1
Introduction

In 2010, the Social Security Administration (SSA) expects more than 3.3 million individuals to apply for disability benefits on the basis that they have a physical or mental impairment that prevents them from engaging in “any substantial gainful activity,” or if children, from engaging in age-appropriate activities at home, at school, or in the community. Determining whether claimants (i.e., applicants) have an impairment that meets SSA’s definition of disability can entail an intensive and lengthy individualized evaluation of their medical condition. The full evaluation requires a consideration of the effects of the medical condition or conditions on the claimant’s ability to function and consideration of the claimant’s age, education, and work history. Under the Supplemental Security Income (SSI) program, claimants also include children under age 18 who have a physical or mental impairment or combination of impairments that cause “marked and severe functional limitations.” The full evaluation of these claimants requires consideration of, and judgments about, functional limitations in six domains of functioning.

To reduce the administrative burden of evaluating the disability of millions of claimants each year, SSA uses a screening tool called the Listing of Impairments, also known as the Listings, to quickly identify claimants with medical conditions so severe that they can be allowed benefits without going through the full evaluation process. This expedites the approval process for the claimants and saves SSA substantial administrative and economic resources.

The Listings describe physical and mental impairments so severe that anyone who has such an impairment cannot be expected to work at all



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 35
1 Introduction In 2010, the Social Security Administration (SSA) expects more than 3.3 million individuals to apply for disability benefits on the basis that they have a physical or mental impairment that prevents them from engaging in “any substantial gainful activity,” or if children, from engaging in age- appropriate activities at home, at school, or in the community. Determin- ing whether claimants (i.e., applicants) have an impairment that meets SSA’s definition of disability can entail an intensive and lengthy individual- ized evaluation of their medical condition. The full evaluation requires a consideration of the effects of the medical condition or conditions on the claimant’s ability to function and consideration of the claimant’s age, edu- cation, and work history. Under the Supplemental Security Income (SSI) program, claimants also include children under age 18 who have a physical or mental impairment or combination of impairments that cause “marked and severe functional limitations.” The full evaluation of these claimants requires consideration of, and judgments about, functional limitations in six domains of functioning. To reduce the administrative burden of evaluating the disability of mil- lions of claimants each year, SSA uses a screening tool called the Listing of Impairments, also known as the Listings, to quickly identify claimants with medical conditions so severe that they can be allowed benefits without go- ing through the full evaluation process. This expedites the approval process for the claimants and saves SSA substantial administrative and economic resources. The Listings describe physical and mental impairments so severe that anyone who has such an impairment cannot be expected to work at all 

OCR for page 35
  CaRdIoVaSCUlaR dISabIlIty regardless of age, education, or work experience, or in the case of a child, has marked and severe functional limitations. Although strict, the Listings account for nearly half of the disability approvals granted each year. In part because of advances in medical treatment, SSA updates and revises the Listings periodically. The Listings are organized by body system (e.g., neurological, musculoskeletal, cardiovascular, immune) and, at any given time, SSA is revising several of the body systems (there are 14 adult and 15 child body systems). In August 2009, SSA commissioned the Institute of Medicine (IOM) to convene a committee to conduct a 1-year study of the Listings and to make concrete recommendations that are designed to improve the usefulness of the cardiovascular listings for evaluating cardiovascular disability claims by improving the sensitivity and specificity of the listing criteria to identify claimants who have impairments that meet SSA’s definition of disability. (See Box 1-1 for relevant excerpts from the contractual statement of work.) The information and recommendations in the report will be part of the in- put to its formal process for developing a Notice of Proposed Rulemaking and, subsequently, final rules that will be published in the federal Register to update the cardiovascular listings. In response to this assignment, the IOM formed a committee of cardio- vascular medical experts to review the cardiovascular listings, medical lit- erature, and advances in technology, and to recommend improvements. The committee’s membership includes a wide range of expertise able to evaluate cardiovascular disability criteria, including coronary artery disease, valvu- lar heart disease, heart failure, congenital heart disease (including adult), peripheral vascular disease, cardiac rehabilitation and stress testing, inter- ventional cardiology, arrhythmia, pulmonary arterial hypertension, nursing, and psychiatric comorbidities. Short biographies of the committee members are in Appendix A. To address its charge, the committee and staff conducted an intensive review of the relevant medical research literature, current clinical prac- tice guidelines, and program data from SSA, and received briefings from knowledgeable stakeholders. Over the course of the 12-month study, the committee met four times (December 2009, and February, April, and June 2010). The public was invited to meet with the committee (December 2009) and to participate in three public webinars (held in April 2010).1 The com- mittee received oral and written statements from various stakeholders (see the Acknowledgments section at the beginning of this report). Committee members also conducted site visits at seven disability determination offices 1 The webinars addressed congenital heart disease (April 5), pulmonary hypertension (April 7), and chronic venous insufficiency and aneurysm (April 14).

OCR for page 35
 IntRodUCtIon BOX 1-1 Cardiovascular Committee’s Statement of Work   IOM  shall  form  a  Consensus  Committee  to  perform  a  focused  review  of  the  medical literature to  determine  the  latest  standards  of  care,  the  latest  technol-  ogy for the understanding of disease processes, and the latest science demon- strating the effect of cardiovascular disorders on patients’ health and functional  capacity . . .   The primary purpose of the Consensus Committee is to make concrete recom- mendations that are designed to improve the utility of the Cardiovascular Listings  for  evaluating  cardiovascular  disability  claims  by  improving  the  sensitivity  and  specificity of the listing criteria to identify individuals who meet SSA’s definition  of disability . . .   The IOM shall form a Consensus Committee composed of approximately 8–12  members having clinical expertise in the cardiovascular system. The responsible  committee shall hold meetings to gather and analyze data and information that  addresses the following tasks. 1.    he Consensus Committee shall review, in a written report for the use of SSA,  T the most current medical literature to determine the latest standards of care,  the latest technology for the understanding of disease processes, and the lat- est science demonstrating the impact of cardiovascular disorders on patients’  health and functional capacity. 2.    he Consensus Committee shall produce a written report for the use of SSA  T analyzing documents received in response to SSA’s Cardiovascular ANPRM  request  for  public  comments,  including  the  AHA  and  ACC  guidelines  to  de- termine  which,  if  any,  guidelines  have  the  potential  to  become  indicators  of  disability as defined by SSA (that is, to assess which, if any, of the comments  or  guidelines  would  be  useful  in  developing  listing  criteria  for  determining  disability). 3.    he Consensus Committee shall produce a written report for the use of SSA  T that compares and contrasts findings in the most current medical literature and  ANPRM public comments with SSA’s current cardiovascular listings, as well as  the key concepts included in the introduction of the cardiovascular listings. 4.    he  Consensus  Committee  shall  recommend  guidance  that,  if  incorporated  T into  the  cardiovascular  listings,  would  improve  their  utility  for  evaluating  dis- ability  claims  based  on  the  cardiovascular  listings. The  Committee  will  take  into account considerations regarding the applicability of their recommenda- tions  in  the  SSA  disability  program.  Examples  of  such  considerations  are:    (1) consistency with standard medical practice, (2) cost and nationwide avail- ability of any recommended tests, and (3) minimal risk and inconvenience to  the claimant. 5.    he Consensus Committee shall produce a written report indicating what evi- T dence, laboratory findings, signs and symptoms within the medical evidence of  record (MER) may improve the sensitivity and specificity of the listing criteria  to identify individuals who meet SSA’s definition of disability. 6.    he Consensus Committee will produce a written report for SSA with all of its  T findings. The report may be made available to the interested public only after  the Task Order has ended.

OCR for page 35
  CaRdIoVaSCUlaR dISabIlIty in different parts of the United States,2 where they spoke with experienced disability examiners and medical consultants who apply the cardiovascular listings. This helped committee members to better understand the disability determination process and the challenges encountered in evaluating cardio- vascular disability. REPORT STRUCTURE This report consists of 16 chapters, of which this introduction is the first. Chapter 2 provides the reader an overview of SSA’s disability deter- mination process. Chapter 3 provides statistics on cardiovascular disease prevalence and incidence as well as trends in cardiovascular claims for Social Security disability benefits. Chapter 4 describes the committee’s approach to evaluating the current Social Security cardiovascular listings disability criteria and designing recommendations to improve them. Chap- ters 5 through 14 address specific cardiovascular conditions: heart failure, cardiomyopathy, and right heart failure (Chapter 5); heart transplantation (Chapter 6); ischemic heart disease (Chapter 7); peripheral artery disease (Chapter 8); chronic venous insufficiency (Chapter 9); congenital heart disease (Chapter 10); pulmonary hypertension (Chapter 11); valvular heart disease (Chapter 12); arrhythmias (Chapter 13); and aneurysm or dissec- tion of the aorta and peripheral arteries (Chapter 14). Chapter 15 addresses the impact of comorbidities. Chapter 16 identifies research that SSA could undertake and support to improve the Listings in the future. 2Oakland, California; San Diego/La Jolla, California; Stone Mountain, Georgia; Boston, Massachusetts; St. Paul, Minnesota; Buffalo, New York; and Washington, DC.