cal condition, at the same time saving SSA the substantial administrative costs of an in-depth vocational evaluation.

SSA currently organizes the Listings under 15 body systems, including the cardiovascular system. Because of the key role the Listings play in the disability determination process, they should reflect advances in medical treatment and diagnostic methods, be cognizant of the changing nature of employment in the United States, and be administratively practical to apply. SSA asked the Institute of Medicine (IOM) to convene an expert committee to recommend improvements in the cardiovascular system listings. Last revised in 2006, the cardiovascular system comprises eight adult and five child categories of impairments. In response to its charge, the IOM committee concluded that the functional performance of individuals with cardiovascular conditions, or with multiple conditions across body systems, deserves greater emphasis in determining disability under the listings. In considering changes that SSA could make to the listings, the committee concluded that relying solely on objective anatomical measures of impairment to assess an individual’s disability status without considering function would be insufficient, as such measures generally correlate only weakly with degree of disability. Incorporating measures of functional assessment allows for a more effective evaluation of the work capacity of the whole person.

The committee’s approach to developing listing-level criteria was first to determine if a test result (e.g., reduced left ventricular ejection fraction) or set of test results is sufficient to ensure that virtually all individuals with such results are unable to work. Second, if anatomical measures are insufficient to evaluate work disability, as is the case for most cardiovascular conditions, the committee recommended that evidence-based functional assessments, if not already required in the listing, should also be applied to meet a listing.

Exercise tests on a treadmill or bicycle provide an objective measure of a person’s maximal aerobic capacity and are commonly used to provide diagnostic and prognostic information. The information can also be compared with the aerobic demands of various jobs, usually expressed as metabolic equivalents (METs). SSA currently uses inability to achieve five METs as a listing-level criterion for ischemic heart disease, heart failure, and congenital heart disease in adults, and will pay to have such tests performed if they are necessary for adjudication and considered safe for the claimant.

The committee determined that the current state of medical evidence shows that exercise tests are generally safe for patients with cardiovascular conditions such as ischemic heart disease, heart failure, and congenital heart disease, and found that SSA’s criteria for determining whether it is safe to order an exercise test are too strict. The committee urges SSA to update the safety criteria to allow broader use of exercise testing in the disability



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