Cardiovascular Listings. August 25, 2009 Institute of Medicine
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1 Cardiovascular Listings August 25, 2009 Institute of Medicine
2 Updating the Cardiovascular Listings Laurence Desi, Sr., M.D., M.P.H. Medical Officer Office of Medical Listings Improvement 2
3 IOM General Reminders SSA s mandate is to determine disability under the law Adjudicators are lay personnel, not physicians Disability examiners are usually college-educated Administrative law judges are lawyers DDS physicians are not cardiologists (usually) Good diagnostic tests are not necessarily good tests of disability because they may not correlate with function 3
4 IOM General Reminders Practical constraints Quality of evidence Especially for those without ongoing medical care MER v. CEs Availability of treatment especially in rural areas Consistency w/ standard medical practice How soon after stenting or CABG can claimant be evaluated for residual disability? (currently 3 months) Cost and nationwide availability of tests PET scan Minimal risk to the claimant Cardiac catheterization 4
5 Cardiovascular System Current Adult Listings 4.02 Chronic Heart Failure 4.04 Ischemic Heart Disease 4.05 Recurrent Arrhythmias 4.06 Symptomatic Congenital Heart Disease (Adults) 4.09 Heart Transplant 4.10 Aneurysm of Aorta or Major Branches (due to any cause) 4.11 Chronic Venous Insufficiency (of lower extremities) 4.12 Peripheral Arterial Disease 5
6 Here are some issues we have with the current Cardiovascular Listings 6
7 Technology Issues What is the current accepted standard for exercise treadmill testing (ETT) with an implanted defibrillator (AICD/PCD) in place? What is the value of ETT in the evaluation of disability with respect to various cardiac conditions? 7
8 Imaging Issues What is the current role of a chest X-ray in cardiac evaluations? Can we make use of non-invasive CT and MRI scans that suggest coronary artery disease? Can a high calcium score on CT scan serve as a proxy for disability? Can we use IVUS (intravascular ultrasound) and abnormal coronary reserve data? 8
9 Additional Listing Issues AHA/ACC guidelines Can we use them to improve disability determination? Use of NYHA classifications? Adults with Congenital Heart Disease (4.06) Need to have their own listing-specific criteria Childhood listings Are not all the same as for adults Obsolescence of listing criteria Is it possible to write criteria that fulfill other requirements but not as subject to medical advances? 9
10 Committee s Tasks Review current medical literature to determine most up-to-date: Standards of Care Technology for understanding CV Disease processes Impact of CV disorders on individual s health and functional capacity Respond to ANPRM comments, including review of AHA/ACC Guidelines Make recommendations for improving CV listings 10
11 Issues from the Field and Clinicians Questions Steven G. Steinberg MD FACC Cardiology Consultant Office of Medical and Vocational Expertise 11
12 Issues Identified in the Field Cardiac Listings are Complex 12
13 Issues Identified in the Field Exercise Tolerance Test Treadmill Bicycle Hand Nuclear Stress Treadmill Pharmacologic Dipyridamole Adenosine Dobutamine Echocardiographic Stress Treadmill Dobutamine Exercise Testing 13
14 Issues Identified in the Field Ejection Fraction MUGA (multigated acquisition) Echocardiography Nuclear Stress Cardiac Catheterization CT (computerized tomography) MRI (magnetic resonance imaging) 14
15 Issues Identified in the Field Do we want the listings simplified? 15
16 Issues Identified in the Field Are these numbers appropriate indicators of disability? Systolic Failure LV diastolic dimension 6cm; EF 30% Diastolic Failure Combined LV wall thickness 2.5 cm, LA 4.5 cm 16
17 Issues Identified in the Field Are the most up-to-date, accepted, and available technologies included? 17
18 Issues Identified in the Field Isovolumetric relaxation time, E/A ratio, tissue Doppler imaging for evaluation of diastolic dysfunction. CT angiography BNP or Pro-BNP levels 18
19 Listing 4.04 Ischemic Heart Disease For ischemic Heart Disease Stress test data Is the 5 MET level the appropriate level of exercise that must be attained? What do we do with pharmacologic stress test data that is not reported in METs? Catheterization data: >1cm in cath reports Length of lesions often not reported Lesion might be referred to as long does that fulfill the requirement? 19
20 Questions from the field What do we do if someone claims disability due to high calcium score on a CAT scan? 20
21 Questions from the field What do we do with IVUS (intravascular ultrasound) data and abnormal coronary flow reserve, that is, data that modifies the potential significance of catheterization findings? 21
22 Questions from the field What do we do with CAT scans and MRIs that suggest tight lesions? 22
23 Questions from the field What do we do with Syndrome X, that is, microvascular ischemia? 23
24 Questions from the field What do we do with vasodepressor episodes without arrhythmias? 24
25 SSA Medical Consultants Questions How do we approach conditions which don t fit any of the categories or listings but which may preclude SGA (substantial gainful activity), such as asymptomatic young people with hypertrophic obstructive cardiomyopathy (HOCM) or channelopathies (genetically-linked electrical abnormalities of the heart)? 25
26 Questions from the field Can we give more specific guidance on how to factor obesity into the cardiovascular listings? 26
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