Cardiovascular Disability Updating the Social Security Listings (2010) / Chapter Skim
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4 Approaches to Revising the Cardiovascular Listings
4 Approaches to Revising the Cardiovascular Listings
Pages 63-76
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From page 63... ...
These include the criteria for evaluating listings, the tradeoff between sensitivity and specificity inherent in designing a screening tool such as the listings, the limited predictive capacity of most clinical factors, the safety of exercise tests, and the impact of comorbidities (discussed in more detail in Chapter 15)
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From page 64... ...
Objective criteria may be easier to use and lead to more consistent decisions, but they do not necessarily lead to more correct decisions. The generally limited ability of objective clinical tests to predict functional capacity or work disability is discussed below.
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From page 65... ...
diagnosis Plus a Specific degree of medical Severity A number of listings require evidence of a certain degree of medical severity according to a specified test or examination, including one cardiovascular listing. For example, the current listing for peripheral artery disease (PAD)
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From page 66... ...
Adding a second basis for meeting a listing that requires less impairment severity -- if the claimant can demonstrate a marked limitation of capacity to function due to that impairment or impairments -- increases the sensitivity of the Listings, that is, identifies more claimants who should be allowed. Examples include: • Systolic heart failure with a left ventricular ejection fraction of 20 percent or less, because this severity would preclude gainful employ ment for nearly everyone, or with a left ventricular ejection fraction between 20 and 30 percent in conjunction with marked functional limitations (see Recommendations 5-3 and 5-1, respectively)
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From page 67... ...
For example, given a diagnosis of systolic heart failure and an ejection factor of 30 percent or less, the current listing is not met unless the claimant is unable to perform 5 metabolic equivalents of task (METs) on an exercise test, or has had three or more episodes of acute heart failure, or has persistent symptoms "which very seriously limit the ability to independently initiate, sustain, or complete activities of daily living." After reviewing evidence regarding the relationship of impairment measures (e.g., the ABI, ejection fraction, degree of left main artery stenosis, pulmonary artery pressure, valvular regurgitation volume to functional capacity)
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From page 68... ...
Allowed individuals may be false positives, who obtain benefits they are not entitled to. The appropriate metrics in this situation are sensitivity, specificity, and related measures of test accuracy.
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From page 69... ...
Limitations on the Predictive Ability of Clinical Factors The limited ability of clinical factors to predict the degree of functional capacity of an individual with an impairment makes it more challenging to increase the sensitivity of the Listings and to maintain high specificity at the same time. For example, most people with a left ventricular ejection fraction of 30 percent or less will not be able to get to and from or function in the workplace, but some will have that capacity.
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From page 70... ...
In most of the recommendations, therefore, the committee tried to increase sensitivity by requiring objective clinical documentation of severe impairments consistent with incapacity to work in most cases (e.g., ejection fraction of less than 30 percent for heart failure) and evidence of very serious functional limitations, which would serve to screen out false positives.
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From page 71... ...
. Maximizing the Use of Exercise Testing The introductory section of the cardiovascular system listings notes that exercise tolerance tests are widely used to determine functional capacity in patients with ischemic heart disease, heart failure, and peripheral artery disease.
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From page 72... ...
According to American College of Cardiology/American Heart Association guidelines for exercise testing (Gibbons et al., 2002) , absolute contraindications for exercise testing are an acute MI within the past 2 days, arrhythmias causing symptoms or hemodynamic compromise, symptomatic and severe aortic stenosis, uncontrolled symptomatic heart failure, acute pulmonary embolus or pulmonary infarction, acute myocarditis or pericarditis, and acute aortic dissection.
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From page 73... ...
We do not agree that this approach brings subjective functional considerations into purely objective medical decisions. Assessment of degree of anatomical impairment is certainly a medical function, performed as part of a regular medical evaluation of patients to determine treatment needs, but assessment of the person's functional capacity is also a medical function and can be performed in the medical setting and documented in the medical record.
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From page 74... ...
2007. Assessment of functional capacity in clinical and research settings: A scientific statement from the American Heart Association Committee on Exercise, Rehabilitation, and Prevention of the Council on Clinical Cardiology and the Council on Cardiovascular Nursing.
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From page 75... ...
2006. Clinical stress testing in the pediatric age group: A statement from the American Heart Association Council on Cardiovascular Disease in the Young, Committee on Atherosclerosis, Hyper tension, and Obesity in Youth.
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