more sophisticated techniques.

Goldman says the diagnosis of leukemia will inevitably be improved with advances in technology. Improved techniques will show that we all have the potential to carry cancer cells but not everybody will see them develop into cancer.

The challenge for the industry will be how it deals with the wealth of information showing potential for cancer when this may not necessarily develop. Goldman says: “In 20 years time, we could be detecting 15 to 20 cancers in one body.”

The same diagnosis can be given for both small and large heart attacks despite different outlooks for future health, says University of Wales cardiology Dr Maurice Buchalter.

Buchalter suggests that an assessment of the left ventricle ejection fraction – how well the left ventricle pumps with each cardiac cycle – could be added to the definition of a myocardial infarction for critical-illness insurance purposes.

An ejection fraction – costing about £300 – is measured weeks after a heart attack and provides a far better assessment of the patient&#39s chances of a further heart attack.

GenRe is proposing to add a left ventricle criteria to its definition for CI purposes. ABI definitions make no mention of left ventricle testing.

University of Edinburgh Professor of medical neurology Charles War-low says the current ABI definition of stroke is flawed because it is only concerned with two factors – has the patient had a stroke and how able is the patient to go about their normal business? It does not mention the recurrence risk or premature mortality, says Warlow.

His concern is that ins-urance companies should not rely on technology to diagnose a stroke as it is too easy for technology-based diagnoses to be inaccurate. Technology should be used to refine clinical diagnosis and not to ach-ieve, it he says.

He says a better app-roach towards the definition of stroke is to include an assessment of stroke severity or its consequen-ces on the patient. The way to achieve this is to create a scale to assess strokes by severity. The assessment should be made after any recovery has been made, usually within three to six months. Warlow says the severity scale should be “valid familiar, easy to use and in plain English”.

He says the insurance sector should adopt the Rankin scale, pioneered by John Rankin of the Univ-ersity of Wisconsin. For difficult cases, a neurologist should be consulted.

The current ABI definition requires a consultant MS neurologist to make a definitive diagnosis satisfying certain criteria. GenRe UK is suggesting payouts for patients diagnosed with a score of five or more on a one to 10 severity scale measured at least three months after the last severe attack. This score chart is known as the Kurtzke EDSS disability score.

But University of Cam-bridge department of neurology Dr Alasdair Coles says payouts should be made for patients rated four on the scale 30 days after relapse. Coles says this adjustment could be made at no extra exp-ense to the insurer as those who reach stage four will reach the next stage of disability within a year of diagnosis.

He recommends that an independent board should be set up for difficult diagnosis.

All speakers recognised the difficulty of creating up-to-date definitions, especially with the progression in diagnosis and technology. ABI policy adviser health and protection Vicki Bolton says: “There are communication problems. Insurers could have a better link with doctors and the medical profession.”

multiple sclerosis

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