blood draw

We all know the routine. The examiner draws blood during a mobile exam. Delays in processing allow those hungry red blood cells to gobble up glucose. The underwriter sees an extremely low glucose reading or the dreaded not valid glucose (NVG) on the laboratory report. Or the laboratory report notes hemolysis is present. Then there are the results of a CBC where the blood was collected Friday afternoon, but not analyzed until Monday morning.

Now what? Does any of this matter to the underwriter?

What changes?

We used to think glycolysis was a seasonal issue. While it is more severe during the warm summer months, ExamOne data shows this issue is present throughout the year. But the question is: does very low glucose or not valid glucose still matter to life insurers?

With the majority of insurers now routinely testing A1c on every blood specimen, concerns with glycolysis are almost eliminated. A1c measures average blood glucose level for the preceding two to three months and is unaffected by glycolysis. Thus, it is a superior underwriting tool for measuring glucose control and is the recommended testing protocol for diagnosing diabetes by the American Diabetes Association.

Companies foregoing A1c testing must order a blood collection recheck or roll the dice and hope the applicant does not have a risk of glucose intolerance or diabetes.

What about hemolysis?

Hemolysis is the breakdown or rupturing of red blood cells. Hemolysis has a minor effect on a few blood analytes—particularly the aspartate aminotransferase (AST)—and is generally of minimal concern to the underwriter. Underwriters can feel comfortable underwriting specimens reported as having slight hemolysis.

Severe hemolysis, however, may have a significant effect on the AST, alanine transaminase (ALT), alkaline phosphatase (ALP), bilirubin, protein, triglyceride and glucose. If the hemolysis is too severe, the laboratory may result those analytes as “not valid – hemolysis” (NVH). Basing underwriting decisions on severely hemolyzed specimens can be risky.

Hemolysis and specimen processing delays can affect complete blood count (CBC) results by falsely decreasing or elevating a number of components in the CBC. Prompt processing of the CBC is critical, especially in cases where the underwriter orders the CBC “for cause.”

CBC results are fairly stable for approximately 72 hours at room temperature. Refrigerated specimens are stable even longer—for another two days. Delays in processing yield questionably accurate results, especially when evaluating anemic applicants.

Two options for reducing or eliminating glycolysis and hemolysis

According to ExamOne data, 15 percent of specimens are impacted by glycolysis and 4 percent are impacted by hemolysis. Advancements in testing protocol and availability of clinical exam centers have helped reduce the prevalence of specimen degradation.

specimen quality

A1c is stable for the life of the purple top tube—28 days—and it is unaffected by pre-analytic conditions such as heat and time, eliminating the risk of glycolysis. ExamOne’s routine risk assessment screen includes A1c testing so every specimen is tested upon arrival at the laboratory.

In addition to being a convenient option for applicants, exam centers provide a level of confidence unmatched in the life insurance industry. ExamOne data shows NVG rates of specimens drawn at exam centers are less than 0.1 percent, while NVH rates are less than 0.5 percent. Blood collected at an ExamOne or Quest Diagnostics exam center is processed and analyzed within 48 hours so the chances of specimen degradation due to temperature or processing delays are significantly reduced, giving insurers confidence they are basing underwriting decisions on accurate health insights.

ExamOne quality is going where no other paramedical company has gone before.  Since late 2011, ExamOne has been intentional about stepping up efforts to raise the bar on quality, specifically in the area of paramedical quality.  One of the challenges inherent with insurance collections is that the majority of them are performed in a mobile environment versus a clinically controlled environment. This can potentially have an adverse effect on certain specimen values.

This blog will be focusing specifically on Not Valid Glucose (NVG) rates and the multi-decade challenge for reporting viable glucose values from mobile collections. The delayed centrifugation allows the red and white cells in the blood to utilize the glucose. Every hour a specimen remains uncentrifuged, the level of glucose continues to drop. Once cells are separated from the serum, the glycolysis process stops. The prevailing thought is that NVG  is a seasonal issue.  However, years of laboratory data reveal that NVG occurs throughout the year and it consistently spikes higher in the warmer months.

With a close ear to clients and where they place value, one of the things most commonly expressed to Medical Director, Dr. Jim Palmier, has been feedback regarding high NVG rates (NVG occurs when the serum glucose test is < 60 mg/dL).  Dr. Palmier knew there was a tremendous opportunity to improve NVG rates and after consulting with internal teams, he shared a vision to address the ongoing challenge of NVG with mobile insurance collections and provided insight for what an improvement shift could mean to the industry.

Our laboratory performed a specimen stability study and has incorporated findings from that study into our operations.  With increased attention around NVG, a decision was made in 2012 to update the initial study and expand it to include temperature variables.  The goal of the new study was to mimic realistic conditions before specimens reached the laboratory.   Results were studied for approximately a dozen laboratory values in three temperature ranges.  Specimen values were evaluated pre and post centrifuging. The results of that study conclusively proved that keeping specimens in a cold environment prior to centrifuging was critical to maintaining specimen integrity and preventing NVG.

Later in 2012, ExamOne was able to obtain examiner level detail of specimen results and began a messaging campaign.  The information being shared not only showed them their individual to examiners rate, but also led to increased awareness within the offices.  The impact of those communications were effective due to frequency, delivery and actionable examiner data.  Additionally we launched a pilot program to keep specimen temperatures low until centrifugation.

Pilot examiners were selected based on volume and NVG performance.  They were provided an insulated bag with ice packs and instructed to perform business as usual except to transport specimens in the new bag.  Early results indicated this could be a viable solution for helping to greatly reduce NVG.  Final pilot results confirmed it.

To date, our monthly year over year NVG improvement continues to be highly favorable with gains averaging more than 20%.  Post pilot activity includes provisioning what is now referred to as a “Chill Out Kit” to exam offices for distribution to examiners.  The efforts underway are a tangible, visible example of the improvement process cycle we follow:

    • Problem Identification
    • Analysis
    • Best Practice Assessment
    • Implementation
    • Validation
    • Adjustment

As an alternative to the traditional mobile collection, ExamOne offers applicants a clinical setting at a Patient Service Center (PSC) to have their exam completed.[1]

We will continue to monitor NVG data and communicate individual examiner performance in an effort to create additional value for mobile collections while realizing sustained double-digit improvement.

[1] According to ExamOne data, specimens drawn at PSCs have an NVG rate of less than 0.1%.