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ORIGINAL ARTICLE

Improving Prognosis of Type 1 Diabetes

Mortality, accidents, and impact on insurance

Knut Borch-Johnsen

OBJECTIVE — Individuals with type 1 diabetes applying for insurance (life, health, accident, etc.) may either see their application being declined by the insurance company or find their premiums being substantially higher than the standard premium. During the last 40–50 years, the prognosis of patients with type 1 diabetes has improved dramatically, partly as a consequence of improved metabolic regulation and partly due to introduction of better treatment for late diabetic complications. The aim of the present study was to determine whether the increased premiums paid by diabetic patients for life insurance and accident insurance reflect the true risk of a diabetic individual.

RESEARCH DESIGN AND METHODS — Mortality: 3,000 type 1 diabetic patients were followed for 12–51 years. The impact of age, sex, year of diagnosis, and development of nephropathy on excess mortality was analyzed. Accidents: A cohort of nearly 7,000 members of the Danish Diabetes Association participating in group accident insurance was followed for 3 years. The risk and outcome of accidents in the diabetic group was compared with similar risks in a nondiabetic group.

RESULTS — Mortality: Over a 40-year period, the median life expectancy of type 1 diabetic patients increased by more than 15 years. The decrease was predominantly explained by a decreasing incidence of nephropathy, so that a simple model for estimating insurance premiums (including age of diagnosis, sex, and presence or absence of diabetic nephropathy) could be established. Accident insurance: Individuals with type 1 diabetes experienced a risk of accidents that was not in excess of that found in two control groups, and the outcome (degree of disability) after the accidents did not differ between the diabetic and the nondiabetic group.

CONCLUSIONS — Type 1 diabetic patients still have a mortality in excess of nondiabetic individuals. Life insurance premiums should, however, always reflect the changing prognosis of type 1 diabetes and thus, continuous monitoring and revisions are needed. For accident insurance, we found no increased risk of accidents; thus, diabetic individuals should be offered accident insurance on normal terms.

Diabetes Care 22 (Suppl. 2):B1–B3, 1999

The prognosis of patients with type 1 diabetes has improved considerably during the last 50 years, as shown in epidemiological studies from Europe (1,2) and the U.S. (3,4). The main reason for this improvement in the prognosis is that the risk of developing diabetic nephropathy has decreased dramatically (5,6) and that patients on their way to developing diabetic nephropathy are diagnosed in the microalbuminuric stage and treated with ACE inhibitors or other antihypertensive agents. The Diabetes Control and Complications Trial and other randomized controlled clinical trials of the effect of strict metabolic control have shown that strict metabolic control can delay or even prevent development of microvascular complications in the retina and kidney (7,8). These results are not only of immense interest and relevance to the individual patient with type 1 diabetes, but they should also be reflected in a socioeconomic impact on factors like health insurance, life insurance, and accident insurance. The American Diabetes Association has continuously worked on this issue for years, and several good ideas are given to the patient and the provider on the Association's World Wide Web site.

DIABETES AND HEALTH INSURANCE— In countries without a nationalized health care system (paid for through federal or local taxes), the diabetic individual needs health insurance. The diabetic individual will have what the insurance companies call a "preexisting condition." This may make it expensive, difficult, or even impossible to obtain health insurance (9). In 1986, the European Regional office of the International Diabetes Federation demonstrated that there was a huge variability within Europe in the rights of the diabetic individual and in the financial burden carried by the individual diabetic patient (10).

It should be a top priority of diabetic associations in each country to ensure the rights of their members, including the right of equal access to health care. This is particularly important in diabetes, as secondary prevention is the key to an improved prognosis. Only through strict metabolic control (7,8), early detection and treatment of microvascular complications (11,12), and secondary prevention against cardiovascular disease (13,14) can we prevent disability, death, and increased costs. This burden should not be carried by the individual patient alone, but should be regulated through specific rules that are necessarily different from country to country and that are adjusted according to the constant changes in care and prognosis (15,16).

LIFE INSURANCE— As already stated, the mortality of type 1 diabetic patients has decreased considerably over the last 50 years. In 1987, we published the results of an analysis of the impact of this decrease on life insurance for patients with type 1 diabetes (17). Based on a cohort of nearly 3,000 type 1 diabetic patients followed for 12–51 years, we found that 1) the median life expectancy increased by >15 years; 2) the decrease in mortality was predominantly explained through the decreasing incidence of nephropathy; and 3) a very simple model for estimation of the insurance premium could be established.

That fact that nephropathy was the most important predictor of mortality was not new, but what was new was the implication that in type 1 diabetic patients insurance should focus entirely on the risk of developing diabetic nephropathy. The important risk factors here were: male sex (relative risk: 1.3), low age at diagnosis, and diabetes duration (18). After >30 years of diabetes duration, the risk of developing nephropathy was very low. Obviously, other factors contribute to the development of diabetic nephropathy. The most important are metabolic regulation, blood pressure, and microalbuminuria. For metabolic regulation, the relevant parameters would, however, be the integrated blood glucose from onset of disease until the date the insurance is issued and the future HbA_1c. These data are not available, and rather than using one single HbA_1c measurement, we recommended that metabolic regulation be disregarded. For blood pressure, we had the same concern. Furthermore, the prognosis will depend on whether or not the patient is treated with antihypertensive agents (11). Microalbuminuria is an early marker for subsequent development of diabetic nephropathy, but as antihypertensive treatment may prevent progression to nephropathy, it was not included in the terms of issue. In conclusion, from this we recommended a model for calculation of issue terms based only on current age, age at diagnosis, sex, positive or negative for proliferative retinopathy, and other preexisting diseases. By age 50, all patients without nephropathy should experience a reduction in insurance premium, as the risk of nephropathy decreases with increasing diabetes duration from 25 years of duration onward. This suggestion was adopted by most insurance companies in the Nordic countries. The last revision took place in the mid 1980s. Since then 10 years have passed, the Diabetes Control and Complications Trial has been completed, and some studies suggest that the prognosis of patients with nephropathy has improved further. It is therefore necessary to reevaluate the mortality data. If we do not undertake these regular revisions, our diabetic patients will pay a higher-than-necessary premium based on their mortality experience. In Denmark, we recently studied a group of >7,000 diabetic patients, members of the Danish Diabetes Association, followed for >3 years (19). The preliminary data analysis indicates that there has been a further decrease in excess mortality, but more detailed analyses are needed before guidelines on insurance terms can be revised.

ACCIDENT INSURANCE— Patients with type 1 diabetes have an increased mortality, an increased morbidity, and an increased risk of postoperative complications. It is likely that these observations have led insurance companies to sell accident insurance to diabetic patients with increased premium and limited coverage. It has been assumed that diabetic patients would be at increased risk of accidents and increased risk of disability in relation to accidents. In searching the literature, however, we have not been able to identify studies supporting the assumption of an increased risk of accidents, so in this case the diabetic patients pay the price for the lack of evidence. This was also demonstrated by Jervell and Nilsson in 1986 (10), when they demonstrated that the terms for accident insurance for individuals with diabetes varied throughout Europe. More recent data from the U.S. confirm the variability in terms (9).

Studies of the risk of accidents in type 1 diabetic patients are difficult to perform for several reasons. A representative cohort of type 1 patients could be followed and all accidents registered. Fatal accidents could be identified through death certificates, but these are very rare events and not of interest in relation to accident insurance, an area where the costs are dominated by the majority of injuries that frequently occur and cause a 5–15% disability. These may be fractures or other events often treated without hospitalization. Self-reported questionnaires have been used, but these would then report the number of accidents, including several events that would cause permanent damage or disability.

In our study, we decided to follow a cohort of diabetic patients who were members of the Danish Diabetes Association, as all members of the Danish Diabetes Association were offered an accident insurance for 3 years free of charge by the Danish Diabetes Association. We followed 7,599 individuals for a period of 3 years. All accidents reported to the insurance company were reviewed by their normal physicians with respect to evaluation of the degree of permanent injury. For comparison, we used two different groups. The first group consisted of all people with individually issued leisure-time accident insurance (n = 62,876), and the second control group consisted of all employees in a Danish bank that had collective full-time accident insurance. The results of the study are described in detail elsewhere (19). The key finding was that individuals with type 1 diabetes experienced a risk of accidents that was not in excess of that found in the two control groups. The total number of accidents in the diabetic group was too small to allow a detailed analysis of the difference in risk of permanent disability between individuals with and without diabetes, but despite the small numbers, the study indicates that no major difference exists between the groups.

Based on these findings, we suggest that the conditions for accidence insurance should be revised and that patients with type 1 diabetes should be given accident insurance under normal conditions and at the normal premium.

CONCLUSIONS— Access to health, life, accident, and other types of insurance is not only a natural but also an essential part of our daily life. Without insurance, we may face difficulties when needing medical service, when buying a house and asking for a loan, etc. Nevertheless, all individuals suffering from a chronic disease have to accept increased premiums in combination with limited coverage when applying for insurance. This is also true for individuals with diabetes, even though we all know that the prognosis and life expectancy has increased considerably over the last 30–50 years, and despite the fact that we can now prevent or delay progression of most late diabetic complications. There is, however, an urgent need for translation of this knowledge into a language understandable to insurance companies. We need to perform studies that can convince the payers of health care—private or public—that prevention is possible and that diabetes is not as serious a disease as it was earlier on. As in all other areas of medicine, we need evidence—not belief and assumptions. Only through obtaining this evidence can we improve the social rights of our patients worldwide.

References
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2. Green A, Borch-Johnsen K, Andersen PK, Hougaard P, Keiding N, Deckert T: Relative mortality of type 1 (insulin-dependent) diabetes mellitus in Denmark 1933–1981. Diabetologia 28:339–342, 1985

3. Hirohata T, MacMahon B, Root HF: The natural history of diabetes. 1. Mortality. Diabetes 16:875–881, 1967

4. Dorman JS, LaPorte R, Kuller LH, Cruickshanks KJ, Orchard TJ, Wagener DK, Becker DJ, Cavender DE, Drash AL: The Pittsburgh Insulin-Dependent Diabetes Mellitus Morbidity and Mortality Study: mortality results. Diabetes 33:271–276, 1984

5. Kofoed-Enevoldsen A, Borch-Johnsen K, Kreiner S, Nerup J, Deckert T: Declining incidence of persistent proteinuria in type 1 (insulin-dependent) diabetic patients in Denmark. Diabetes 36:205–209, 1987

6. Krolewski AS, Warram JH, Christlieb AR, Busick EJ, Kahn CR: The changing natural history of nephropathy in type 1 diabetes. Am J Med 78:785–794, 1985

7. The Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329:977–986, 1993

8. Wang PH, Lau J, Chalmers CT: Meta analysis of effects of intensive blood-glucose control on late complications of type 1 diabetes. Lancet 341:1306–1309, 1993

9. Songer TJ, LaPorte R, Dorman JS, Orchard TJ, Becker DJ, Drash AL: Health, life, and automobile insurance characteristics in adults with IDDM. Diabetes Care 14:318–324, 1991

10. Jervell J, Nilsson B: Social Rights of Diabetic Patients in Europe: A Survey of the European Regional Organisation of the International Diabetes Federation. Aelvsjoe, Sweden, Swedish Diabetes Association, 1985

11. Mathiesen ER, Hommel E, Giese J. Parving HH: Efficacy of captopril in postponing nephropathy in normotensive insulin-dependent diabetic patients with microalbuminuria. BMJ 303:81–87, 1991

12. Diabetic Retinopathy Study Research Group: Photocoagulation treatment of proliferative diabetic retinopathy: clinical application of the DRS findings. Diabetic Retinopathy Study Report 8. Ophthalmology 88:583–600, 1981

13. Pyörälä K, Pedersen TR, Kjekshus J, Færgemand O, Olsson AG, Thorgeirsson G: The Scandinavian Simvastatin Survival Study (4S) Group: cholesterol lowering with simvastatin improves prognosis of diabetic patients with coronary heart disease. Diabetes Care 20:614–620, 1997

14. Eastman RC, Keen H: The impact of cardiovascular disease on people with diabetes: the potential for prevention. Lancet 350 (Suppl. 1):29–32, 1997

15. Wheeler ML, Warren-Boulton E: Diabetes patient education programs: quality and reimbursement. Diabetes Care 15 (Suppl. 1):36–40, 1992

16. Clark CM, Kinney ED: Standards for the care of diabetes: origins, uses and the implications for third party payment. Diabetes Care 15 (Suppl. 1):10–14, 1992

17. Ramlau-Hansen H, Jespersen NCB, Andersen PK, Borch-Johnsen K, Deckert T: Life insurance for insulin-dependent diabetics. Scand Actuarial J 19–36, 1987

18. Borch-Johnsen K, Andersen PK, Deckert T: The effect of proteinuria on relative mortality in type 1 (insulin-dependent) diabetes mellitus. Diabetologia 28:590–596, 1985

19. Mathiesen B, Borch-Johnsen K: Diabetes and accident insurance: a 3-year follow-up on 7,599 insured diabetic individuals. Diabetes Care 20:1781–1784, 1997

From the Steno Diabetes Centre, Gentofte, Denmark.

Address correspondence and reprint requests to Knut Borch-Johnsen, Steno Diabetes Centre, Niels Steensensvej 2, DK-2820 Gentofte, Denmark. E-mail: kbjo@novo.dk.

Received for publication 27 May 1998 and accepted in revised form 20 August 1998.

This article is based on a presentation at a satellite symposium of the 16th International Diabetes Federation Congress. The symposium and the publication of this article were made possible by educational grants from Hoechst Marion Roussel AG.

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