Jose Pagan
Jose Pagan
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Chair and Professor of the Department of Public Health Policy and Management
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Professional overview
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Dr. Pagán received his PhD in economics from the University of New Mexico and is a former Robert Wood Johnson Foundation Health & Society Scholar with expertise in health economics and population health. He has led research, implementation, and evaluation projects on the redesign of health care delivery and payment systems. He is interested in population health management, health care payment and delivery system reform, and the social determinants of health. Over the years his research has been funded through grants and contracts from the Department of Defense, the Agency for Healthcare Research and Quality, the National Institutes of Health, the Centers for Medicare & Medicaid Services, the European Commission, and the Robert Wood Johnson Foundation, among others.
Dr. Pagán is Chair of the Board of Directors of NYC Health + Hospitals, the largest public healthcare system in the United States. He also served as Chair of the National Advisory Committee of the Robert Wood Johnson Foundation’s Health Policy Research Scholars and was a member of the Board of Directors of the Interdisciplinary Association for Population Health Science and the American Society of Health Economists.
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Areas of research and study
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Applied EconomicsHealth EconomicsPopulation HealthPublic Health Policy
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Publications
Publications
Cost-effectiveness of population-based screening for chronic kidney disease among the general population and adults with diabetes in China: a modelling study
AbstractWen, F., Wang, J., Yang, C., Wang, F., Li, Y., Zhang, L., & Pagán, J. A. (n.d.).Publication year
2025Journal title
The Lancet Regional Health - Western PacificVolume
56AbstractBackground: Despite the majority of patients with chronic kidney disease (CKD) live in low- and middle-income countries, most evidence on screening strategies is derived from high-income countries, where the contexts differ significantly. This study aims to assess the cost-effectiveness of population-based CKD screening strategies in both the general population and adults with diabetes in China. Methods: A validated microsimulation model of CKD was developed to evaluate the costs and health consequences of population-based CKD screening strategies from a societal perspective. A cohort of the population aged 45 years in China was simulated over their lifetime. Model parameters were estimated based on the existing literature and various data sources in China. Main outcomes included the averted number of cases with cardiovascular disease (CVD) and kidney failure with replacement therapy (KFRT) under the population-based screening strategy compared with usual care, and the incremental cost-effectiveness ratios (ICERs). CKD screening with different frequencies and for different age groups in both the general population and adults with diabetes were considered. One-way sensitivity analyses were performed to assess the robustness of the results. Findings: The ICER of annual screening starting at 45 years of age was $10,588 per quality-adjusted life year (QALY) for the general population and $9184 per QALY for adults with diabetes. Other screening strategies were also cost-effective compared to usual care, with ICERs less than three times the per-capita gross domestic product of China ($35,501). The most prominent absolute decrease in lifetime incidence of KFRT and CVD were also observed with the annual screening strategy in both the general population and in adults with diabetes. Specifically, the decreases were 1.88 and 8.55 per 1000 individuals for KFRT, and 35.07 and 19.92 per 1000 individuals for CVD, respectively. Interpretation: CKD screening in both the general population and adults with diabetes is cost-effective and could avert substantial numbers of KFRT and CVD cases in China. Funding: This study was supported by grants from National Natural Science Foundation of China ( 72125009), National Key Research and Development Program of China ( 2022YFF1203001), National High Level Hospital Clinical Research Funding (State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University, 24QZ007), Peking University Medicine Sailing Program for Young Scholars’ Scientific & Technological Innovation ( BMU2023YFJHMX014), Young Elite Scientists Sponsorship Program by CAST ( 2022QNRC001), and CAMS Innovation Fund for Medical Sciences ( 2019-I2M-5–046).Diabetes Management Through Remote Patient Monitoring: A Mixed-Methods Evaluation of Program Enrollment and Attrition
AbstractSu, D., Michaud, T. L., Ern, J., Li, J., Chen, L., Li, Y., Shi, L., Zhang, D., Andersen, J., & Pagán, J. A. (n.d.).Publication year
2025Journal title
Healthcare (Switzerland)Volume
13Issue
7AbstractBackground: Despite the growing use of remote patient monitoring (RPM) in diabetes management, few studies have assessed program enrollment and attrition. This study adopted a mixed-methods approach to examining factors linked to program enrollment and attrition amongst a large sample of patients who went through RPM in diabetes management. Methods: Based on quantitative data from the Remote Interventions Improving Specialty Complex Care program conducted in Nebraska from 2014 to 2018, chi-squared or t tests were used to compare three groups of patients with diabetes who had been contacted for program participation: those who completed the intervention, withdrew from the intervention, or declined to participate. Logistic regression was used to identify factors associated with program dropout. Inductive thematic analysis was conducted to assess patient feedback based on semi-structured interviews with patients from the three groups. Results: Out of the 1993 patients with diabetes invited for participation, 13% (n = 256) declined to participate, 16% (n = 317) withdrew before completion, and 71% (n = 1420) completed the intervention. Being younger or having poorer health (as indicated by higher blood glucose or blood pressure) at the baseline was associated with higher odds of program withdrawal. The top reason patients cited for declining participation or withdrawal from RPM was not having enough time to complete the intervention. Patients who declined to participate mentioned that an offer of incentives or more information at the beginning of the intervention may increase their motivation for participation. Conclusions: Being younger or having poorer health at the baseline was associated with higher odds of withdrawing from the RPM program. Future RPM programs can increase program retention by becoming more responsive to the health needs of vulnerable patients who struggle with managing their diabetes or related comorbidities at the baseline.Forging hospital and community partnerships to enable care coordination for opioid use disorder
AbstractLindenfeld, Z., Franz, B., Lai, A. Y., Pagán, J. A., Fenstemaker, C., Cronin, C. E., & Chang, J. E. (n.d.).Publication year
2025Journal title
Addiction Science and Clinical PracticeVolume
20Issue
1AbstractBackground: Programs that aim to increase access to substance use disorder (SUD) treatment in hospital-based settings have proliferated in recent years. These efforts include transitional opioid programs (TOPs), which navigate patients to community-based SUD treatment programs post-discharge. Successful navigation from TOPs to outpatient treatment hinges on effective coordination between hospitals and post-discharge endpoints, yet it is unclear how hospitals can best develop effective partnerships with outpatient treatment organizations. The objective of this study is to synthesize the common themes underpinning the development of partnerships to facilitate care transitions between TOPs and ongoing SUD treatment. Methods: Qualitative study with staff and providers from hospitals affiliated with four safety-net health systems (n = 21) and leaders from community-based organizations (CBOs) and treatment facilities that had established referral partnerships with one of the four health systems in our study (n = 4). Results: Analysis of interview transcripts revealed seven common themes that underpinned the development of care transitions partnerships: (1) Active, intentional outreach; (2) Responding to a community need; (3) External Enabling Factors; (4) Leveraging reputations and community connections; (5) Focusing on operations; (6) Reciprocal relationships; and (7) Building Infrastructure and Processes to Ensure Collaboration. The seven identified themes were categorized into three groups corresponding to different partnership development stages. The first group revolves around the initial stage of meeting and developing a relationship (themes #1–4). The second set focuses on navigating and resolving challenges that arise in the partnership (themes #5–6). Lastly, the third group pertains to sustaining a partnership long-term (theme #7). Conclusions: This study identifies seven core themes underlying the development of care transition partnerships for SUD patients within four safety net health systems and their CBO partners. These themes demonstrate how partner organizations can establish the trust, reciprocity, and commitment necessary to support patients through the critical transition period.Need of the hour: A service failure recovery reorientation for U.S. hospitals
AbstractChakraborty, S., & Pagán, J. A. (n.d.).Publication year
2025Journal title
Health Care Management ReviewVolume
50Issue
2Page(s)
122-129AbstractIssue: Many hospitals in the United States are facing significant postpandemic operational challenges largely as a result of increasing demand for health care services. Operational issues increase the risk of service failures. Improving the patient experience after service failures may lead to better outcomes for both patients and hospitals. Critical Theoretical Analysis: Drawing support from service failure recovery and quality management paradigms, we suggest that hospitals could periodically obtain deidentified patient feedback data drawn from multiple sources—including social media—to build a comprehensive patient experience dashboard that can be used to improve health care quality. Insight/Advance: We offer an overarching conceptual framework to support organizational learning and make hospitals more adaptive to patient feedback. Staff members and leaders could examine patient feedback data to identify service failures and take appropriate action to prevent their recurrence in hospitals. A patient experience dashboard can be developed to document and visualize remedial actions taken by hospitals against each past service failure and shared with all stakeholders. Practice Implications: Reorienting health care as a service where hospitals immediately listen to patients and promptly address their questions and concerns may help to strengthen the continuity of health care services offered by hospitals as well as improve their financial position, quality of care, and the overall patient experience.Population, demographic and socioeconomic characteristics associated with state preemption laws in the United States, 2009-2018
AbstractPagán, J. A., Silver, D., Akiya, K., & Pomeranz, J. L. (n.d.).Publication year
2025Journal title
PloS oneVolume
20Issue
4AbstractObjective In the United States, preemption laws enacted by state governments can remove local government authority to enact policy and undermine community self-determination and local democracy. No study to date has evaluated the population, demographic, and socioeconomic characteristics associated with state preemption of public health policies. Our study identifies state characteristics associated with preemption of local paid sick leave, food and nutrition, tobacco control, and firearm safety policies. Methods We conducted a Classification and Regression Tree (CART) analysis using state-level demographic, socioeconomic, and population health indicators from 2009 to 2018 to predict state ceiling preemption of local paid sick leave, food and nutrition, tobacco control, and firearm safety policies. Results Several demographic, economic, political, and health factors best distinguish states with and without preemption in each of the four domains. Total state population was an important characteristic in all four trees and the non-Hispanic Black population was important in three trees. All other age- and race/ethnicity-related demographic variables included were important characteristics in at least one tree. Additionally, adult obesity and flu vaccination were relevant in the paid sick leave tree and firearm-deaths, suicide-deaths, and the unemployment rate were relevant in the firearm safety tree. The relationship between specific factors and preemption in each of the four domains varied depending on the location of the factor within the trees. Conclusions and relevance Specific population, demographic and economic characteristics in a state are associated with the adoption of ceiling preemption of paid sick, food and nutrition, tobacco, and firearm safety laws, but these characteristics vary by domain. Our study identified which populations within groups of states may be affected by preemption. The findings can inform whether preemption laws considered or adopted in a state may also require protective measures for population groups that could be adversely affected by these laws.Racial and Ethnic Disparities in Adolescent Utilization of School Based Mental Health Services
AbstractGrunin, L., Pagán, J. A., Yu, G., Squires, A., & Cohen, S. S. (n.d.).Publication year
2025Journal title
Child and Youth Care ForumAbstractBackground: Adolescent mental health is a major public health concern in the United States and schools are an ideal location to offer mental health services. Objective: An examination of combined racial/ethnic disparities pertaining to socio-demographic and contextual factors associated with adolescent utilization of school based mental health services (SBMHS) was conducted to optimize the use and potential benefits of these services. Method: Data from the 2019 National Survey on Drug Use and Health was used to estimate multilevel and multivariable logistic regression models. Indicators included socio-demographics, depression, religiosity, parental monitoring and support, and school and academic engagement. Results: Asian adolescents were less likely to utilize SBMHS compared to their White counterparts (OR = 0.62; 95% CI = 0.41, 0.95). All five racial/ethnic groups reported a statistically higher likelihood of utilizing SBMHS as depressive symptoms increased (OR = 1.15–1.28). Black adolescents were the only racial/ethnic group who reported lower odds (OR = 0.93; 95% CI = 0.88, 0.98) of utilizing SBMHS as their religiosity increased. Parental monitoring and support was not associated with SBMHS use for any group. White, Black, and Asian adolescents reported greater odds of utilizing SBMHS as their school and academic engagement increased (OR = 1.12; 95% CI = 1.05, 1.19; OR = 1.15; 95% CI = 1.01, 1.31; OR = 1.43; 95% CI = 1.04, 1.95, respectively). Conclusion: Findings enhance understanding of the racial/ethnic disparities involved with adolescent utilization of SBMHS and may help identify those in need, tailor interventions, and optimize use of evidence-based treatments.SpaCE: a spatial counterfactual explainable deep learning model for predicting out-of-hospital cardiac arrest survival outcome
AbstractZhang, J., Mu, L., Zhang, D., Chen, Z., Rajbhandari-Thapa, J., Pagán, J. A., Li, Y., Mai, G., & Zhou, Z. (n.d.).Publication year
2025Journal title
International Journal of Geographical Information ScienceAbstractUnderstanding the relationship between risk factors, geospatial patterns, and disease outcomes is essential in health geography research. These relationships can inform the implementation of healthcare and public health strategies to improve health outcomes. To accurately uncover such complex relationships, it is necessary to have a predictive model capable of integrating both health variables and spatial information to forecast health outcomes, along with a tool to interpret and reveal the patterns identified by this model. We developed a Spatial Counterfactual Explainable Deep Learning model (SpaCE), comprising a spatially explicit health outcome predictor and a prototype-guided counterfactual explanation. The SpaCE model unifies geospatial and health variables to improve predictions and generates hypothetical examples with minimal changes but opposite outcomes. Using these counterfactuals, SpaCE assesses the impact of each variable in different spatial contexts. We evaluated the model for predicting cardiac arrest survival outcomes. With a 0.682 AUCROC score, the SpaCE exceeds baseline models by 10.2%. Further analysis also reveals that the geospatial context significantly affects how various risk factors affect the survival outcomes of patients. Overall, the SpaCE model significantly improves predictive accuracy and explainability. It provides targeted interventions at both individual and geographic levels, and the cardiac arrest case study shows its high adaptability to various disease scenarios.Violent crime victimization and mental health among adolescents in Mexico
AbstractBalmori-de-la-Miyar, J., Tennyson, S., Silverio-Murillo, A., & Pagán, J. A. (n.d.).Publication year
2025Journal title
Preventive Medicine ReportsVolume
53AbstractObjectives: To understand the association between violent crime victimization and mental health outcomes among adolescents in Mexico, and to define the link between the nominal classification of violent crime and mental health outcomes. Methods: We used fixed-effects linear and logistic regressions and survey data from the 2018–2019, 2021, 2022, and 2023 National Health and Nutrition Survey (n = 26,187). Survey waves were conducted in all 32 Mexican states during: July 2018–June 2019, July–December 2021, July–December 2022, and July–October 2023. Results: Violent crime victimization was associated with higher scores of having depressive symptoms (CESD-7) (b = 1.93 points, ± 0.26), and greater likelihood of suicidal ideation (adjusted odds ratio (aOR) = 5.32, ± 0.86) and suicide attempts in the last twelve months (aOR = 6.87, ± 2.74). More serious classes of violent crime relate to worse mental health outcomes among adolescents. Specifically, kidnapping, the most serious class of violent crime in our data, correlates with worse mental health outcomes when compared to robbery or aggravated assault. Conclusions: Violent crime victimization is linked to increased depressive symptoms, suicidal ideation, and suicide attempts among adolescents. More serious classes of violent crime are associated with worse mental health outcomes in this population.Barriers and Facilitators to Establishing Partnerships for Substance Use Disorder Care Transitions Between Safety-Net Hospitals and Community-Based Organizations
AbstractLindenfeld, Z., Franz, B., Lai, A., Pagan, J., Fenstemaker, C., Cronin, C. E., & Chang, J. E. (n.d.).Publication year
2024Journal title
Journal of general internal medicineVolume
39Issue
12Page(s)
2150-2159AbstractBackground: The effectiveness of hospital-based transitional opioid programs (TOPs), which aim to connect patients with substance use disorders (SUD) to ongoing treatment in the community following initiation of medication for opioid use disorder (MOUD) treatment in the hospital, hinges on successful patient transitions. These transitions are enabled by strong partnerships between hospitals and community-based organizations (CBOs). However, no prior study has specifically examined barriers and facilitators to establishing SUD care transition partnerships between hospitals and CBOs. Objective: To identify barriers and facilitators to developing partnerships between hospitals and CBOs to facilitate care transitions for patients with SUDs. Design: Qualitative study using semi structured interviews conducted between November 2022-August 2023. Participants: Staff and providers from hospitals affiliated with four safety-net health systems (n=21), and leaders and staff from the CBOs with which they had established partnerships (n=5). Approach: Interview questions focused on barriers and facilitators to implementing TOPs, developing partnerships with CBOs, and successfully transitioning SUD patients from hospital settings to CBOs. Key Results: We identified four key barriers to establishing transition partnerships: policy and philosophical differences between organizations, ineffective communication, limited trust, and a lack of connectivity between data systems. We also identified three facilitators to partnership development: strategies focused on building partnership quality, strategic staffing, and organizing partnership processes. Conclusions: Our findings demonstrate that while multiple barriers to developing hospital-CBO partnerships exist, stakeholders can adopt implementation strategies that mitigate these challenges such as using mediators, cross-hiring, and focusing on mutually beneficial services, even within resource-limited safety-net settings. Policymakers and health system leaders who wish to optimize TOPs in their facilities should focus on adopting implementation strategies to support transition partnerships such as inadequate data collection and sharing systems.Cost-Associated Unmet Dental, Vision, And Hearing Needs Among Low-Income Medicare Advantage Beneficiaries
AbstractGupta, A., Johnston, K. J., Silver, D., Meyers, D. J., Glied, S. A., & Pagán, J. A. (n.d.).Publication year
2024Journal title
Health AffairsVolume
43Issue
10Page(s)
1392-1399AbstractMedicare Advantage (MA) supplemental benefits offered at no or low premiums are a key value proposition for low-income beneficiaries. Despite nearly $20 billion in rebate payments to MA plans for funding supplemental benefits, their quality or enrollee access is not monitored. Using 2018–19 Medicare Current Beneficiary Survey data linked to MA plan data, we found that regardless of plan benefit generosity, low-income beneficiaries were more likely to report dental, vision, and hearing unmet needs because of cost. Enrollment in plans with higher corresponding-year (that is, the same year as unmet need measurement) star ratings was associated with lower dental unmet need. Income-related disparities in dental unmet needs were lower in the highest-rated plans. However, prior-year star ratings that determined plan payments were not associated with unmet needs or disparities in those needs. Policy makers should consider monitoring supplemental benefits for equity and access, and they should assess the value added by quality bonus payments to high-rated plans for beneficiaries’ access.Cost-Effectiveness of the Second COVID-19 Booster Vaccination in the USA
AbstractLi, R., Lu, P., Fairley, C. K., Pagán, J. A., Hu, W., Yang, Q., Zhuang, G., Shen, M., Li, Y., & Zhang, L. (n.d.).Publication year
2024Journal title
Applied Health Economics and Health PolicyVolume
22Issue
1Page(s)
85-95AbstractObjective: To assess the cost effectiveness of the second COVID-19 booster vaccination with different age groups. Methods: We developed a decision-analytic Susceptible-Exposed-Infected-Recovered (SEIR)-Markov model by five age groups (0–4 years, 5–11 years 12–17 years, 18–49 years, and 50+ years) and calibrated the model by actual mortality in each age group in the USA. We conducted five scenarios to evaluate the cost effectiveness of the second booster strategy and incremental benefits if the strategy would expand to 18–49 years and 12–17 years, from a health care system perspective. The analysis was reported according to the Consolidated Health Economic Evaluation Reporting Standards 2022 statement. Results: Implementing the second booster strategy for those aged ≥ 50 years cost $823 million but reduced direct medical costs by $1166 million, corresponding to a benefit-cost ratio of 1.42. Moreover, the strategy also resulted in a gain of 2596 quality-adjusted life-years (QALYs) during the 180-day evaluation period, indicating it was dominant. Further, vaccinating individuals aged 18–49 years with the second booster would result in an additional gain of $1592 million and 8790 QALYs. Similarly, expanding the vaccination to individuals aged 12–17 years would result in an additional gain of $16 million and 403 QALYs. However, if social interaction between all age groups was severed, vaccination expansion to ages 18–49 and 12–17 years would no longer be dominant but cost effective with an incremental cost-effectiveness ratio (ICER) of $37,572 and $26,705/QALY gained, respectively. Conclusion: The second booster strategy was likely to be dominant in reducing the disease burden of the COVID-19 pandemic. Expanding the second booster strategy to ages 18–49 and 12–17 years would remain dominant due to their social contacts with the older age group.Discrimination in Medical Settings across Populations: Evidence From the All of Us Research Program
AbstractWang, V. H. C., Cuevas, A. G., Osokpo, O. H., Chang, J. E., Zhang, D., Hu, A., Yun, J., Lee, A., Du, S., Williams, D. R., & Pagán, J. A. (n.d.).Publication year
2024Journal title
American journal of preventive medicineVolume
67Issue
4Page(s)
568-580AbstractIntroduction: Discrimination in medical settings (DMS) contributes to healthcare disparities in the United States, but few studies have determined the extent of DMS in a large national sample and across different populations. This study estimated the national prevalence of DMS and described demographic and health-related characteristics associated with experiencing DMS in seven different situations. Methods: Survey data from 41,875 adults participating in the All of Us Research Program collected in 2021–2022 and logistic regression were used to examine the association between sociodemographic and health-related characteristics and self-reported DMS among adults engaged with a healthcare provider within the past 12 months. Statistical analysis was performed in 2023–2024. Results: About 36.89% of adults reported having experienced at least one DMS situation. Adults with relative social and medical disadvantages had higher prevalence of experiencing DMS. Compared to their counterparts, respondents with higher odds of experiencing DMS in at least one situation identified as female, non-Hispanic Black, having at least some college, living in the South, renter, having other living arrangement, being publicly insured, not having a usual source of care, having multiple chronic conditions, having any disability, and reporting fair or poor health, p<0.05. Conclusions: The findings indicate a high prevalence of DMS, particularly among some population groups. Characterizing DMS may be a valuable tool for identifying populations at risk within the healthcare system and optimizing the overall patient care experience. Implementing relevant policies remains an essential strategy for mitigating the prevalence of DMS and reducing healthcare disparities.Enrollment Patterns of Medicare Advantage Beneficiaries by Dental, Vision, and Hearing Benefits
AbstractGupta, A., Silver, D., Meyers, D. J., Murray, G., Glied, S., & Pagán, J. A. (n.d.).Publication year
2024Journal title
JAMA Health ForumVolume
5Issue
1Page(s)
E234936AbstractImportance: Most Medicare beneficiaries now choose to enroll in Medicare Advantage (MA) plans. Racial and ethnic minority group and low-income beneficiaries are increasingly enrolling in MA plans. Objective: To examine whether dental, vision, and hearing supplemental benefits offered in MA plans are associated with the plan choices of traditionally underserved Medicare beneficiaries. Design, Setting, and Participants: This exploratory observational cross-sectional study used data from the 2018 to 2020 Medicare Current Beneficiary Survey linked to MA plan benefits. The nationally representative sample comprised primarily community-dwelling MA beneficiaries enrolled in general enrollment MA plans. Data analysis was performed between April and October 2023. Exposures: Beneficiary self-identified race and ethnicity and combined individual and spouse income and educational attainment. Main Outcomes and Measures: Binary indicators were developed to determine whether beneficiaries were enrolled in a plan offering any dental, comprehensive dental, any vision, eyewear, any hearing, or hearing aid benefit. Mixed-effects logistic regression models were estimated to report average marginal effects adjusted for beneficiary-level demographic and health characteristics, plan attributes, and plan availability. Results: This study included 8139 (weighted N = 31 million) eligible MA beneficiaries, with a mean (SD) age of 77.7 (7.5) years. More than half of beneficiaries (54.9%) were women; 9.8% self-identified as Black, 2.0% as Hispanic, 83.9% as White, and 4.2% as other or multiple races or ethnicities. Plan choices by dental benefits were examined among 7516 beneficiaries who were not enrolled in any dental standalone plan, by vision benefits for 8026 beneficiaries not enrolled in any vision standalone plan, and by hearing benefits for 8131 beneficiaries not enrolled in any hearing standalone plan. Black beneficiaries were more likely to enroll in plans with any dental benefit (9.0 percentage points [95% CI, 3.4-14.4]; P <.001), any comprehensive dental benefit (11.2 percentage points [95% CI, 5.7-16.7]; P <.001), any eye benefit (3.0 percentage points [95% CI, 1.0 to 5.0]; P =.004), or any eyewear benefit (6.0 percentage points [95% CI, 0.6-11.5]; P =.03) compared with White beneficiaries. Lower-income individuals (earning ≤200% of the federal poverty level) were more likely to enroll in a plan with a comprehensive dental benefit (4.4 percentage-point difference [95% CI, 0.1-7.9]; P =.01) compared with higher-income beneficiaries. Beneficiaries without a college degree were more likely to enroll in a plan with a comprehensive dental benefit (4.7 percentage-point difference [95% CI, 1.4-8.0]; P =.005) compared with those with higher educational attainment. Conclusions and Relevance: The results of this study suggest that racial and ethnic minority individuals and those with lower income or educational attainment are more likely to choose MA plans with dental or vision benefits. As the federal government prepares to adjust MA plan star ratings for health equity, implements MA payment cuts, and allows increasing flexibility in supplemental benefit offerings, these findings may inform benefit monitoring for MA..Examining the relationship between social determinants of health, measures of structural racism and county-level overdose deaths from 2017–2020
AbstractLindenfeld, Z., Silver, D., Pagán, J. A., Zhang, D. S., & Chang, J. E. (n.d.).Publication year
2024Journal title
PloS oneVolume
19Issue
5AbstractIntroduction Despite being an important determinant of health outcomes, measures of structural racism are lacking in studies examining the relationship between the social determinants of health (SDOH) and overdose deaths. The aim of this study is to examine the association between per capita revenue generated from fines and forfeitures, a novel measure of structural racism, and other SDOH with county-level overdose deaths from 2017–2020. Methods This longitudinal analysis of 2,846 counties from 2017–2020 used bivariate and multivariate Generalized Estimating Equations models to estimate associations between county overdose mortality rates and SDOH characteristics, including the fines and forfeitures measure. Results In our multivariate model, higher per capita fine and forfeiture revenue (5.76; CI: 4.76, 6.78), households receiving food stamps (1.15; CI: 0.77, 1.53), residents that are veterans (1.07; CI: 0.52, 1.63), substance use treatment availability (4.69; CI: 3.03, 6.33) and lower population density (-0.002; CI: -0.004, -0.001) and percent of Black residents (-0.7‘; CI: -1.01, -0.42) were significantly associated with higher overdose death rates. There was a significant additive interaction between the fines and forfeitures measure (0.10; CI: 0.03, 0.17) and the percent of Black residents. Conclusions Our findings suggest that structural racism, along with other SDOH, is associated with overdose deaths. Future research should focus on connecting individual-level data on fines and forfeitures to overdose deaths and other health outcomes, include measures of justice-related fines, such as court fees, and assess whether interventions aimed at increasing economic vitality in disadvantaged communities impact overdose deaths in a meaningful way.Global prevalence of violence against children and adolescents during COVID-19: A meta-analysis
AbstractNiu, L., Li, Y., Bai, R., Pagán, J. A., Zhang, D., & Diaz, A. (n.d.).Publication year
2024Journal title
Child Abuse and NeglectVolume
154AbstractBackground: Recent studies suggest that children and adolescents are at an increased risk of experiencing violence during the COVID-19 pandemic. However, there is limited knowledge about the prevalence of violence against children and adolescents across different regions in the world. Objective: To estimate the pooled prevalence of violence against children and adolescents during the COVID-19 pandemic and explore how geographical and methodological factors explain the variation across studies. Methods: We conducted a systematic search of MEDLINE, Embase, and PsycInfo databases for articles published from January 1, 2020 to October 1, 2022. The study protocol was pre-registered with PROSPERO (CRD42022338181). We included published and unpublished studies available in English that reported the prevalence of violence (e.g., physical, emotional, or sexual violence, neglect, bullying) against children and adolescents (age <18 years) during the pandemic. Data extraction followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. A total of 2740 nonduplicate titles and abstracts were screened, and 217 full-text articles were reviewed for eligibility. Results: Twenty-five studies with 66,637 participants met inclusion criteria. Based on random-effects meta-analysis, the pooled prevalence of violence against children and adolescents was 24 % (95%CI 18 %–30 %). The reported prevalence was higher in studies conducted in low- and middle-income countries compared to high-income countries. Conclusions: Over one in five children and adolescents globally reported ever experiencing violence during the COVID-19 pandemic. Our findings highlight the urgent need for effective child protection policies and interventions, as well as multisectoral collaboration, to reduce violence against children and adolescents.Medical financial hardship between young adult cancer survivors and matched individuals without cancer in the United States
AbstractLi, L., Zhang, D., Li, Y., Jain, M., Lin, X., Hu, R., Liu, J., Thapa, J., Mu, L., Chen, Z., Liu, B., & Pagán, J. A. (n.d.).Publication year
2024Journal title
JNCI Cancer SpectrumVolume
8Issue
2AbstractBackground: Young adult cancer survivors face medical financial hardships that may lead to delaying or forgoing medical care. This study describes the medical financial difficulties young adult cancer survivors in the United States experience in the post–Patient Protection and Affordable Care Act period. Method: We identified 1009 cancer survivors aged 18 to 39 years from the National Health Interview Survey (2015-2022) and matched 963 (95%) cancer survivors to 2733 control individuals using nearest-neighbor matching. We used conditional logistic regression to examine the association between cancer history and medical financial hardship and to assess whether this association varied by age, sex, race and ethnicity, and region of residence. Results: Compared with those who did not have a history of cancer, young adult cancer survivors were more likely to report material financial hardship (22.8% vs 15.2%; odds ratio ¼ 1.65, 95% confidence interval ¼ 1.50 to 1.81) and behavior-related financial hardship (34.3% vs 24.4%; odds ratio ¼ 1.62, 95% confidence interval ¼ 1.49 to 1.76) but not psychological financial hardship (52.6% vs 50.9%; odds ratio ¼ 1.07, 95% confidence interval ¼ 0.99 to 1.16). Young adult cancer survivors who were Hispanic or lived in the Midwest and South were more likely to report psychological financial hardship than their counterparts. Conclusions: We found that young adult cancer survivors were more likely to experience material and behavior-related financial hardship than young adults without a history of cancer. We also identified specific subgroups of young adult cancer survivors that may benefit from targeted policies and interventions to alleviate medical financial hardship.Medicare Advantage Plan Star Ratings and County Social Vulnerability
AbstractGupta, A., Silver, D., Meyers, D. J., Glied, S., & Pagán, J. A. (n.d.).Publication year
2024Journal title
JAMA network openVolume
7Issue
7AbstractIMPORTANCE The star rating of a Medicare Advantage (MA) plan is meant to represent plan performance, and it determines the size of quality bonuses. Consumer access to MA plans with a high star rating may vary by the extent of social vulnerability in geographic regions. OBJECTIVE To examine the association between a county’s Social Vulnerability Index (SVI) and the star rating of a county’s MA plans. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used 2023 Centers for Medicare & Medicaid Services data for all MA plans linked to 2020 county-level SVI data from the Centers for Disease Control and Prevention. Data were analyzed from March to October 2023. EXPOSURE Quintile rank of county based on composite and theme-specific SVI scores, with quartile 1 (Q1) representing the least vulnerable counties and Q5, the most vulnerable counties. The SVI is a multidimensional measure of a county’s social vulnerability across 4 themes: socioeconomic status, household characteristics (such as disability, age, and language), racial and ethnic minority status, and housing type and transportation. MAIN OUTCOMES AND MEASURES County-level mean star rating and the number of MA plans with low-rated (<3.5 stars), high-rated (3.5 or 4.0 stars), and highest-rated (≥4.5 stars) plans. RESULTS Across 3075 counties, the median county-level star rating was 4.1 (IQR, 3.9-4.3) in Q1 counties and 3.8 (IQR, 3.6-4.0) in Q5 counties (P < .001). The mean star rating of MA plans was lower (difference, −0.24 points; 95% CI, −0.28 to −0.21 points; P < .001), the number of low-rated plans was higher (incidence rate ratio, 1.81; 95% CI, 1.61-2.06; P < .001), and the number of highest-rated plans was lower (incidence rate ratio, 0.75; 95% CI, 0.70-0.81; P < .001) in Q5 counties compared with Q1 counties. Similar patterns were found across theme-specific SVI score quintiles and for 2022 star ratings. CONCLUSIONS AND RELEVANCE In this cross-sectional study, the most socially vulnerable counties were found to have the fewest highest-rated plans for MA beneficiaries. As MA enrollment grows in socially vulnerable regions, this may exacerbate regional differences in health outcomes for Medicare beneficiaries.Racial and ethnic differences in the receipt of continuous positive airway pressure treatment for obstructive sleep apnea
AbstractWang, V. H. C., Li, Y., Kent, D. T., Pagán, J. A., Arabadjian, M., Divers, J., & Zhang, D. (n.d.).Publication year
2024Journal title
Sleep MedicineVolume
124Page(s)
42-49AbstractObjective: To examine the pattern of health services access and utilization that may contribute to racial/ethnic disparities in receiving continuous positive airway pressure (CPAP) treatment for obstructive sleep apnea (OSA). Methods: This cross-sectional study used a national sample from the All of Us Research Program, which included over 80 % of participants from underrepresented populations in biomedical research. Study participants included adults aged 18 years and older diagnosed with OSA (N = 8518). Diagnosis of OSA and CPAP treatment were ascertained by diagnostic and procedural codes from the electronic health records. Sociodemographic characteristics and health service utilization factors were identified using self-reported survey data. Results: With this national survey, the overall diagnosed prevalence of OSA was 8.8 %, with rates of 8.12 % in non-Hispanic (NH) Black adults, 5.99 % in Hispanic adults, and 10.35 % in NH White adults. When comparing to NH White adults, Hispanic adults were less likely to receive CPAP treatment for OSA after adjusting for socioeconomic and demographic characteristics, access to and utilization of health services, and comorbidities such as obesity and having multiple chronic conditions (OR = 0.73, 95 % CI = 0.59,0.90), p < 0.01. Conclusions: The rates of CPAP treatment among OSA patients are not consistent across racial and ethnic groups. Unequal access to health services based on residence may contribute to these differences. Interventions that target disparities in OSA diagnosis, access to treatment, and barriers in insurance coverage could potentially help reduce racial and ethnic differences in OSA diagnosis and management.Rural-urban disparities in the availability of hospital-based screening, medications for opioid use disorder, and addiction consult services
AbstractFranz, B., Cronin, C. E., Lindenfeld, Z., Pagan, J. A., Lai, A. Y., Krawczyk, N., Rivera, B. D., & Chang, J. E. (n.d.).Publication year
2024Journal title
Journal of Substance Use and Addiction TreatmentVolume
160AbstractIntroduction: Hospitals are an ideal setting to stage opioid-related interventions with patients who are hospitalized due to overdose or other substance use–related complications. Transitional opioid programs—which initiate care and provide linkages upon discharge, such as screening, initiation of medications for opioid use disorder, and addiction consult services—have become the gold standard, but implementation has been uneven. The purpose of this study was to assess disparities in the availability of hospital-based transitional opioid programs, across rural and urban hospital settings in the United States. Methods: Using hospital administrative data paired with county-level demographic data, we conducted bivariate and regression analyses to assess rural-urban differences in the availability of transitional opioid services including screening, addiction consult services, and MOUD in U.S general medical centers, controlling for hospital- and community-level factors. Our sample included 2846 general medical hospitals that completed the 2021 American Hospital Association (AHA) Annual Survey of Hospitals. Our primary outcomes were five self-reported measures: whether the hospital provided screening in the ED; provided screening in the inpatient setting; whether the hospital provided addiction consult services in the ED; provided addiction consult services in the inpatient setting; and whether the hospital provided medications for opioid use disorder. Results: Rural hospitals did not have lower odds of screening for OUD or other SUDs than urban hospitals, but both micropolitan rural counties and noncore rural counties had significantly lower odds of having addiction consult services in either the ED (OR: 0.74, 95 % CI: 0.58, 0.95; OR: 0.68, 95 % CI: 0.50, 0.91) or inpatient setting (OR: 0.76, 95 % CI: 0.59, 0.97; OR: 0.68, 95 % CI: 0.50, 0.93), respectively, or of offering MOUD (OR: 0.69, 95 % CI: 0.52, 0.90; OR: 0.52, 95 % CI: 0.37, 0.74). Conclusions: Our study suggests that evidence-based interventions, such as medications for opioid use disorder and addiction consult services, are less often available in rural hospitals, which may contribute to rural-urban disparities in health outcomes secondary to OUD. A priority for population health improvement should be developing implementation strategies to support rural hospital adoption of transitional opioid programs.The Ecology of Economic Distress and Life Expectancy
AbstractWeeks, W. B., Chang, J. E., Pagán, J. A., Adamson, E., Weinstein, J., & Ferres, J. M. (n.d.).Publication year
2024Journal title
International Journal of Public HealthVolume
69AbstractObjectives: To determine whether life expectancy (LE) changes between 2000 and 2019 were associated with race, rural status, local economic prosperity, and changes in local economic prosperity, at the county level. Methods: Between 12/1/22 and 2/28/23, we conducted a retrospective analysis of 2000 and 2019 data from 3,123 United States counties. For Total, White, and Black populations, we compared LE changes for counties across the rural-urban continuum, the local economic prosperity continuum, and for counties in which local economic prosperity dramatically improved or declined. Results: In both years, overall, across the rural-urban continuum, and for all studied populations, LE decreased with each progression from the most to least prosperous quintile (all p < 0.001); improving county prosperity between 2000–2019 was associated with greater LE gains (p < 0.001 for all). Conclusion: At the county level, race, rurality, and local economic distress were all associated with LE; improvements in local economic conditions were associated with accelerated LE. Policymakers should appreciate the health externalities of investing in areas experiencing poor economic prosperity if their goal is to improve population health.The Impact of Medicaid Accountable Care Organizations on Health Care Utilization, Quality Measures, Health Outcomes and Costs from 2012 to 2023: A Scoping Review
AbstractHolm, J., Pagán, J. A., & Silver, D. (n.d.).Publication year
2024Journal title
Medical Care Research and ReviewVolume
81Issue
5Page(s)
355-369AbstractMost of the evidence regarding the success of ACOs is from the Medicare program. This review evaluates the impacts of ACOs within the Medicaid population. We identified 32 relevant studies published between 2012 and 2023 which analyzed the association of Medicaid ACOs and health care utilization (n = 21), quality measures (n = 18), health outcomes (n = 10), and cost reduction (n = 3). The results of our review regarding the effectiveness of Medicaid ACOs are mixed. Significant improvements included increased primary care visits, reduced admissions, and reduced inpatient stays. Cost reductions were reported in a few studies, and savings were largely dependent on length of attribution and years elapsed after ACO implementation. Adopting the ACO model for the Medicaid population brings some different challenges from those with the Medicare population, which may limit its success, particularly given differences in state Medicaid programs.The role of quality management in healthcare
AbstractKaynak, H., Chakraborty, S., & Pagán, J. A. (n.d.). In The Palgrave Handbook of Supply Chain Management: A supply chain perspective (1–).Publication year
2024Page(s)
443-464AbstractIn this chapter we first highlight the pressing supply chain management issues plaguing the US healthcare. Because hospitals play a critical role in the healthcare ecosystem and continuous improvement, quality leadership, teamwork, andsupplier relations are key factors in managing healthcare quality, hospitals are at the center of our research. Proceeding with a conceptual representation of a typical US hospital supply chain in mind, we offer a conceptual framework depicting hospital quality management practices and quality performance. Finally, we discuss two major emergent concerns and research areas in healthcare - population health management and managing stressful environments in healthcare - and offer our insights drawn from quality management in the context of the US healthcare supply chain.United States Federal Policies Contributing to Health and Health Care Inequities in Puerto Rico
AbstractMcSorley, A. M. M., Rivera-González, A. C., Lopez Mercado, D., Pagán, J. A., Purtle, J., & Ortega, A. N. (n.d.).Publication year
2024Journal title
American journal of public healthVolume
114Page(s)
S478-S484AbstractPuerto Rico, a territory of the United States since 1898, has recently experienced an increasing frequency and intensity of natural disasters and public health emergencies. In 2022, Hurricane Fiona became the latest storm to attract media attention and cast a light on Puerto Rico's deteriorating conditions, including infrastructural failings, health care provider shortages, and high levels of chronic illness. Although recent events have been uniquely devastating, decades of inequitable US federal policy practices have fueled the persistence of health inequities in the territory. Here we demonstrate how existing health and health care inequities in Puerto Rico have been exacerbated by compounding disasters but are rooted in the differential treatment of the territory under US federal policies. Specifically, we focus on the unequal US Federal Emergency Management Agency response to disasters in the territory, the lack of parity in federal Medicaid funding for Puerto Rico, and Puerto Rico's limited political power as a territory of the United States. We also provide empirically supported policy recommendations aimed at reducing health and health care inequities in the often-forgotten US territory of Puerto Rico.Use of calibration to improve the precision of estimates obtained from All of Us data
AbstractWang, V. H. C., Holm, J., & Pagán, J. A. (n.d.).Publication year
2024Journal title
Journal of the American Medical Informatics Association : JAMIAVolume
31Issue
12Page(s)
2985-2988AbstractOBJECTIVES: To highlight the use of calibration weighting to improve the precision of estimates obtained from All of Us data and increase the return of value to communities from the All of Us Research Program. MATERIALS AND METHODS: We used All of Us (2017-2022) data and raking to obtain prevalence estimates in two examples: discrimination in medical settings (N = 41 875) and food insecurity (N = 82 266). Weights were constructed using known population proportions (age, sex, race/ethnicity, region of residence, annual household income, and home ownership) from the 2020 National Health Interview Survey. RESULTS: About 37% of adults experienced discrimination in a medical setting. About 20% of adults who had not seen a doctor reported being food insecure compared with 14% of adults who regularly saw a doctor. CONCLUSIONS: Calibration using raking is cost-effective and may lead to more precise estimates when analyzing All of Us data.Weighting the United States All of Us Research Program data to known population estimates using raking
AbstractWang, V. H. C., Lei, J., Shi, T., & Pagán, J. A. (n.d.).Publication year
2024Journal title
Preventive Medicine ReportsVolume
43AbstractBackground: The All of Us Research Program aims to collect longitudinal health-related data from a million individuals in the United States. An inherent challenge of a non-probability sampling strategy through voluntary participation in All of Us is that findings may not be nationally representative for addressing health and health care at the population level. We generated survey weights for the All of Us data that can be used to address the challenge. Research design: We developed raked weights using demographic, health, and socioeconomic variables available in both the 2020 National Health Interview Survey (NHIS) and All of Us. We then compared the unweighted and weighted prevalence of a set of health-related variables (health behaviors, health conditions, and health insurance coverage) estimated from All of Us data with the weighted prevalence estimates obtained from NHIS data. Subjects: The sample included 100,391 All of Us participants 18 years of age and older with complete data collected between May 2017 and January 2022 across the United States. Results: Final variables in the raking procedure included age, sex, race/ethnicity, region of residence, annual household income, and home ownership. The mean percentage difference between known proportions obtained from the NHIS and All of Us was reduced by 18.89% for health-related variables after applying the raked weights. Conclusions: Raking improved the comparability of prevalence estimates obtained from All of Us to known national prevalence estimates. Refining the process of variable selection for raking may further improve the comparability between All of Us and nationally representative data.