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Cardiovascular Disability: Updating the Social Security Listings 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
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Cardiovascular Disability: Updating the Social Security Listings 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 input 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 cardiovascular medical experts to review the cardiovascular listings, medical literature, 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, valvular heart disease, heart failure, congenital heart disease (including adult), peripheral vascular disease, cardiac rehabilitation and stress testing, interventional 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 practice 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 committee 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).
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Cardiovascular Disability: Updating the Social Security Listings 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 technology for the understanding of disease processes, and the latest science demonstrating the effect of cardiovascular disorders on patients’ health and functional capacity … The primary purpose of the Consensus Committee is to make concrete recommendations 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. The Consensus Committee shall review, in a written report for the use of SSA, the most current medical literature to determine the latest standards of care, the latest technology for the understanding of disease processes, and the latest science demonstrating the impact of cardiovascular disorders on patients’ health and functional capacity. The Consensus Committee shall produce a written report for the use of SSA analyzing documents received in response to SSA’s Cardiovascular ANPRM request for public comments, including the AHA and ACC guidelines to determine 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). The Consensus Committee shall produce a written report for the use of SSA thatcomparesandcontrastsfindingsinthemostcurrentmedicalliteratureand ANPRM public comments with SSA’s current cardiovascular listings, as well as the key concepts included in the introduction of the cardiovascular listings. The Consensus Committee shall recommend guidance that, if incorporated into the cardiovascular listings, would improve their utility for evaluating disability claims based on the cardiovascular listings. The Committee will take into account considerations regarding the applicability of their recommendations in the SSA disability program. Examples of such considerations are: (1) consistency with standard medical practice, (2) cost and nationwide availability of any recommended tests, and (3) minimal risk and inconvenience to the claimant. The Consensus Committee shall produce a written report indicating what evidence, 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. The Consensus Committee will produce a written report for SSA with all of its findings. The report may be made available to the interested public only after the Task Order has ended.
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Cardiovascular Disability: Updating the Social Security Listings 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 cardiovascular 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 determination 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. Chapters 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 dissection 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. 2 Oakland, California; San Diego/La Jolla, California; Stone Mountain, Georgia; Boston, Massachusetts; St. Paul, Minnesota; Buffalo, New York; and Washington, DC.