Publications

The Affordable Care Act is a substantial reform of the U.S. health care insurance system. Using the RAND COMPARE model, researchers assessed the act's potential economic effects on Pennsylvania, factoring in an optional expansion of Medicaid, and found the state would enjoy significant net benefits. With or without the expansion of Medicaid, the act will increase insurance coverage to hundreds of thousands of Pennsylvanians, but the COMPARE model estimates that the expansion of Medicaid eligibility would cover an additional 350,000 people and bring more than $2 billion in federal spending into the state annually than if the state did not expand. Should the state expand Medicaid, the additional spending will add more than $3 billion a year to the state's GDP and support 35,000 jobs. But Medicaid expansion is not without cost for the state; the estimated cumulative effect on Pennsylvania's Medicaid spending will be $180 million higher with the expansion than without between 2014 and 2020. Substantial reductions in uncompensated care costs for hospitals are possible even without expansion, but savings to hospitals for uncompensated care funding are even larger with the Medicaid expansion, amounting to $550 million or more each year.

BACKGROUND: The impact of evidence-based guidelines and controlled trial data on use of cholesterol-lowering medications in older adults is unclear.

OBJECTIVE: To examine whether utilization patterns of cholesterol-lowering medications in community-dwelling older adults changed following the release of the National Cholesterol Education Program Adult Treatment Panel III guidelines and results from the Prospective Study of Pravastatin in the Elderly at Risk in 2002.

METHODS: Community-dwelling elderly individuals who were enrolled in the Health, Aging and Body Composition Study in 1997-1998 were followed for up to 11 years. An interrupted time series analysis with multivariable generalized estimating equations (GEEs) was used to examine changes in level and trend in cholesterol-lowering medication use before and after 2002, adjusting for sociodemographics, health-related behaviors, and health status.

RESULTS: Cholesterol-lowering medication use increased nearly 3-fold from 14.9% in 1997-1998 to 42.6% in 2007-2008, with statins representing the most common class used (87-94%). Multivariable GEE results revealed no significant difference in the level of cholesterol-lowering medication use after 2002 (adjusted OR 0.95; 95% CI 0.89-1.02). Multivariable GEE results revealed that trend changes in the rate of increase in cholesterol-lowering medication declined after 2002 (adjusted ratio of ORs 0.92; 95% CI 0.89-0.95).

CONCLUSIONS: The use of cholesterol-lowering medication increased substantially over a decade in community-dwelling elderly individuals but was not related to a change in level or trend following the release of the guidelines and evidence-based data.

OBJECTIVE: Second-generation antipsychotics captured most of the U.S. antipsychotic market shortly after their introduction. Little is known about how second-generation antipsychotics have diffused in other countries with different health systems. The study objective was to describe trends in antipsychotic use in the United States and France from 1998 to 2008.

METHODS: Pharmaceutical policies in France and the United States are briefly described, followed by descriptive data on quarterly prescriptions for oral antipsychotics dispensed between January 1998 and September 2008. Data are from Xponent for the United States and the GERS database for France. Trends in the use of first- versus second-generation antipsychotics and in ingredient formulations of second-generation antipsychotics used are reported.

RESULTS: Between 1998 and 2008, total antipsychotic use in the United States increased by 78%. Total use in France was consistently higher despite a 9% decrease during the period. By 2008, second-generation antipsychotics represented 86% of the antipsychotics sold in the U.S. market, versus only 40% of the French market. However, average annual growth rates in use of second-generation antipsychotics were similar in the two countries. In France, use of all but one second-generation antipsychotic steadily increased, whereas in the United States trends in the use of newer drugs varied substantially by drug. For example, use of olanzapine decreased after 2003, but use of quetiapine increased.

CONCLUSIONS: These results highlight markedly divergent trends in the diffusion of new antipsychotics in France and the United States. Some differences may be explained by differences in health systems; others may reflect physicians' preferences and norms of practice.

OBJECTIVES: To assess the effect of initiating antidepressant therapy with a generic prescription on adherence to antidepressant therapy among Medicare patients. A second objective is to assess how the effect might be moderated by the Medicare Part D coverage gap.

STUDY DESIGN AND METHODS: Adherence to antidepressant therapy was measured by (a lack of) disruption in medication use defined by a gap of 30 days or more in antidepressant possession and monthly days of possession, both measured over 180 days since antidepressant initiation. We used a 5% random sample of Medicare fee-for-service beneficiaries who received a new depression diagnosis in the first half of 2007 and initiated antidepressant therapy within 60 days (n = 16,778). We estimated a Cox proportional hazard model for antidepressant disruption and a mixedeffects linear model for monthly possession. All analyses were stratified by 4 cohorts defined by Part D low-income subsidy (LIS) status and Medicare entitlement (aged vs disabled).

RESULTS: Generic initiation was associated with improved adherence among all 4 cohorts, with a stronger effect among the non-LIS patients. Hazard ratios for antidepressant disruption ranged from 0.71 (95% confidence interval [CI], 0.53-0.96) among non-LIS, disabled patients to 0.88 (95% CI, 0.79-0.98) among LIS, aged patients. Generic initiation was associated with increases in days of monthly possession in all 4 cohorts and an additional benefit during the coverage gap for non-LIS patients.

CONCLUSIONS: Generic initiation can be an important tool to improve adherence to antidepressant treatment among Medicare patients and to mitigate the negative effects of the Part D coverage gap.

BACKGROUND: Information about the prevalence and correlates of self-reported medication nonadherence using multiple measures in older adults with chronic cardiovascular conditions is needed.

OBJECTIVE: To examine the prevalence and correlates of self-reported medication nonadherence among community-dwelling elders with chronic cardiovascular conditions.

METHODS: Participants (n = 897) included members from the Health, Aging and Body Composition Study with coronary heart disease, diabetes mellitus, and/or hypertension at Year 10. Self-reported nonadherence was measured by the 4-item Morisky Medication Adherence Scale (MMAS-4) and 2-item cost-related nonadherence (CRN-2) scale at Year 11. Factors (demographic, health status, and access to care) were examined for association with the MMAS-4 and then for association with the CRN-2 scale.

RESULTS: Nonadherence per the MMAS-4 and CRN-2 scale was reported by 40.7% and 7.7% of participants, respectively, with little overlap (3.7%). Multivariable logistic regression analyses found that black race was significantly associated with nonadherence per the MMAS-4 (P = 0.002) and the CRN-2 scale (P = 0.005). Other correlates of nonadherence per the MMAS-4 (with independent associations) included having cancer (P = 0.04), a history of falls (P = 0.02), sleep disturbances (P = 0.04) and having a hospitalization in the previous 6 months (P = 0.005). Conversely, being unmarried (P = 0.049), having worse self-reported health (P = 0.04) and needs being poorly met by income (P = 0.02) showed significant independent associations with nonadherence per the CRN-2 scale.

CONCLUSIONS: Self-reported medication nonadherence was common in older adults with chronic cardiovascular conditions and only one factor - race - was associated with both types. The research implication of this finding is that it highlights the need to measure both types of self-reported nonadherence in older adults. Moreover, the administration of these quick measures in the clinical setting should help identify specific actions such as patient education or greater use of generic medications or pill boxes that may address barriers to medication nonadherence.

Time-bin encoding is a robust form of optical quantum information, especially for transmission in optical fibers. To readout the information, the separation of the time bins must be larger than the detector time resolution, typically on the order of nanoseconds for photon counters. In the present work, we demonstrate a technique using a nonlinear interaction between chirped entangled time-bin photons and shaped laser pulses to perform projective measurements on arbitrary time-bin states with picosecond-scale separations. We demonstrate a tomographically complete set of time-bin qubit projective measurements and show the fidelity of operations is sufficiently high to violate the Clauser-Horne-Shimony-Holt-Bell inequality by more than 6 standard deviations.

BACKGROUND: Older blacks are less likely to receive guideline-recommended antilipemic therapy and achieve lipid control than older whites because, in part, of out-of-pocket costs. We sought to determine whether racial differences in antilipemic use and lipid control narrowed after Medicare Part D's implementation.

METHODS: This before-after study included 1,091 black and white adults 70 years or older with coronary heart disease and/or diabetes mellitus from the Health Aging and Body Composition Study. Primary outcomes were antilipemic use and low-density lipoprotein cholesterol control. Key independent variables were race, time (pre-Part D vs post-Part D), and their interaction.

RESULTS: Before Part D, fewer blacks than whites reported taking an antilipemic (32.70% vs 49.35%), and this difference was sustained after Part D (blacks 48.30% vs whites 64.57%). Multivariable generalized estimating equations confirmed no post-Part D change in racial differences in antilipemic use (adjusted ratio of the odds ratio 1.07, 95% CI 0.79-1.45). Compared with whites, more blacks had poor lipid control both before Part D (24.30% vs 12.36%, respectively) and after Part D (24.46% vs 13.72%, respectively), with no post-Part D change in racial differences in lipid control (adjusted ratio of the odds ratio 0.82, 95% CI 0.51-1.33).

CONCLUSION: Although antilipemic use increased after Medicare Part D for both races, this policy change was associated with a change neither in lipid control for either racial group nor in the racial differences in antilipemic use or lipid control.

Genital powder use has been associated with risk of epithelial ovarian cancer in some, but not all, epidemiologic investigations, possibly reflecting the carcinogenic effects of talc particles found in most of these products. Whether risk increases with number of genital powder applications and for all histologic types of ovarian cancer also remains uncertain. Therefore, we estimated the association between self-reported genital powder use and epithelial ovarian cancer risk in eight population-based case-control studies. Individual data from each study were collected and harmonized. Lifetime number of genital powder applications was estimated from duration and frequency of use. Pooled ORs were calculated using conditional logistic regression matched on study and age and adjusted for potential confounders. Subtype-specific risks were estimated according to tumor behavior and histology. 8,525 cases and 9,859 controls were included in the analyses. Genital powder use was associated with a modest increased risk of epithelial ovarian cancer [OR, 1.24; 95% confidence interval (CI), 1.15-1.33] relative to women who never used powder. Risk was elevated for invasive serous (OR, 1.20; 95% CI, 1.09-1.32), endometrioid (OR, 1.22; 95% CI, 1.04-1.43), and clear cell (OR, 1.24; 95% CI, 1.01-1.52) tumors, and for borderline serous tumors (OR, 1.46; 95% CI, 1.24-1.72). Among genital powder users, we observed no significant trend (P = 0.17) in risk with increasing number of lifetime applications (assessed in quartiles). We noted no increase in risk among women who only reported nongenital powder use. In summary, genital powder use is a modifiable exposure associated with small-to-moderate increases in risk of most histologic subtypes of epithelial ovarian cancer.

BACKGROUND: The impact of evidence-based guidelines and controlled trial data on use of cholesterol-lowering medications in older adults is unclear.

OBJECTIVE: To examine whether utilization patterns of cholesterol-lowering medications in community-dwelling older adults changed following the release of the National Cholesterol Education Program Adult Treatment Panel III guidelines and results from the Prospective Study of Pravastatin in the Elderly at Risk in 2002.

METHODS: Community-dwelling elderly individuals who were enrolled in the Health, Aging and Body Composition Study in 1997-1998 were followed for up to 11 years. An interrupted time series analysis with multivariable generalized estimating equations (GEEs) was used to examine changes in level and trend in cholesterol-lowering medication use before and after 2002, adjusting for sociodemographics, health-related behaviors, and health status.

RESULTS: Cholesterol-lowering medication use increased nearly 3-fold from 14.9% in 1997-1998 to 42.6% in 2007-2008, with statins representing the most common class used (87-94%). Multivariable GEE results revealed no significant difference in the level of cholesterol-lowering medication use after 2002 (adjusted OR 0.95; 95% CI 0.89-1.02). Multivariable GEE results revealed that trend changes in the rate of increase in cholesterol-lowering medication declined after 2002 (adjusted ratio of ORs 0.92; 95% CI 0.89-0.95).

CONCLUSIONS: The use of cholesterol-lowering medication increased substantially over a decade in community-dwelling elderly individuals but was not related to a change in level or trend following the release of the guidelines and evidence-based data.

PURPOSE: Meta-analyses are routinely shaping patient care decisions. However, it is unknown whether meta-analyses are increasing in cardiology or whether complete search strategies are used. The purpose of this study was to assess the quality of search strategies of meta-analyses.

METHODS: Meta-analyses assessing cardiovascular drug therapy published from 2006 to 2011 were identified through PubMed/Medline with the terms "cardiovascular agents" and "drug therapy."

RESULTS: A total of 130 meta-analyses were identified. There was a 100% increase with the largest growth from 2008 to 2009. Only half of the analyses used 3 databases to identify studies for inclusion, which was predictive of using search terms ( P < .01; odds ratio, 3.05, 95% confidence interval, 1.341-6.952) and using a quality assessment tool ( P < .001; odds ratio, 3.05; 95% confidence interval, 2.038-8.066).

CONCLUSIONS: Meta-analyses evaluating cardiovascular drug therapy increased in 2011. Meta-analyses should exhaust all resources to identify trials for inclusion. As meta-analyses continue to change clinical practice, researchers and clinicians must critically assess the quality of these studies.