The push to get newer and less invasive insurance testing has been going on for at least the last decade. Competition is fierce, convenience is king, and insurance companies are striving to get the most information they can out of more simplified testing. When the testing is new and not commercially used by the average doctor in practice, decisions based on the results can cause confusion and aggressive questioning by both physician and client. Three tests in this category are BNP, CRP and CDT.
BNP, short for B-type natriuretic peptide, has actually been used for many years by cardiologists in practice to diagnose congestive heart failure and distinguish whether some non-specific signs such as shortness of breath, fatigue and leg swelling may be indicative of pulmonary or cardiac disease. It was also used by cardiologists to optimize treatment for post-heart attack patients as well as to gauge the prognosis of those with congestive heart failure.
As older people slow down, constitutional symptoms become more pronounced. Differentiating regular aging-induced changes from insidious congestive heart failure is important to clinicians and also to underwriters in determining future prognosis.
BNP has also been found to be a predictor of arrhythmia in the future and has a very important role in prognosticating diabetes and those who will undergo heart surgery in the future. Some insurers are even doing away with treadmill testing at older ages and substituting a BNP result, which adds convenience to the insurance process.
As with all testing, BNP isn’t foolproof. Renal disease will cause elevations, and even normal people may have increases. Many people with abnormal BNP are insured when their medical rating takes into account the primary disease process. However, because many physicians don’t use BNP in screening (there is still much ongoing research), it can lead to questions in the field when a result causes a rating or declination.
CRP, or C-reactive protein, has been available for many years in assessing cardiovascular risk but is as controversial today as when it first came out. The original testing of CRP, which is an acute phase protein that increases with inflammation in the body, was used to help assess people who had autoimmune disease (such as lupus, for example), systemic arthritis, and certain forms of inflammatory bowel disease. A newer, more sensitive version, called hs-CRP (high sensitivity) has been used to attempt to predict recurrent coronary events in people who have had angina or heart attack and in the prognosis of people who have stroke or peripheral artery disease.
With this in mind, it should appear that CRP would be a terrific tool as an aid to prognostication of life expectancy that insurers could use, but it hasn’t quite turned out that way in practice. The value fluctuates in different circumstances, and many results may have to be obtained to get a true representative value.
The newest ASCOT trial (Anglo-Scandinavian Cardiac Outcomes Trial), which the American Heart Association is following carefully, found CRP to be a weak and sometimes non-significant predictive factor; and cardiologists often use the test to determine only whether cholesterol lowering statins are good treatment in patients at risk. So while perhaps helpful as part of an overall picture, the individual results provoke almost as many questions as answers.
CDT is another test that is not usually a part of clinical practice for most doctors but which insurers have come to rely on in risk assessment. CDT is carbohydrate-deficient transferrin, and is a very useful marker for detection of sustained alcohol use. Since alcohol abuse has such a myriad of complicating factors in mortality prediction (liver, cardiac, neurologic disease, as well as an increase in accidents, overdose and suicide), insurers need to know this in risk assessment. CDT is a great helper in differentiating mild from significant alcohol use and abuse.
In years past, GGTP was the marker most used to look for alcohol abuse, especially in the presence of other signs of liver disease. However, too many other conditions caused GGTP to be elevated, including causes that had nothing to do with the liver (such as bone) and medications. CDT is much more specific diagnostically and turns out to be a good marker for large consumption of alcohol.
Like all testing, CDT isn’t foolproof. Some people have inborn disorders of glycosylation which are inconsequential in their daily function but which elevate the test falsely. Certain medications, such as those used to control seizures, also raise CDT.
The test is best used in combination with a high index of suspicion, such as when a doctor notes significant alcohol use on an attending physician statement or in a pattern of recurrent accidents or suspicious motor vehicle reports. Alcohol questionnaires and even physician assessments of alcohol abuse may not always be well-correlated, so the CDT is a good adjunct for the overall picture.
All three tests have utility in insurance assessment, but their use is as a help in drawing an overall picture of risk, not as individual factors which decide the case on their own. As the testing isn’t part of the usual metabolic profiles drawn by most doctors during a physical or office exam, both doctors and clients may have questions as to the use and reliability of the testing. Insurers are careful to always use the tests in context of the entire medical picture of the applicant, and hope that the testing provides a less invasive and more convenient way of facilitating a decision on an application in selected circumstances.
