CARDIOVASCULAR DISABILITY
Updating the Social Security Listings
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu
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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
This study was supported by Contract No. SS-00-08-60149 between the National Academy of Sciences and the Social Security Administration. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.
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Suggested citation: IOM (Institute of Medicine). 2010. Cardiovascular disability: Updating the Social Security listings. Washington, DC: The National Academies Press.
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
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COMMITTEE ON SOCIAL SECURITY CARDIOVASCULAR DISABILITY CRITERIA
NANETTE K. WENGER (Chair),
Emory University School of Medicine and Grady Memorial Hospital, Atlanta, Georgia
WILLIAM E. BODEN,
University at Buffalo Schools of Medicine and Public Health and Kaleida Health, New York
BLASE A. CARABELLO,
Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
ROBERT M. CARNEY,
Washington University School of Medicine, St. Louis, Missouri
MANUEL D. CERQUEIRA,
Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Ohio
MICHAEL H. CRIQUI,
University of California, San Diego
ANDREW E. EPSTEIN,
University of Pennsylvania and Philadelphia Veterans Affairs Medical Center
ERIKA S. FROELICHER,
University of California, San Francisco
GARY H. GIBBONS,
Morehouse School of Medicine, Atlanta, Georgia
MARK A. HLATKY,
Stanford University, California
ALICE K. JACOBS,
Boston University School of Medicine and Boston Medical Center, Massachusetts
KAREN S. KUEHL,
George Washington University, Children’s National Medical Center, and Washington Hospital Center, Washington, DC
TODD D. MILLER,
Mayo Clinic, Rochester, Minnesota
LYNNE W. STEVENSON,
Harvard Medical School and Brigham and Women’s Hospital, Boston, Massachusetts
Consultant
HOWARD H. GOLDMAN,
University of Maryland School of Medicine, Baltimore
Study Staff
FREDERICK (RICK) ERDTMANN, Director,
Board on the Health of Select Populations
MICHAEL McGEARY, Study Director
SUSAN R. McCUTCHEN, Senior Program Associate
ERIN E. WILHELM, Research Associate
LAVITA D. COATES-FOGLE, Senior Program Assistant
PAMELA RAMEY-McCRAY, Administrative Assistant
SAMANTHA CHAO, Program Officer
JOI WASHINGTON, Senior Program Assistant
ANDREA COHEN, Financial Associate
WILLIAM McLEOD, Senior Librarian
Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
James A. Blumenthal, Duke University Medical Center, Durham, North Carolina
Robert O. Bonow, Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital, Chicago, Illinois
Deborah Chyun, New York University
David P. Faxon, Brigham and Women’s Hospital, Boston, Massachusetts
Gary S. Francis, Cleveland Clinic and Case Western Reserve University, Minneapolis, Minnesota
William L. Henrich, University of Texas Health Science at San Antonio
William R. Hiatt, University of Colorado, Denver
Stuart Rich, University of Chicago Medical Center, Illinois
Roberta G. Williams, University of Southern California and Childrens Hospital, Los Angeles
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Harlan M. Krumholz, Yale University, and Johanna T. Dwyer, Tufts University. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
Preface
The Committee on Social Security Cardiovascular Disability Criteria, an ad hoc committee of medical experts appointed by the Institute of Medicine (IOM), was charged to conduct a study to assist the Social Security Administration (SSA) with revising its criteria for cardiovascular disability in its Listing of Impairments (“the Listings”). The committee reviewed the current cardiovascular disability criteria in the Listings and identified areas in which the committee believed the cardiovascular listings should be revised and updated based on current medical knowledge and practice. Specifically, the committee (1) conducted a comprehensive review of the relevant research literature and current professional practice guidelines developed jointly by the American Heart Association and the American College of Cardiology; (2) assessed the current cardiovascular listings in light of current research knowledge and evidence-based medical practice; and (3) produced a concise report with specific recommendations for revision of the cardiovascular listings based on evidence (to the extent possible) and on professional judgment (where evidence was lacking). SSA uses the Listings to expedite the approval of claims from individuals who are so obviously disabled that they have a high probability of being found disabled if SSA went through the full disability determination process. The primary purpose of the consensus committee was to make concrete recommendations designed to improve the utility of the cardiovascular listings for evaluating disability claims by improving the sensitivity and specificity of the listing criteria to identify individuals who meet SSA’s definition of disability, that is, those who are no longer able to engage in substantial work activities.
The contemporary approach to patient-centered care is designed to achieve optimal outcomes, including disease outcomes. This is the approach that the committee extended to tailor a process for disability evaluation that would ensure optimal outcomes.
The committee is grateful for the contributions of many individuals who expanded our knowledge and understanding of cardiovascular disability and suggested improvements in the disability evaluation process. They are listed in the Acknowledgments section of this report. The committee acknowledges with deepest appreciation the expert support and collegial relationship of the IOM staff. They are Michael McGeary (study director), Susan McCutchen (senior program associate), Erin Wilhelm (research associate), LaVita Coates-Fogle (senior program assistant), and Frederick (Rick) Erdtmann (director, Board on the Health of Select Populations).
The cardiovascular community has a tradition of evidence-based clinical practice guidelines that address a number of cardiovascular disease states. These guidelines are updated periodically to reflect current knowledge. A specific and uniform grading system identifies the level of evidence and the robustness of the database supporting this evidence. However, a review of the currently applicable clinical practice guidelines, although with abundant recommendations for diagnostic and prognostic testing, clinical management, and resultant outcomes, clearly shows (as viewed by the committee) an unmet need for a research base for the evaluation of cardiovascular disability.
The approach of the committee is its unique contribution. Careful review of the scientific literature from both primary and secondary sources was undertaken to identify tests or procedures that would quantify functional capacity and, furthermore, be generally available either in the claimants’ medical records or for purchase in the assessment of potential claimants. With this in mind, we sought to apply the best available knowledge and to recommend new practices and perspectives to ensure the optimal outcomes for disability claimants who meet SSA’s definition of disability.
Highlighted in the committee deliberations was that a large number of recently available cardiovascular test procedures precisely delineate anatomy or pathoanatomy, but that there is no consistent relationship between anatomy and functional capacity. The committee therefore concluded that the tests delineating anatomy should be used to define the presence and severity of disease, but that the disability process usually requires additional information on the functional limitations imposed by the disease. The committee recommended revisions in most of the current listings and suggested new listings for certain cardiovascular problems, including hypertrophic cardiomyopathy, right heart failure, and pulmonary hypertension. We developed flowcharts for decision making for most of the cardiovascular listings to assist the adjudicator in the definition of disease and levels
of functional limitations required to meet those listings. We also reviewed important comorbidities that the adjudicator should consider in assessing whether a claimant’s cardiovascular condition equals a listing. Finally, we delineated four areas of research that SSA could pursue to improve the disability decision process, including the listings.
The committee first met in December 2009, with three subsequent formal sessions in February, April, and June 2010 (and numerous conference calls), during which we categorized and evaluated cardiovascular medically determinable physical and mental impairments that could be expected to result in death or that have lasted or can be expected to last for a continuous period of not less than 12 months.
I would like to express my personal gratitude for the skills and dedication of the individual committee members and for their expertise, enthusiasm, and energy. On behalf of the committee, I would also like to thank Howard Goldman, who chairs IOM’s standing committee of medical experts to assist SSA, for his participation and advice.
The intellectual content is evidence based and objective. The conclusions were reached by consensus and are the combined judgment of the committee. Our emphasis in this report is on consistency, quality, and appropriateness criteria.
Future covariables that should influence disability determination and guide its research agenda include the impact of changes in the national and regional economy, changes in health insurance and access to health care and disease evaluation, and the expansion of the evidence base enabled by open government, among others. All are likely to alter cardiovascular disease outcomes and inform consequent cardiovascular disability determinations.
Nanette K. Wenger
Chair, Committee on Social Security Cardiovascular Disability Criteria
Acknowledgments
Many individuals and organizations contributed to the study. In particular, the committee and staff would like to thank:
ROBYN BARST, Columbia University College of Physicians and Surgeons
AMY BASKEN, National Congenital Heart Association
MARGARET BEARDSWORTH, Pulmonary Hypertension Association
WILLIAM R. DAVIDSON, JR., Penn State Milton S. Hershey Medical Center
CHRISTINE DEHAAN, Social Security Administration
LAURENCE DESI, SR., Social Security Administration
ROBIN DOYLE, Social Security Administration
SHEILA EVERETT, Social Security Administration
HARRISON FARBER, Boston University
JAMES W. FASULES, American College of Cardiology
JOSEPHINE GRIMA, National Marfan Foundation
LARRY F. HAMM, American Association of Cardiovascular and Pulmonary Rehabilitation
MONTE HETLAND, Social Security Administration
JAMILLAH JACKSON, Social Security Administration
KATHERINE KRONER, Pulmonary Hypertension Association
VANESSA LEVINE, Alliance of Community Health Plans
GAVIN LINDBERG, Health and Medicine Council of Washington
JOANNA MARASHLIAN, Social Security Administration
PATRICK E. MCBRIDE, American Association of Cardiovascular and Pulmonary Rehabilitation
GREGORY L. MONETA, Oregon Health and Science University
MICHELLE J. NICKOLAUS, Penn State Milton S. Hershey Medical Center
MIKE O’CONNOR, Social Security Administration
RONALD J. OUDIZ, University of California, Los Angeles
KEVIN PARMER, Social Security Administration
JEFFREY PRICE, National Association of Disability Examiners (NADE) and North Carolina Disability Determination Services
J. SCOTT PRITCHARD, NADE and Oregon Disability Determination Services
FRANK SCHUSTER, Social Security Administration
PAUL SCOTT, Social Security Administration
ARTHUR R. SPENCER, Social Security Administration
SHIRLEETA STANTON, Social Security Administration
STEVEN STEINBERG, Social Security Administration
JANET TRUHE, Social Security Administration
AMY VERSTAPPEN, Adult Congenital Heart Association
CHERYL WILLIAMS, Social Security Administration
ROBERTA G. WILLIAMS, University of Southern California
In addition, the committee would like to thank those at the Social Security Administration headquarters and regional offices who helped arrange the visits of committee members to state disability determination services (DDS) offices and the staff in the DDSs who took the time to explain the disability determination process and how the Listings are used in that process, and to discuss practical problems encountered in using them.
Tables, Figures, and Boxes
TABLES
O-1 |
Current Adult and Child Cardiovascular Listings, |
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2-1 |
Numbers of Disability Program Beneficiaries and Benefit Amounts, 2008, |
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6-1 |
Survival Rates After Heart Transplantation, by Sex, |
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7-1 |
Canadian Cardiovascular Society Functional Classification of Angina, |
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7-2 |
Other Variables Associated with Multivessel CHD or Worse Prognosis, |
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7-3 |
Criteria to Meet a Listing Through the Use of an Exercise Stress Test, |
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7-4 |
Optimal Pharmacologic Therapy Based on the COURAGE Trial, |
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9-1 |
Clinical Classification of Chronic Venous Disease (CVD), |
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12-1 |
Characterization of Severe Valve Disease, |
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14-1 |
Normal Adult Thoracic Aortic Diameters, |
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B-1 |
Literature Table of Cardiovascular Employment and Disability Articles, |
FIGURES
3-1 |
Annual number of initial adult cardiovascular claims, 1990–2008, |
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3-2 |
Annual allowance rate for initial adult cardiovascular claims, 1990–2008, |
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3-3 |
Annual percentage of initial adult allowances made on the basis of the cardiovascular listings, 1990–2008, |
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3-4 |
Annual number of initial adult allowances based on the cardiovascular listings, 1999–2009, |
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3-5 |
Percentage of adult initial allowances based on the cardiovascular listings, by selected impairment code, 1989–2008, |
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5-1 |
Recommended listing-level criteria for systolic and diastolic heart failure, |
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5-2 |
Recommended listing-level criteria for hypertrophic cardiomyopathy, |
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5-3 |
Recommended listing-level criteria for right heart failure, |
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7-1 |
Coronary heart disease listings, |
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7-2 |
Coronary heart disease listings: Ischemic heart disease ladder flow diagram, |
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10-1 |
Documentation of congenital heart defect likely to require surgery, diagnosis of significant heart disease in infancy or childhood, |
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10-2 |
Documentation of congenital heart defect likely to require surgery, disabled by Groups A and B, birth to age 12, |
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10-3 |
Documentation of congenital heart defect, disabled by Group C, ages 12 to 18, |
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10-4 |
Documentation of congenital heart defect disabled as adults, ages 18 and over, |
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11-1 |
Meeting criteria for disability due to pulmonary hypertension, |
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12-1 |
Determining listing-level disability for claimants with valvular heart disease, |
BOXES
1-1 |
Cardiovascular Committee’s Statement of Work, |
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4-1 |
Committee’s Approach to Revising the Listings, |
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5-1 |
Current Listing for Chronic Heart Failure, |
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6-1 |
Current Listing for Heart Transplant, |
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7-1 |
Current Adult Listing for Ischemic Heart Disease, |
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7-2 |
Current Childhood Listing for Ischemic Heart Disease, |
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8-1 |
Current Listing for Peripheral Arterial Disease, |
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8-2 |
1.00 Musculoskeletal System, |
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9-1 |
Current Listing for Chronic Venous Insufficiency, |
10-1 |
Current Congenital Heart Disease Listing for Children, |
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10-2 |
Current Congenital Heart Disease Listing for Adults, |
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13-1 |
Current Listing for Recurrent Arrhythmias, |
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14-1 |
Current Listing for Aneurysm of Aorta or Major Branches, |
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B-1 |
Definition of Tiers, |
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C-1 |
American College of Cardiology/American Heart Association (ACC/AHA Guidelines), |
Abbreviations and Acronyms
AAA abdominal aortic aneurysm
ABI ankle-brachial index
ACC American College of Cardiology
ACE angiotensin-converting enzyme
ACS acute coronary syndrome
ADLs activities of daily living
AHA American Heart Association
ALJ administrative law judge
AR aortic regurgitation
AVNRT atrioventricular nodal reentrant tachycardia
AVRT atrioventricular reentrant tachycardia
BMI body mass index
BMS bare metal stents
BNP brain natriuretic peptide
BP blood pressure
BRFSS Behavioral Risk Factor Surveillance System
CABG coronary artery bypass graft
CAD coronary artery disease
CCB calcium channel blocker
CCS Canadian Cardiovascular Society
CDC Centers for Disease Control and Prevention
CDR continuing disability review
CE consultative examination
CHD chronic heart disease
cm centimeter
COPD chronic obstructive pulmonary disease
CPX cardiopulmonary exercise
CT computed tomography
CTA computed tomography angiography
CVD cardiovascular disease; chronic venous disease
CVI chronic venous insufficiency
CXR chest x-ray
DDS disability determination services
DES drug-eluting stent
DM diabetes mellitus
Dx diagnosis
ECG electrocardiogram
EECP enhanced external counterpulsation
EF ejection fraction
ESV end systolic volume
ETT exercise tolerance test
EVAR endovascular aneurysm repair
FDA Food and Drug Administration
HDL high-density lipoprotein cholesterol
HF heart failure
HFpEF heart failure with preserved ejection fraction
IADLs instrumental activities of daily living
ICD implantable cardioverter-defibrillator
ICD International Classification of Diseases
IHD ischemic heart disease
IOM Institute of Medicine
kg kilogram
LA left atrial/atrium
LDL low-density lipoprotein cholesterol
LED lower extremity disease
LV left ventricle
LVDD left ventricular diastolic dysfunction
LVEF left ventricular ejection fraction
LVOT left ventricular outflow tract
m meter
MER medical evidence of record
MESA Multi-Ethnic Study of Atherosclerosis
METs metabolic equivalents of task
MI myocardial infarction
MIE medical improvement expected
min minute
MINE medical improvement not expected
MIP medical improvement possible
ml milliliter
mm millimeter
mm Hg millimeters of mercury
mph miles per hour
MR mitral regurgitation
MRA magnetic resonance angiography
MRI magnetic resonance imaging
NHANES National Health and Nutrition Examination Survey
NHLBI National Heart, Lung, and Blood Institute
NPRM Notice of Proposed Rulemaking
NRC National Research Council
NT-proBNP N-terminal prohormone brain natriuretic peptide
O2 oxygen
PAD peripheral artery disease
PCI percutaneous coronary intervention
PET positron emission tomography
PO2 partial pressure of oxygen
POMS Program Operations Manual System
proBNP prohormone brain natriuretic peptide
PVC premature ventricular contraction
PVD peripheral vascular disease
RER respiratory exchange ratio
RFC residual functional capacity
SD standard deviation
sec second
SGA substantial gainful activity
SIP Sickness Impact Profile
SPECT single-photon emission computerized tomography
SRS summed reversibility score
SSA Social Security Administration
SSDI Social Security Disability Insurance
SSI Supplemental Security Income
SSS summed stress score
TA thoracic aorta
TBI toe-brachial index
TG triglycerides
TID transient ischemic dilatation
Torr Torricelli
U.S. United States
VHD valvular heart disease
VO2 oxygen consumption
WHO World Health Organization
WMA wall motion abnormality
WMI wall motion index