Lung Testing and Underwriting
The most common lung test used by physicians in an office setting is called spirometry. It is quick and easy procedure that only requires the patient to breathe into a tube.
(See this link to view the equipment used for spirometry http://www.nlm.nih.gov/medlineplus/ency/imagepage/1142.htm)
In less than twenty minutes the spirometry test provides an objective measurement of lung function. The test, it turns out, can deliver crucial life expectancy information to the underwriter. This is because abnormal spirometry findings can predict:
- Increased prevalence of heart disease
- Death rates from heart attacks
- Increased risk of lung cancer
- Increased mortality from all causes
So what does this simple office tests that takes less than twenty minutes to perform really measure? As important, how do the test results impact the underwriting process?
Spirometry involves two types of lung testing:
1. Static
2. Dynamic
The static portion of the test is called Forced Vital Capacity (FVC). It measures the maximum volume of air that can be forcibly and rapidly exhaled following a maximum inspiration (i.e. Fill up the lungs and then blow out as much air as possible). This is not a timed test.
The dynamic portion of the test is called Forced Expiratory Volume in first second (FEV1). It measures the volume of air expelled in the first second of forced expiration following a maximum inspiration (i.e. Fill up the lungs and then blow out as fast and as much air as possible). It is expressed as a percentage of the total volume (i.e. FVC). This is a timed test.
You can compare the static and dynamic elements of spirometry to gain additional information about lung function. This is called the FEV1/FVC ratio. The normal ratio between the FEV1 and FVC (FEV1/FVC) is 70-75%. This means that in patients with normal lung function, 75% of the total air they expel is expelled in the first second.
Normal values for FEV1 and FVC are based on population studies and vary according to race, height, age, and gender. They are expressed in both absolute numbers and percent predicted of normal.
Spirometry tests for two main types of lung disorders:
1. Obstructive
2. Restrictive
Obstructive disorders are abnormalities in airflow that are the result of disease of the inside (called the lumen) of the airway. Asthma, asthmatic bronchitis and emphysema are examples of obstructive disorders. Since it is hard to exhale with obstructive disorders, the flow rate is reduced as reflected by a reduced FEV1 and possibly a reduced FVC. The increase in FEV1 causes the FEV1/FVC ratio (normally 70-75%) to be less than 70%.
Obstructive disorders can be reversible or nonreversible. Asthma is a good example of a reversible obstructive disorder. Emphysema is a good example of a nonreversible obstructive disorder.
Restrictive disorders are abnormalities of the lung tissue itself or the capacity of the lungs to expand. Fibrosis (i.e. scar tissue replacing normal lung tissue) and physical deformities are examples of restrictive disorders. Since it is hard to inhale with restrictive disorders, the air volume is reduced as reflected by a reduced FVC and possibly a reduced FEV1. The reduction in FVC causes the FEV1/FVC ratio (normally 70-75%) to be greater than 80%.
Sample Cases
A 35-year-old female, non-smoker is applying for life insurance and is noted to have a recent history of progressive shortness of breath in her medical file. A spirometry test performed by her physician reveals:
FVC: 60% of normal
FEV1: 58% of normal
FEV1/FVC: 96%
With an increased FEV1/FVC ratio and a reduced FVC this applicant appears to have a restrictive disorder.
Restrictive Lung Disease: FEV1 to FVC Ratio normal or elevated
FVC over 80%: Normal
FVC over 60%: Mild restrictive lung disease
FVC over 40-50%: Moderate restrictive lung disease
FVC under 50%: Severe restrictive lung disease
A 45-year-old male, smoker is applying for life insurance. He has a 60-year pack history of smoking (i.e. 2 packs a day for 30 years). His medical file reveals a progressive shortness of breath with exercise. A spirometry test performed by his physician reveals:
FVC: 70% of normal
FEV1: 30% of normal
FEV1/FVC: 42%
With a decreased FEV1/FVC ratio and a reduced FEV1 this applicant appears to have an obstructive disorder.
Obstructive Lung Disease: FEV1 to FVC Ratio Low
FEV1 over 80%: Normal
FEV1 over 60%: Mild obstructive lung disease
FEV1 over 40-50%: Moderate obstructive lung disease
FEV1 under 40%: Severe obstructive lung disease
Underwriting Comment
Applicants with abnormal spirometry values can be insurable, but it is important to identify the underlying cause of the abnormalities. While the spirometry test can point to either an obstructive or restrictive disorder, it does not diagnose the exact lung disorder. A complete history, physical examination and additional testing are essential in formulating a correct diagnosis.
Once the exact disorder has been identified, its potential for progression and severity, the applicant’s smoking history and spirometry findings can be used to determine insurability.
The following items should be kept in mind when using spirometry for underwriting assessments:
1. Spirometry is not a "fool proof" test.
Spirometry is "effort dependent" which means the patient has to give 100% to get an accurate result. It is a simple test, but one that suffers from poor coaching and poor effort on the client’s part in many cases. When in doubt, repeat the test. As in all underwriting evaluations, underwrite the overall applicant and not the test.
2. Make sure you know the real smoking history.
The smoking history is a crucial piece of underwriting information in the face of symptoms (i.e. shortness of breath) or abnormal spirometry findings. It is not enough to simply know that the client "used to smoke but quit." Quantify how many years smoking, how many packs a day and exact date of the client quit.
3. Spirometry rarely appears in a medical file as a routine test.
Unlike blood pressure testing, spirometry is not a routine test for 80% of U.S. practitioners. If you find a spirometry test in a medical file, you need to find out why it was ordered, even if it is normal.
4. FEV1 values of 40% or less indicate severe disease.
Applicants with a history of chronic bronchitis or emphysema and FEV1 values of 40% or less are uninsurable for individual coverage.
5. Find out the client’s medications.
It is important to know what medications the patient is taking at the time of the spirometry; especially those used to treat lung disorders (i.e. inhalers, antibiotics, etc.).
