Publications

By projecting onto complex optical mode profiles, it is possible to estimate arbitrarily small separations between objects with quantum-limited precision, free of uncertainty arising from overlapping intensity profiles. Here we extend these techniques to the time-frequency domain using mode-selective sum-frequency generation with shaped ultrafast pulses. We experimentally resolve temporal and spectral separations between incoherent mixtures of single-photon level signals ten times smaller than their optical bandwidths with a tenfold improvement in precision over the intensity-only Cramér-Rao bound.

BACKGROUND: Sexually transmitted infection (STI) screening prevents complications and is cost-effective. Annual screening is recommended in sexually active women below 25 years and older women at increased risk. Cervical cancer (CC) screening guideline changes in 2009 and 2012 recommended less frequent screening, causing concern that STI screening would decrease. Pennsylvania Medicaid implemented a family planning program in 2007 which covered women's health services (including STI testing) for uninsured women. It is unclear how STI screening was affected by these countervailing forces.

OBJECTIVE: The main objective of this study was to assess STI screening before and after CC screening guideline changes and family planning program implementation, and to determine factors associated with STI screening.

RESEARCH DESIGN: This study was an observational cross-sectional study of Pennsylvania Medicaid administrative claims from 2007 to 2013.

SUBJECTS: Sixteen-year-old to 30-year-old women enrolled in Pennsylvania Medicaid.

MEASURES: Annual STI screening, defined as receipt of ≥1 STI test in respective 1-year periods.

RESULTS: Our population included 1,226,079 women-years for 467,143 women. STI screening increased by 48% between 2007 and 2011, and stabilized by 2013. Odds for STI screening were higher among black compared with white women [adjusted odds ratio (AOR), 2.56; 95% confidence interval (CI), 2.60-3.10]; Hispanic compared with non-Hispanic women (AOR, 1.42; 95% CI, 1.39-1.46); family planning program enrollees (AOR, 1.42; 95% CI, 1.40-1.45); and urban compared with rural residents (AOR, 1.05; 95% CI, 1.03-1.06).

CONCLUSIONS: STI screening dramatically increased between 2007 and 2011. Potential reasons are family planning program implementation, increased urine/vaginal testing, and reporting improvements. It is reassuring that STI screening did not decrease despite CC screening guideline changes. Between 2011 and 2013, rates stabilized at 45% among all women and 60% among sexually active women below 25 years, suggesting opportunities for improvement.

OBJECTIVE: Guidelines recommend that rheumatoid arthritis (RA) patients with moderate-to-high disease activity (MHDAS) adjust disease-modifying antirheumatic drug (DMARD) therapy at least every 3 months until reaching low disease activity or remission (LDAS). We examined how quickly RA patients with MHDAS adjust DMARD therapy in clinical practice, and whether those who adjust DMARDs within 90 days in response to MHDAS reach LDAS sooner.

METHODS: We identified RA patients with MHDAS in the University of Pittsburgh Rheumatoid Arthritis Comparative Effectiveness Research registry, and conducted a competing risks regression on time to DMARD therapy adjustment and a Cox regression on time to LDAS.

RESULTS: We identified 538 eligible subjects with 943.5 patient-years of followup. Sixty percent of patients with persistent MHDAS adjusted DMARDs within 90 days. Among all subjects, median times to DMARD adjustment and LDAS were 154 (interquartile range [IQR] 1-706) days and 301 (IQR 140-706) days, respectively. Being elderly (subdistribution hazard ratio [SHR] 0.61, P = 0.02), lower baseline disease activity (SHR 0.72, P < 0.01), longer duration of RA (SHR 0.98, P < 0.01), and biologic use (SHR 0.71, P < 0.01) were significantly associated with longer times to therapy adjustment. African American race (hazard ratio [HR] 0.63, P = 0.01), higher baseline disease activity (HR 0.75, P < 0.01), and not adjusting DMARD therapy within 90 days (HR 0.76, P = 0.01) were associated with longer times to LDAS.

CONCLUSION: Adjusting DMARDs within 90 days was associated with shorter times to LDAS, but many patients with persistent MHDAS waited >90 days to adjust DMARDs. Interventions are needed to address the timeliness of DMARD adjustments for RA patients with MHDAS.

Although physicians learn about new medical technologies from their peers, the magnitude and source of peer influence is unknown. We estimate the effect of peer adoption of three first-in-class medications (dabigatran, sitigliptin, and aliskiren) on physicians' own adoption of those medications. We included 11,958 physicians in Pennsylvania prescribing anticoagulant, antidiabetic, and antihypertensive medications. We constructed 4 types of peer networks based on shared Medicare and Medicaid patients, medical group affiliation, hospital affiliation, and medical school/residency training. Instrumental variables analysis was used to estimate the causal effect of peer adoption (fraction of peers in each network adopting the new drug) on physician adoption (prescribing at least the median number prescriptions within 15 months of the new drug's introduction). We illustrate how physician network position can inform targeting of interventions to physicians by computing a social multiplier. Dabigatran was adopted by 25.2%, sitagliptin by 24.5% and aliskiren by 8.3% of physicians. A 10-percentage point increase in peer adoption in the patient-sharing network led to a 5.90% (SE = 1.50%, p<0.001) increase in physician adoption of dabigatran, 8.32% (SE = 1.51%, p<0.001) increase in sitagliptin, and 7.84% increase in aliskiren adoption (SE = 2.93%, p<0.001). Peer effects through shared hospital affiliation were positive but not significant, and medical group and training network effects were not reliably estimated. Physicians in the top decile of patient-sharing network peers were estimated to have nearly 2-fold stronger influence on their peers' adoption compared to physicians in the top decile of prescribing volume. Limitations include lack of detailed clinical information and pharmaceutical promotion, variables which may influence physician adoption but which are unlikely to bias our peer effect estimates. Peer adoption, especially by those with whom physicians share patients, strongly influenced physician adoption of new drugs. Our study shows the potential for using information on physician peer networks to improve technology diffusion.

BACKGROUND: The Pharmacy Quality Alliance (PQA) recently developed 3 quality measures for prescribing opioids: high dosages, multiple providers and pharmacies, and concurrent use of opioids and benzodiazepines.

OBJECTIVE: To examine the prevalence of the PQA measures and identify the patient demographic and health characteristics associated with the measures.

METHODS: We conducted a cross-sectional analysis using Pennsylvania Medicaid data (2013-2015). We limited our analyses to noncancer patients who were aged 18-64 years and not dual-eligible for Medicare/Medicaid. Per PQA specifications, patients were required to possess ≥ 2 opioid prescriptions for ≥ 15 days annual supply each year. Outcome measures included (a) high dosages, defined as > 120 morphine milligram equivalents for ≥ 90 consecutive days; (b) multiple providers/pharmacies, defined as receiving opioid prescriptions from ≥ 4 providers and ≥ 4 pharmacies; and (c) concurrent use of opioids and benzodiazepines, defined as ≥ 30 cumulative days of overlapping opioids and benzodiazepines among individuals having ≥ 2 opioid and ≥ 2 benzodiazepine fills. Patient characteristics assessed included demographics; other medication use; and physical, mental, and behavioral health comorbidities. We present descriptive and multivariable statistical analyses of the data to describe trends in quality measure prevalence and associations with enrollee health characteristics.

RESULTS: Numbers of enrollees meeting inclusion criteria ranged from 73,082 in 2013 to 85,710 in 2015. From 2013 to 2015, high dosage prevalence increased from 5.1% to 5.5%; the use of multiple providers/pharmacies decreased from 7.1% to 5.0%; and concurrent use of opioids and benzodiazepines decreased from 29.1% to 28.4% (all P < 0.05). A substantial portion of patients with > 1 PQA measure from 2013 to 2015 was eligible for Medicaid because of disability (41.8%-81.9%). Enrollees with opioid use disorder were more likely to have high dosages (adjusted odds ratio [AOR] = 2.01, 95% CI = 1.83-2.21). Enrollees with anxiety and mood disorders were more likely to have multiple providers/pharmacies (anxiety: AOR = 1.54, 95% CI = 1.43-1.65; mood: AOR = 1.15, 95% CI = 1.06-1.25) and concurrent use of opioids and benzodiazepines (anxiety: AOR = 3.50, 95% CI = 3.38-3.63; mood: AOR = 1.42, 95% CI = 1.36-1.48).

CONCLUSIONS: Given high levels of eligibility based on disability and the prevalence of mood, anxiety, and opioid use disorders among those identified by the quality measures, providers may require additional support to care for this patient population.

DISCLOSURES: This project was supported by a grant from the Centers for Disease Control and Prevention and was also supported by an intergovernmental agreement between the Pennsylvania Department of Human Services and the University of Pittsburgh. Lo-Ciganic was supported by the University of Arizona Health Sciences Career Development Award. The other authors have nothing to disclose. The conclusions, findings, and opinions expressed by authors contributing to this article do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the Commonwealth of Pennsylvania. A portion of these results was presented at the Association for Medical Education and Research in Substance Abuse 41st National Conference; November 2-4, 2017; Washington, DC.

Entangled photon pair sources based on bulk optics are approaching optimal design and implementation, with high state fidelities, spectral purities and heralding efficiencies, but generally low brightness. Integrated entanglement sources, while providing higher brightness and low-power operation, often sacrifice performance in output state quality and coupling efficiency. Here we present a polarization-entangled pair source based on a hybrid approach of waveguiding and bulk optics, addressing every metric simultaneously. We show 96 % fidelity to the singlet state, 82 % Hong-Ou-Mandel interference visibility, 43 % average Klyshko efficiency, and a high brightness of 2.9 × 106 pairs/(mode·s·mW), while requiring only microwatts of pump power.

BACKGROUND: Overlapping use of opioids and benzodiazepines is associated with increased risk for overdose. Veterans receiving medications concurrently from the U.S. Department of Veterans Affairs (VA) and Medicare may be at higher risk for such overlap.

OBJECTIVE: To assess the association between dual use of VA and Medicare drug benefits and receipt of overlapping opioid and benzodiazepine prescriptions.

DESIGN: Cross-sectional.

SETTING: VA and Medicare.

PARTICIPANTS: All veterans enrolled in VA and Medicare Part D who filled at least 2 opioid prescriptions in 2013 (n = 368 891).

MEASUREMENTS: Outcomes were the proportion of patients with a Pharmacy Quality Alliance (PQA) measure of opioid-benzodiazepine overlap (≥2 filled prescriptions for benzodiazepines with ≥30 days of overlap with opioids) and the proportion of patients with high-dose opioid-benzodiazepine overlap (≥30 days of overlap with a daily opioid dose >120 morphine milligram equivalents). Augmented inverse probability weighting regression was used to compare these measures by prescription drug source: VA only, Medicare only, or VA and Medicare (dual use).

RESULTS: Of 368 891 eligible veterans, 18.3% received prescriptions from the VA only, 30.3% from Medicare only, and 51.4% from both VA and Medicare. The proportion with PQA opioid-benzodiazepine overlap was larger for the dual-use group than the VA-only group (23.1% vs. 17.3%; adjusted risk ratio [aRR], 1.27 [95% CI, 1.24 to 1.30]) and Medicare-only group (23.1% vs. 16.5%; aRR, 1.12 [CI, 1.10 to 1.14]). The proportion with high-dose overlap was also larger for the dual-use group than the VA-only group (4.7% vs. 2.3%; aRR, 2.23 [CI, 2.10 to 2.36]) and Medicare-only group (4.7% vs. 2.9%; aRR, 1.06 [CI, 1.02 to 1.11]).

LIMITATION: Data are from 2013 and cannot capture medications purchased without insurance; unmeasured confounding may remain in this cross-sectional study.

CONCLUSION: Among a national cohort of veterans dually enrolled in VA and Medicare, receiving prescriptions from both sources was associated with greater risk for receiving potentially unsafe overlapping prescriptions for opioids and benzodiazepines.

PRIMARY FUNDING SOURCE: U.S. Department of Veterans Affairs.

OBJECTIVES: The Alternative Quality Contract (AQC) implemented in 2009 by Blue Cross Blue Shield of Massachusetts (BCBSMA) is intended to improve quality and control costs by putting providers at risk for total medical spending and tying payment to performance on specified quality measures. We examined the AQC's early effects on use of and spending on medication treatment (MT) for addiction among individuals with alcohol use disorders (AUDs) and opioid use disorders (OUDs), conditions not subject to any performance measurement in the AQC.

METHODS: Using data from 2006 to 2011, we use difference-in-difference estimation of the effect of the AQC on MT using a comparison group of enrollees in BCBSMA whose providers did not participate in the AQC. We compared AQC and non-AQC enrollees with AUDs (n = 37,113 person-years) and/or OUDs (n = 12,727 person-years) on any use of MT, number of prescriptions filled, and MT spending adjusting for demographic and health status characteristics.

RESULTS: There was no difference in MT use among AQC enrollees with OUD (38.7%) relative to the comparison group (39.1%) (adjusted difference = -0.4%, 95% confidence interval -3.8% to 3.0%, P = 0.82). Likewise, there was no difference in MT use for AUD between the AQC (6.3%) and comparison group (6.5%) (P = 0.64). Similarly, we detected no differences in number of prescriptions or spending.

CONCLUSIONS: Despite incentives for improved integration and quality of care under a global payment contract, the initial 3 years of the AQC showed no impact on MT use for AUD or OUD among privately insured enrollees with behavioral health benefits.

OBJECTIVE:  This article aims to evaluate whether the use of a double-balloon catheter with oral misoprostol results in a lower rate of cesarean and shorter times to delivery than the use of the double-balloon catheter with oral placebo.

STUDY DESIGN:  In a double-blind randomized controlled trial, a double-balloon catheter was used for induction of labor with two doses of either 50 µg of misoprostol or placebo. Outcomes included cesarean rate, time to vaginal delivery, change in Bishop's score, and oxytocin usage.

RESULTS:  A total of 343 women were screened and 199 randomized: 99 to the misoprostol arm and 100 to the placebo arm. Cesarean delivery rate was not different between the groups (misoprostol: 13.1% vs. placebo: 17.0%, p = 0.45). Time to vaginal delivery was significantly shorter (mean: 14.6 ± 6.9 vs. 20.8 ± 13.8 hours, p < 0.0001), change in Bishop's score was significantly greater (median: 5 vs. 4 points, p = 0.005), and use of oxytocin was significantly less frequent (86.9 vs. 98.0% patients, p = 0.01) in the misoprostol group.

CONCLUSION:  The use of a double-balloon catheter with oral misoprostol for induction did not reduce the cesarean delivery rate, but did result in shorter labors, a greater increase in Bishop's score, and a lower need for oxytocin use.

Although physicians learn about new medical technologies from their peers, the magnitude and source of peer influence is unknown. We estimate the effect of peer adoption of three first-in-class medications (dabigatran, sitigliptin, and aliskiren) on physicians' own adoption of those medications. We included 11,958 physicians in Pennsylvania prescribing anticoagulant, antidiabetic, and antihypertensive medications. We constructed 4 types of peer networks based on shared Medicare and Medicaid patients, medical group affiliation, hospital affiliation, and medical school/residency training. Instrumental variables analysis was used to estimate the causal effect of peer adoption (fraction of peers in each network adopting the new drug) on physician adoption (prescribing at least the median number prescriptions within 15 months of the new drug's introduction). We illustrate how physician network position can inform targeting of interventions to physicians by computing a social multiplier. Dabigatran was adopted by 25.2%, sitagliptin by 24.5% and aliskiren by 8.3% of physicians. A 10-percentage point increase in peer adoption in the patient-sharing network led to a 5.90% (SE = 1.50%, p<0.001) increase in physician adoption of dabigatran, 8.32% (SE = 1.51%, p<0.001) increase in sitagliptin, and 7.84% increase in aliskiren adoption (SE = 2.93%, p<0.001). Peer effects through shared hospital affiliation were positive but not significant, and medical group and training network effects were not reliably estimated. Physicians in the top decile of patient-sharing network peers were estimated to have nearly 2-fold stronger influence on their peers' adoption compared to physicians in the top decile of prescribing volume. Limitations include lack of detailed clinical information and pharmaceutical promotion, variables which may influence physician adoption but which are unlikely to bias our peer effect estimates. Peer adoption, especially by those with whom physicians share patients, strongly influenced physician adoption of new drugs. Our study shows the potential for using information on physician peer networks to improve technology diffusion.