SAHIE provide information on health insurance coverage by age, sex, race, Hispanic origin and income categories at the state level and by age, sex and income categories at the county level. They therefore enable local planners to determine, for instance, the counties in which low-income children are most likely to lack health insurance coverage. The data pertain to those under age 65.

In September, the Census Bureau will release health insurance coverage estimates from the 2009 American Community Survey (ACS). These single-year estimates will be available for counties and other geographic areas with total populations of 65,000 or more. The health insurance question was added to the 2008 ACS to permit the U.S. Department of Health and Human Services to more accurately understand state and local health insurance needs. Eventually the ACS will have health insurance coverage data for smaller areas from three-year and five-year estimates.

The results are from a new survey from MedAxiom, a subscription-based service provider and information resource that provides benchmarking and performance data to cardiology practices to help them improve organizational focus, efficiency and profitability.

Specifically, this survey, the largest quantifiable one of its kind, confirms that older Americans are relying more on medical specialists, such as cardiologists, to address their specific healthcare needs.  The number of patients seeking specialty heart care continues to grow; cardiologists surveyed by MedAxiom reported that they each saw an average of 343 new patients in 2009, continuing an increasing trend of the past several years.  Perhaps just as important is the upwards trend in return visits; cardiologists saw an average of 1,700 return appointments last year with existing patients.  This is the highest yearly number yet recorded, indicating an ongoing commitment to providing consistent, high quality healthcare.

Practices reporting data to MedAxiom also reported increases in several key cardiology tests, conducted both in-office and at hospitals. "This is largely due to the growth in the total number of patients being seen by cardiologists," saidPatrick White, MedAxiom's president.  "It's not because cardiologists are doing more tests per patient.  Conversely, we have seen cardiologists become more effective in their use of technology to produce the best results."  White noted that even as reimbursements for tests continue to drop, cardiologists reduced their operating costs on 2009 in a successful effort to minimize their losses.

Further results from the MedAxiom survey include:

• Hospital admissions per cardiologist continued their downward trend over the five-year period, indicating cardiologists' commitment to better, lower cost outpatient care.
• The average number of treadmill tests per cardiologist fell to their lowest level in a decade, but stress echocardiogram tests increased to their highest level, with an average of four percent of all patients undergoing such stress testing.
• Cardiologists performed five percent more nuclear studies in 2009 (280) than they did in 2008, the highest number in three years.  But that increase directly correlates with the increase in the number of patients seen; on average, nuclear studies were performed on one of every seven patients, the same as in the previous two years.

The survey also found that America's cardiologists are modifying their operations and an increasing number are merging practices with each other as well as folding into larger health care organizations to ensure long-term financial stability, while ensuring that patients' needs continue to be met. "Smaller and midsized firms will face economic pressures to merge with larger firms or hospital practices. All practices will have to address the best ways to balance providing more personalized service to a growing number of patients seeking cardiac care in a cost-effective fashion," said White.

"We are optimistic about the future of cardiology, despite the significant negative impact of administrative and legislative regulation. More people need ? and want ? the type of quality, specialty care that cardiologists are capable of providing," White added.

Study authors looked at emergency room data from January 1, 2004 through December 21, 2005, and found about 144,799 medical device adverse events (MDAEs). They determined that the most common type of injuries affected the eyeball, pubic region, finger, face and ear. While MDAEs decreased as children approached 10 years old, they spiked again as kids entered their teens. Girls 16 to 21 were affected at older ages, while boys under 10 were most likely to experience device problems.

The researchers concluded that regulators and healthcare providers need to develop better preventative measures to keep kids from being injured by devices. "Targeted interventions should be developed and resources should be directed to address pediatric MDAEs with the greatest public health impact," notes the authors.

An analysis of carotid revascularization procedures among Medicare patients over a three-year period, found that the East North Central region had the greatest odds of endarterectomy (OR 1.60, 95% CI 1.55 to 1.65) and stenting (OR 1.61, 95% CI 1.46 to 1.78) compared with New England, according to Manesh Patel, MD, of Duke University, and colleagues.

After adjusting for demographic and clinical characteristics, there were also significant geographic variations in the odds of carotid revascularization. Overall, the New England, Mountain, and Pacific regions tended to have the lowest rates of revascularization, whereas the East and West South and North Central regions had higher rates, Patel and co-authors wrote in the July 26 issue of the Archives of Internal Medicine.

The researchers also found considerable differences in the use of diagnostic imaging prior to revascularization. "Most patients who underwent carotid stenting had previously undergone ultrasonography and x-ray angiography; almost one-fifth underwent ultrasonography, MRA, and x-ray angiography; and more than 10% underwent ultrasonography alone," they noted.

"These findings suggest that the development of consensus regarding clinical criteria for carotid imaging, such as a national standard for appropriate use criteria, is required," the authors commented.

Endarterectomy has been the recommended treatment for patients with carotid artery disease since the publication of several randomized trials in the 1990s. In 2004, the Centers for Medicare and Medicaid Services (CMS) said it would pay for carotid stenting as well.

Little is known about patterns in the use of carotid revascularization since that decision, so the researchers analyzed CMS claims between Jan. 1, 2003 and Dec. 31, 2006.

A total of 320,354 patients had endarterectomy over that time, but the rate of that procedure fell from 3.2 per 1,000 person-years in 2003 to 2.6 per 1,000 in 2006.

Carotid stenting was performed in 19,444 patients from Jan. 1, 2005 through the end of the study.

"The low observed rate of carotid stenting is likely related to the fact that the CMS national coverage decision ... was limited to patients at high surgical risk," the researchers wrote.

They noted that the overall rate of revascularization did not increase during that time.

"Uptake (of stenting) was rapid and high in some areas where doctors were already conducting carotid revascularization to clear blockages," Patel said in a statement released by Duke. "In areas where doctors had been doing more surgery, patients tended to start getting more stents."

The strongest predictors of stenting were:

• Prior endarterectomy (OR 3.06, 95% CI 2.65 to 3.53)
• Coronary artery disease (OR 2.12, 95% CI 2.03 to 2.21)
• Male sex (OR 1.62, 95% CI 1.56 to 1.68)
• Peripheral vascular disease (OR 1.58, 95% CI 1.52 to 1.64)

Male sex and peripheral vascular disease were also predictors of endarterectomy (OR 1.63, 95% CI 1.61 to 1.65 and OR 1.37, 1.35 to 1.39, respectively).

Finally, in 2005, mortality for endarterectomy was 1.2% at 30 days and 6.8% at one year; those rates stood at 2.3% at 30 days and 10.3% at one year for stenting.

"More attention should be directed toward management of stroke risk, including the use of revascularization among patients already experiencing symptoms," Patel said in the statement. "We also need further research to understand the best treatment for those patents without symptoms."

"While our findings show vast differences in the methods of revascularization across the country," he added, "the question remains: which patients are the best candidates for revascularization?"

The researchers noted that their analysis included only patients enrolled in fee-for-service Medicare, so "the generalizability of the results to all Medicare beneficiaries is unclear." They further noted that the analysis was limited by information available in Medicare claims, a lack of detailed clinical data, and restricted multivariable analyses.

Since the study was restricted to Medicare claims, the analysis does not reflect data for carotid revascularization in patients younger than 65, the authors also noted. And, because the multivariable analyses was restricted to patients who underwent MRA or angiography (invasive or noninvasive), the results may not be generalizable to patients for whom revascularization was preceded by carotid ultrasonography only, they added.

In an accompanying editorial in the Archives of Internal Medicine, Ethan A. Halm, MD, MPH, of the University of Texas Southwestern Medical Center, wrote that better risk prediction tools are needed to help physicians individualize the short- and long-term risks and benefits of revascularization."

"Because carotid revascularization is a 'preference-sensitive condition,'" he wrote, "evidence-based decision aids should be developed to inform patients about the pros and cons of all their treatment options so that their preferences ... are heavily factored into a shared decision about treatment."

CTC could be a cost-effective screening option for this population only if the cost of the test was substantially less than that of colonoscopy, or if a large proportion of otherwise unscreened persons were to undergo screening by CTC, the researchers comment.

"If CTC screening is reimbursed at roughly the same rate as colonoscopy, the cost, relative to the benefit derived and to the availability and costs of other colorectal cancer screening tests, is too high for it to be a cost-effective screening strategy," note the authors, led by Amy B. Knudsen, PhD, a senior scientist at the Institute for Technology Assessment, Massachusetts General Hospital, in Boston.

Mixed Opinions

Experts are decidedly mixed on the use of CTC, and as Russell Harris, MD, MPH, points out in an accompanying editorial, 2 national guidelines have reached opposing conclusions. In 2008, the US Preventive Services Task Force (USPSTF) added colonoscopy to its list of recommended colorectal cancer screening tests, but at the same time it found that the evidence for CTC was "insufficient" to adequately weigh the benefits and harms.

Conversely, a joint guideline was issued that same year by the Multi-Society Task Force, the American Cancer Society, and the American College of Radiology, which added CTC to its list of recommended colorectal cancer screening tests.

In March 2009, the Centers for Medicare and Medicaid Services (CMS) decided against granting reimbursement for CTC as a screening test for colorectal cancer. As reported by Medscape Medical News at that time, they found that "the evidence is not sufficient to conclude that screening [CTC] improves health benefits for asymptomatic average-risk Medicare beneficiaries."

Better Primary Screening Option Needed

The current study makes an important contribution to this discussion, as it examines the cost-effectiveness of CTC screening in the Medicare population, notes Dr. Harris, a professor of medicine at the University of North Carolina, Chapel Hill. However, both CTC and optical colonoscopy have their own benefits and harms.


"What is really needed is a better screening test for the average-risk person," Dr. Harris told Medscape Medical News. "Think about the other screening tests that we have — like mammography, Pap smears, and prostate-specific antigen for prostate cancer. None of them are as invasive or as expensive, or require the kind of preparation needed for colonoscopy."

Colonoscopy will be needed for individuals who need further work-up, but an easier, less expensive, and less-invasive test is needed as a primary screening test for average risk individuals, he explained.

Dr. Harris was a member of the USPSTF when the CTC recommendation was made, but if he were to vote again today on whether to include CTC on the list of recommended colorectal cancer screening tests, "I would still vote that the evidence is insufficient and thus would not recommend it," he notes in his editorial.

An important concern of CTC is the potential harm of the many extracolonic findings, said Dr. Harris, pointing out that studies of CTC have found that extracolonic findings occur in 40% to 98% of individuals. As many as one quarter of all individuals who have a single CTC will undergo further diagnostic workup.

"They may undergo more studies or surgery that they don't need," he said, noting that CTC basically amounts to a screening program for other cancers such as lung, adrenal, kidney, pancreas, and liver, in much in the way of whole-body CT scans. The USPSTF does not currently recommend screening for any of these cancers.

As the effects of the incidental findings from this "semi" whole-body screening on the quality and length of lives are not known, it was not included in the current analysis, Dr. Harris writes. "But that does not mean that decision makers should assume there are no negative effects."

One argument in favor of CTC is that it may be more palatable to people, and thus increase the screening rate. However, Dr. Harris explained that most people who do not get screened are either unaware of the recommendations or available tests or are unable to afford screening tests. "Adding CTC to the list is not going to increase adherence to screening under those circumstances," he said.

He also pointed out that there are potential harms associated with optical colonoscopy. "It is common practice to remove all polyps during a colonoscopy, no matter how small they are," he said. "Most of these will never become cancer, but every procedure increases the risk of complications. It is also expensive to remove them."

Optical colonoscopy would provide more of benefit compared with CTC if small polyps are proven to an important factor in colorectal cancer mortality, and if it turns out that waiting until the next screening round is not effective in preventing these deaths, Dr. Harris writes, but if these small polyps are not important contributors, "or if waiting until the next screening round is as effective as detecting them when they are small, then polyps are being removed unnecessarily by optical colonoscopy," he comments.

So this is a form of "over-treatment," he adds, "subjecting many people to an increased risk of optical colonoscopy complications and subjecting all of us to increased cost."

There are multiple gaps and uncertainties in the evidence concerning the benefits and harms of CTC and optical colonoscopy, "leading to an impressive degree of uncertainty," he writes. "Even with modeling and our best guesses, the trade-offs between benefits and harms are not obvious."


Currently Not Cost-Effective

The current analysis was undertaken at the request of the CMS to perform a cost-effectiveness analysis of CTC screening among the average-risk Medicare beneficiaries. The primary objective was to identify the reimbursement rate at which CTC could be considered cost-effective as compared with the colorectal cancer screening tests that are currently reimbursed by the CMS.

Dr. Knudsen and colleagues used 3 independently developed microsimulation models of colorectal cancer to assess the health outcomes and costs associated with 15 screening strategies, including no screening, CTC screening every 5 years, annual fecal occult blood test (FOBT), flexible sigmoidoscopy every 5 years, flexible sigmoidoscopy every 5 years in conjunction with annual FOBT, and colonoscopy every 10 years, among a previously unscreened cohort of 65-year-old average-risk Medicare beneficiaries.

Going under the assumption that there was perfect adherence with all screening tests, the undiscounted number of life-years gained from CTC screening ranged from 143 to 178 per 1000 65-year-olds. This was slightly lower than the number of life-years gained from 10-yearly colonoscopy (152 - 185 per 1000 65-year-olds) but was comparable to the rate from 5-yearly sigmoidoscopy with annual FOBT (149 - 177 per 1000 65-year-olds).

The researchers noted that if CTC screening were reimbursed at $488 per scan, a number slightly lower than that for colonoscopy without polypectomy, it would be the most expensive strategy. Relative to the benefit that would be derived and to the availability and costs of other screening tests, CTC would not be a cost-effective screening strategy.

Depending on the microsimulation model used, CTC screening could be cost-effective if it were priced at from $108 to $205 per scan. The researchers' sensitivity analyses showed that if adherence to CTC screening was 25% higher than adherence to the other available screening tests, it could be cost-effective if reimbursed at $488 per scan.

The authors concluded that "at the current test characteristics, CTC could be a cost-effective option for colorectal cancer screening among Medicare enrollees if the test cost was substantially less than that of colonoscopy or if its availability would entice a large proportion of otherwise unscreened persons to be screened."

However, after getting lots of protest, Medicare decided to exempt certain oral drugs from the new system until 2014, which could be good news for Genzyme.

Under the new system, the Centers for Medicare and Medicaid Services will pay a set fee for each dialysis treatment. That so-called bundled payment is supposed to cover both the dialysis service, in which wastes are removed from the body, and the drugs and laboratory tests that accompany it. The new system starts phasing in on Jan. 1.

The new system somewhat resembles concepts in the new health care law, but the dialysis system reform was initiated earlier by Congress, under different legislation.

Until now, Medicare has paid a set fee for the service but certain drugs, like Epogen, are reimbursed separately.

Critics say that gave hospitals and dialysis clinics financial incentives to use a lot of Epogen, which dominates the dialysis market because of Amgen’s patent position. Amgen sells about $2.5 billion of Epogen a year, virtually all for use in dialysis in the United States, and the drug is one of the biggest pharmaceutical expenses for Medicare.

Concern about this system grew stronger when some clinical trials revealed that overuse of Epogen might harm patients, increasing their risk of heart attacks and strokes.

“When drugs remain outside the payment bundle, financial issues can influence both facility and patient behavior, as the over-utilization of EPO to the detriment of patient care in the past has demonstrated,’’ Medicare said in its ruling Monday.

Of course, the new system could have the opposite effect. Epogen will go from being a potential profit source for dialysis clinics to an expense that detracts from profit. So now there will be an incentive to under-use the drug, perhaps subjecting dialysis patients to more anemia and fatigue.

But clinics will have to meet certain standards for quality of care, which Medicare hopes will deter under-use. Medicare said it expects less costly alternatives might be used.

One approach would be to give Epogen by separate injections under the skin. Less of the drug is needed that way than when it is given through the intravenous line now used to deliver dialysis.

When they had a financial incentive to use more Epogen, dialysis clinics resisted giving such separate injections, saying they added to the pain and discomfort for patients. Now, however, many clinics are expected to switch.

Analysts have been expecting the final rules since Medicare first proposed the changes last year, and they have by and large already factored in a reduction in sales of Epogen of as much as 40 percent.

In a note to clients Monday afternoon, however, Jim Birchenough, an analyst at Barclays Capital, said such estimates might be too high and that the transition to giving patients separate injections will occur gradually.

The big suspense in the final rules would be whether Medicare would stick with its original proposal to include certain oral drugs, like Amgen’s Sensipar and Genzyme’s Renvela, in the bundle. These drugs are used to control calcium and phosphorus levels in the patient’s blood.

Opponents of inclusion of the oral drugs argued Medicare had no right to do so, because the drugs typically are not given at the dialysis clinic. Like most other pills, patients get a prescription and Medicare pays for the drugs under its prescription coverage, known as Part D, not under its dialysis program.

The opponents also said that because the drugs were expensive, inclusion in the bundle would curtail their use, to the detriment of patients.

In the final rules issued Monday, Medicare defended its position to include the drugs, but postponed the starting date by three years, until Jan. 1, 2014, to allow time for the study of “operational and safety issues.’’

An undercover investigation by the Government Accountability Office found that four genetic testing companies delivered contradictory predictions based on the same person's DNA. Investigators also found that test results often contradicted patients' actual medical histories.

"Consumers need to know that today, genetic testing for certain diseases appears to be more of an art than a science," said GAO investigator Gregory Kutz, in testimony before a House Energy and Commerce Subcommittee.

The GAO presented its findings at a Congressional hearing to scrutinize the personalized genetic industry, which until recently operated below the radar of federal regulators.

Genomic testing companies market saliva-based kits designed to detect whether individuals are genetically predisposed to get certain inheritable diseases like breast cancer or Alzheimer's Disease. Such tests have been sold online for years, but they began attracting federal scrutiny in May when Pathway Genomics announced plans to market its products in retail pharmacies.

That plan was scuttled by the Food and Drug Administration, which said the tests must undergo federal testing.

The chief executive of Pathway testified alongside counterparts from Navigenics and 23andMe, saying their companies used the latest technology to give consumers insight into their genetic makeup.

But the GAO report suggests the companies still have a long way to go in drawing accurate conclusions.

The agency submitted DNA samples from five staffers to four different genetic testing companies. When considering the same disease, the companies' results contradicted each other nearly 70 percent of the time, according to GAO. In response to the same patient's DNA, one company claimed he was at above-average risk for prostate cancer, a second said he was below average and two others said his risks were average.

In another case, a patient implanted with a pacemaker to control irregular heart beat was told he was at decreased risk of developing the heart condition.

"I believe, as do our experts, that these results clearly show that these tests are not ready for prime time," Kuntz said.

Kuntz told lawmakers that the tests don't constitute fraud because the companies believe in the accuracy of their methods — but they should still be subject to regulatory standards.

According to the companies, the disparate results reported by GAO are a result of different analytical methods used by each company.

23andMe CEO Ashley Gould told lawmakers the company is working with competitors and the FDA to standardize methods for analyzing genes.

As tests that predict the presence of a medical condition, genetic tests fall under the regulation of the FDA, though the agency has only recently begun scrutinizing the space.

In June the FDA issued letters to several genomic testing firms, asking them to submit their products for federal review.

FDA's device chief Jeffrey Shuren said that action was overdue.

"If there's any issue with the FDA, it's why didn't we act sooner," Shuren said.

The agency is in the process of meeting with companies and may take additional actions against the companies and their products.

The top two communities, however, remained unchanged from last year. Once again, the most popular 55+ community in the country is Green Valley, a vast retirement community near the Mexican border in Arizona. The Villages, home to 80,000 active retirees near Ocala, Florida, repeated as the #2 active adult community on the list.

“It is interesting that regional active adult communities compete so effectively vs. the established national brands like Del Webb,” Topretirements.com President John Brady said. “Many of the communities on this list are relatively new, stand-alone communities, yet they have established strong brand awareness among baby boomers looking for their best place to retire.”

The list of Best 50 Active Adult Communities at Topretirements.com for 2010:

1. Green Valley (Green Valley, AZ)
2. The Villages (Ocala, FL)
3. Holly Lake Ranch* (Tyler, TX)
4. The Settlement at Powhatan Creek* (Williamsburg, VA)
5. Hot Springs Village* (Hot Springs, AR)
6. Tellico Village (TN)
7. Laguna Woods Village (Laguna Woods, CA)
8. The Village of San Buenas*, (Costa Rica)
9. Silver Sage Village (Boulder, CO)
10. Hampton Lake* (Bluffton, SC)
11. Enchanted Canyon (Prescott, AZ)
12. Crest Mountain (Asheville, NC)
13. Sun City (Sun City, AZ)
14. The Moorings (Vero Beach, FL)
15. Fairfield Glade (TN)
16. The Residence at South Park (Charlotte, NC)
17. The Orchard Villas (Apex, NC)
18. Century Village (Southern FL)
19. High Country Villas (San Diego, CA)
20. Robson Ranch* (near Dallas, TX)
21. Rarity Bay* (Vonore, TN)
22. The Venetian at Capri Isles (Venice, FL)
23. Biltmore Lake (Asheville, NC)
24. Pelican Sound (Estero, FL)
25. The Villages at Lynx Creek (Prescott, AZ)
26. The Village at Penn State (State College, PA)
27. Lakewood Ranch (Sarasota, FL)
28. Merrill Gardens at Parmer Woods (Austin, TX)
29. Millville by the Sea (Bethany Beach, DE)
30. Ladd Landing (Knoxville, TN)
31. Querencia at Barton Creek (Austin, TX)
32. Sun City of Texas (Georgetown, TX)
33. Pine Lakes (Prescott, AZ)
34. Terra Vista at Citrus Hills* (Hernando, FL)
35. Lofts at Mica Village (Asheville, NC)
36. Bayside* (Selbyville, DE)
37. Talking Rock (Prescott, AZ)
38. Carolina Preserve (Cary, NC)
39. Shenandoah* (Winchester, VA)
40. The Cliffs at Walnut Cove (Asheville, NC)
41. West Bay (Lewes, DE)
42. The Ponds* (Summerville, SC)
43. Sun City Grand (Surprise, AZ)
44. Soleil Laurel Canyon* (Canton, GA)
45. Southern Meadow* (Magnolia, DE)
46. Pleasant Place (Paris, TN)
47. The Half-Way Tree Mobile Home Park (Hendersonville, NC)
48. Four Seasons Charlottesville (Charlottesville, VA)
49. Bay Crossing (Lewes, DE)
50. Venetian Falls (Venice, FL)

Several advertisers at Topretirements.com made the list (indicated by *). Advertisers get preferred positioning on the site, which no doubt helped their rankings, the Web service said in a statement.