Chair and Professor of the Department of Public Health Policy and Management
Dr. Pagán is also Director of the Center for Health Innovation at The New York Academy of Medicine and Adjunct Senior Fellow and member of the Executive Advisory Board of the Leonard Davis Institute of Health Economics at the University of Pennsylvania.
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. 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. He is also a member of the Board of Directors of the Interdisciplinary Association for Population Health Science and a member of the National Advisory Committee of the Robert Wood Johnson Foundation’s Health Policy Research Scholars.
Applied EconomicsHealth EconomicsPopulation HealthPublic Health Policy
Decoding Nonadherence to Hypertensive Medication in New York City: A Population Segmentation ApproachLi, Y., Jasani, F., Su, D., Zhang, D., Shi, L., Yi, S. S., & Pagan, J.
Journal titleJournal of Primary Care and Community Health
Volume10Objective: Nearly one-third of adults in New York City (NYC) have high blood pressure and many social, economic, and behavioral factors may influence nonadherence to antihypertensive medication. The objective of this study is to identify profiles of adults who are not taking antihypertensive medications despite being advised to do so. Methods: We used a machine learning–based population segmentation approach to identify population profiles related to nonadherence to antihypertensive medication. We used data from the 2016 NYC Community Health Survey to identify and segment adults into subgroups according to their level of nonadherence to antihypertensive medications. Results: We found that more than 10% of adults in NYC were not taking antihypertensive medications despite being advised to do so by their health care providers. We identified age, neighborhood poverty, diabetes, household income, health insurance coverage, and race/ethnicity as important characteristics that can be used to predict nonadherence behaviors as well as used to segment adults with hypertension into 10 subgroups. Conclusions: Identifying segments of adults who do not adhere to hypertensive medications has practical implications as this knowledge can be used to develop targeted interventions to address this population health management challenge and reduce health disparities.
Measuring Efforts of Nonprofit Hospitals to Address Opioid Abuse After the Affordable Care ActFranz, B., Cronin, C. E., Wainwright, A., & Pagan, J.
Journal titleJournal of Primary Care and Community Health
Volume10Objectives: To assess the strategies that nonprofit hospitals are adopting to address opioid abuse after requirements for community engagement expanded in the Affordable Care Act. Methods: We constructed a dataset of implementation activities for a 20% random sample of nonprofit hospitals in the United States. Using logistic regression, we assessed the extent to which strategies adopted are new, existing, or primarily partnerships. Using negative binomial regression, we assessed the total number of strategies adopted. We controlled for hospital and community characteristics as well as state policies related to opioid abuse. Results: Most strategies adopted by hospitals were new and clinical in nature and the most common number of strategies adopted was one. Hospitals in the Northeast were more likely to adopt a higher number of strategies and to partner with community-based organizations. Hospitals that partner with community-based organizations were more likely to adopt strategies that engage in harm reduction, targeted risk education, or focus on addressing social determinants of health. Conclusions: Community, institutional, and state policy characteristics predict hospital involvement in addressing opioid abuse. These findings underscore several opportunities to support hospital-led interventions to address opioid abuse.
Spatial enablement to support environmental, demographic, socioeconomics and health data integration and analysis for big cities: A case study with asthma hospitalizations in New York CityPala, D., Pagan, J., Parimbelli, E., Rocca, M. T., Bellazzi, R., & Casella, V.
Journal titleFrontiers in Medicine
Volume6The percentage of the world's population living in urban areas is projected to increase in the next decades. Big cities are heterogeneous environments in which socioeconomic and environmental differences among the neighborhoods are often very pronounced. Each individual, during his/her life, is constantly subject to a mix of exposures that have an effect on their phenotype but are frequently difficult to identify, especially in an urban environment. Studying how the combination of environmental and socioeconomic factors which the population is exposed to influences pathological outcomes can help transforming public health from a reactive to a predictive system. Thanks to the application of state-of-the-art spatially enabled methods, patients can be stratified according to their characteristics and the geographical context they live in, optimizing healthcare processes and the reducing its costs. Some public health studies focusing specifically on urban areas have been conducted, but they usually consider a coarse spatial subdivision, as a consequence of scarce availability of well-integrated data regarding health and environmental exposure at a sufficient level of granularity to enable meaningful statistical analyses. In this paper, we present an application of highly fine-grained spatial resolution methods to New York City data. We investigated the link between asthma hospitalizations and a combination of air pollution and other environmental and socioeconomic factors. We first performed an explorative analysis using spatial clustering methods that shows that asthma is related to numerous factors whose level of influence varies considerably among neighborhoods. We then performed a Geographically Weighted Regression with different covariates and determined which environmental and socioeconomic factors can predict hospitalizations and how they vary throughout the city. These methods showed to be promising both for visualization and analysis of demographic and epidemiological urban dynamics, that can be used to organize targeted intervention and treatment policies to address the single citizens considering the factors he/she is exposed to. We found a link between asthma and several factors such as PM 2.5 , age, health insurance coverage, race, poverty, obesity, industrial areas and recycling. This study has been conducted within the PULSE project, funded by the European Commission, briefly presented in this paper.
The Impact of Ritual Bathing in a Holy Hindu River on Waterborne DiseasesRoy Chowdhury, S., Bohara, A. K., Katuwal, H., Pagan, J., & Thacher, J. A.
Journal titleDeveloping Economies
Page(s)36-54In this paper, we identify the role of religious practices on individual outcomes by examining if bathing in polluted river water for religious reasons affects the likelihood of missing days at work. To exploit the relationship, we use a primary survey (N = 1,200) of the residents of Kathmandu Valley, Nepal on their Bagmati River water usage. Probit and negative binomial estimation strategies reveal that bathing in river water, driven by traditional and cultural norms, is significantly associated with a higher probability of missing work. Among other factors, accessibility to personal sanitation facilities have a negative and significant correlation with the likelihood of missing work due to health reasons.
Assessing the Impact of Language Access Regulations on the Provision of Pharmacy ServicesWeiss, L., Scherer, M., Chantarat, T., Oshiro, T., Padgen, P., Pagan, J., Rosenfeld, P., & Yin, H. S.
Journal titleJournal of Urban Health
Page(s)1-8Approximately 25 million people in the United States are limited English proficient (LEP). Appropriate language services can improve care for LEP individuals, and health care facilities receiving federal funds are required to provide such services. Recognizing the risk of inadequate comprehension of prescription medication instructions, between 2008 and 2012, New York City and State passed a series of regulations that require chain pharmacies to provide translated prescription labels and other language services to LEP patients. We surveyed pharmacists before (2006) and after (2015) implementation of the regulations to assess their impact in chain pharmacies. Our findings demonstrate a significant improvement in capacity of chains to assist LEP patients. A higher proportion of chain pharmacies surveyed in 2015 reported printing translated labels, access and use of telephone interpreter services, multilingual signage, and documentation of language needs in patient records. These findings illustrate the potential impact of policy changes on institutional practices that impact large and vulnerable portions of the population.
Cost-effectiveness analysis of intensive hypertension control in ChinaXie, X., He, T., Kang, J., Siscovick, D. S., Li, Y., & Pagan, J.
Journal titlePreventive Medicine
Page(s)110-114China has the largest population of adults with hypertension in the world. Recent clinical trials have shown that intensive hypertension control can help patients achieve lower blood pressure and reduce the incidence of major cardiovascular disease (CVD) events, but this level of hypertension control also incurs additional costs to patients and society and may result in a substantial increase in adverse events. The objective of this study is to assess the cost-effectiveness of intensive hypertension control to inform health policymakers and health care delivery systems in China in their decision-making regarding hypertension treatment strategies. We developed a Markov based simulation model of hypertension to assess the impact of intensive and standard hypertension control strategies for the Chinese population who are diagnosed with hypertension. Model parameters were estimated based on the best available data and the literature. We projected that intensive hypertension control would avert about 2.2 million coronary heart disease events and 4.4 million stroke events for all hypertensive patients in China in 10 years compared to standard hypertension control. The incremental cost-effectiveness ratio (ICER) for intensive hypertension control was estimated at 7876 CNY per quality-adjusted life year (QALY) compared to standard hypertension control. Intensive hypertension control would be more cost-effective than standard hypertension control in China. Our findings indicated that China should consider expanding intensive hypertension control among hypertensive patients given its great potential in preventing CVD.
Power Up for Health—Participants’ Perspectives on an Adaptation of the National Diabetes Prevention Program to Engage MenRealmuto, L., Kamler, A., Weiss, L., Gary-Webb, T. L., Hodge, M. E., Pagan, J., & Walker, E. A.
Journal titleAmerican Journal of Men's Health
Page(s)981-988The National Diabetes Prevention Program (NDPP) has been effectively translated to various community and clinical settings; however, regardless of setting, enrollment among men and lower-income populations is low. This study presents participant perspectives on Power Up for Health, a novel NDPP pilot adaption for men residing in low-income communities in New York City. We conducted nine interviews and one focus group with seven participants after the program ended. Interview and focus group participants had positive perceptions of the program and described the all-male aspect of the program and its reliance on male coaches as major strengths. Men felt the all-male adaptation allowed for more open, in-depth conversations on eating habits, weight loss, body image, and masculinity. Participants also reported increased knowledge and changes to their dietary and physical activity habits. Recommendations for improving the program included making the sessions more interactive by, for example, adding exercise or healthy cooking demonstrations. Overall, findings from the pilot suggest this NDPP adaptation was acceptable to men and facilitated behavior change and unique discussions that would likely not have occurred in a mixed-gender NDPP implementation.
Remote Patient Monitoring and Clinical Outcomes for Postdischarge Patients with Type 2 DiabetesMichaud, T. L., Siahpush, M., Schwab, R. J., Eiland, L. A., Devany, M., Hansen, G., Slachetka, T. S., Boilesen, E., Tak, H. J., Wilson, F. A., Wang, H., Pagan, J., & Su, D.
Journal titlePopulation Health Management
Page(s)387-394The objective of this study was to evaluate changes in clinical outcomes for patients with type 2 diabetes (T2D) after a 3-month remote patient monitoring (RPM) program, and examine the relationship between hemoglobin A1c (HbA1c) outcomes and participant characteristics. The study sample included 955 patients with T2D who were admitted to an urban Midwestern medical center for any reason from 2014 to 2017, and used RPM for 3 months after discharge. Clinical outcomes included HbA1c, weight, body mass index (BMI), and patient activation scores. Logistic regression was used to estimate the likelihood of having a postintervention HbA1c <9% by patient characteristics, among those who had baseline HbA1c >9%. Most patients experienced decreases in HbA1c (67%) and BMI (58%), and increases in patient activation scores (67%) (P < 0.001 in all 3 cases) at the end of RPM. Logistic regression analyses revealed that among patients who had HbA1c >9% at baseline, men (odds ratio [OR] = 3.72; 95% confidence interval [CI], 1.43-9.64), those who had increased patient activation scores after intervention (OR = 1.05; 95% CI, 1.01-1.09), those who had higher baseline patient activation scores, and those who had a greater number of biometric data uploads during the intervention (OR = 1.02; 95% CI, 1.00-1.04) were more likely to have reduced their HbA1c to <9% at the end of RPM. RPM for postdischarge patients with T2D might be a promising approach for HbA1c control with increased patient engagement. Future studies with study designs that include a control group should provide more robust evidence.
Assessing the role of access and price on the consumption of fruits and vegetables across New York City using agent-based modelingLi, Y., Zhang, D., Thapa, J. R., Madondo, K., Yi, S., Fisher, E., Griffin, K., Liu, B., Wang, Y., & Pagan, J.
Journal titlePreventive MedicineMost residents in New York City (NYC) do not consume sufficient fruits and vegetables every day. Difficulties with access and high prices of fruits and vegetables in some neighborhoods contribute to different consumption patterns across NYC neighborhoods. We developed an agent-based model (ABM) to predict dietary behaviors of individuals at the borough and neighborhood levels. Model parameters were estimated from the 2014 NYC Community Health Survey, United States Census data, and the literature. We simulated six hypothetical interventions designed to improve access and reduce the price of fruits and vegetables. We found that all interventions would lead to increases in fruit and vegetable consumption but the results vary substantially across boroughs and neighborhoods. For example, a 10% increase in the number of fruit/vegetable vendors combined with a 10% decrease in the prices of fruits and vegetables would lead to a median increase of 2.28% (range: 0.65%-4.92%) in the consumption of fruits and vegetables, depending on neighborhood. We also found that the impact of increasing the number of vendors on fruit/vegetable consumption is more pronounced in unhealthier local food environments while the impact of reducing prices on fruits/vegetable consumption is more pronounced in neighborhoods with low levels of education. An agent-based model of dietary behaviors that takes into account neighborhood context has the potential to inform how fruit/vegetable access and pricing strategies may specifically work in tandem to increase the consumption of fruits and vegetables at the local level.
Cost-effectiveness of a patient navigation program to improve cervical cancer screeningLi, Y., Carlson, E., Villarreal, R., Meraz, L., & Pagan, J.
Journal titleAmerican Journal of Managed Care
Page(s)429-434OBJECTIVES: To assess the cost-effectiveness of a community-based patient navigation program to improve cervical cancer screening among Hispanic women 18 or older in San Antonio, Texas. STUDY DESIGN: We used a microsimulation model of cervical cancer to project the long-term cost-effectiveness of a community-based patient navigation program compared with current practice. METHODS: We used program data from 2012 to 2015 and published data from the existing literature as model input. Taking a societal perspective, we estimated the lifetime costs, life expectancy, and quality-adjusted life-years and conducted 2-way sensitivity analyses to account for parameter uncertainty. RESULTS: The patient navigation program resulted in a per-capita gain of 0.2 years of life expectancy. The program was highly cost-effective relative to no intervention (incremental cost-effectiveness ratio of $748). The program costs would have to increase up to 10 times from $311 for it not to be cost-effective. CONCLUSIONS: The 3-year community-based patient navigation program effectively increased cervical cancer screening uptake and adherence and improved the cost-effectiveness of the screening program for Hispanic women 18 years or older in San Antonio, Texas. Future research is needed to translate and disseminate the patient navigation program to other socioeconomic and demographic groups to test its robustness and design.
Delivery and Payment Redesign to Reduce Disparities in High Risk Postpartum CareHowell, E. A., Padrón, N. A., Beane, S. J., Stone, J., Walther, V., Balbierz, A., Kumar, R., & Pagan, J.
Journal titleMaternal and Child Health Journal
Page(s)432-438Purpose This paper describes the implementation of an innovative program that aims to improve postpartum care through a set of coordinated delivery and payment system changes designed to use postpartum care as an opportunity to impact the current and future health of vulnerable women and reduce disparities in health outcomes among minority women. Description A large health care system, a Medicaid managed care organization, and a multidisciplinary team of experts in obstetrics, health economics, and health disparities designed an intervention to improve postpartum care for women identified as high-risk. The program includes a social work/care management component and a payment system redesign with a cost-sharing arrangement between the health system and the Medicaid managed care plan to cover the cost of staff, clinician education, performance feedback, and clinic/clinician financial incentives. The goal is to enroll 510 high-risk postpartum mothers. Assessment The primary outcome of interest is a timely postpartum visit in accordance with NCQA healthcare effectiveness data and information set guidelines. Secondary outcomes include care process measures for women with specific high-risk conditions, emergency room visits, postpartum readmissions, depression screens, and health care costs. Conclusion Our evidence-based program focuses on an important area of maternal health, targets racial/ethnic disparities in postpartum care, utilizes an innovative payment reform strategy, and brings together insurers, researchers, clinicians, and policy experts to work together to foster health and wellness for postpartum women and reduce disparities.
Identifying policy levers and opportunities for action across states to achieve health equityBerenson, J., Li, Y., Lynch, J., & Pagan, J.
Journal titleHealth Affairs
Page(s)1048-1056In the United States, steps to advance health equity often take place at the state and local levels rather than the national level. Using publicly available data sources, we developed a scorecard for all fifty states and the District of Columbia that measures indicators of the use of five evidence-based policies to address domains related to health equity. The indicators are the cigarette excise tax rate, a state's Medicaid expansion status and the size of its coverage gap, percentage of four-year olds enrolled in state-funded pre-kindergarten, minimum wage level, and the presence of state-funded housing subsidy programs and homelessness prevention and rapid rehousing programs. We found that states varied significantly in their implementation of the selected policies and concluded that a variety of approaches to encourage policy changes at the state level will be needed to create healthier and more equitable communities. We describe promising, feasible state-level approaches for states to "do something, do more, do better" when they take action on the five selected policies that can promote health equity.
Integrating principles from behavioral economics into patient navigation programs targeting cancer screeningLi, Y., Wilson, F. A., Villarreal, R., & Pagan, J.
Nutrition Label Use and Sodium Intake in the U.S.Zhang, D., Li, Y., Wang, G., Moran, A. E., & Pagan, J.
Journal titleAmerican Journal of Preventive Medicine
Page(s)S220-S227Introduction High sodium intake is a major risk factor for hypertension, but evidence is limited on which interventions are effective in reducing sodium consumption. This study examined the associations between frequent use of nutrition labels and daily sodium intake and the consumption of high-sodium foods in the U.S. Methods Using the 2007–2008 and 2009–2010 Flexible Consumer Behavior Survey, this study compared sodium intake measured from the 24-hour dietary recalls, availability of salty snacks at home, and frequencies of eating frozen meals/pizzas between frequent (i.e., always or most of the time) and infrequent nutrition label users. Also, the study examined the association between nutrition label use and sodium-related dietary behaviors across different demographic and socioeconomic groups. Data were analyzed in 2016. Results Frequent users of nutrition labels consumed 92.79 mg less sodium per day (95% CI= −160.21, −25.37), were less likely to always or most of the time have salty snacks available at home (OR=0.86, 95% CI=0.76, 0.97), but were just as likely to eat frozen meals or pizzas (incidence rate ratio=0.96, 95% CI=0.84, 1.08) compared with infrequent label users. The associations between nutrition label use and sodium intake differed considerably across age, gender, and socioeconomic groups. Conclusions Frequent use of nutrition labels appears to be associated with lower consumption of sodium and high-sodium foods in the U.S. Given this small reduction, interventions such as enhancing nutrition label use could be less effective if implemented without other strategies.
Systems science simulation modeling to inform urban health policy and planningLi, Y., Boufford, J. I. M., & Pagan, J.
Page(s)151-166More than half of the population in the world lives in cities and urban populations are still rapidly expanding. Increasing population growth in cities inevitably brings about the intensification of urban health problems. The multidimensional nature of factors associated with health together with the dynamic, interconnected environment of cities moderates the effects of policies and interventions that are designed to improve population health. With the emergence of the “Internet of Things” and the availability of “Big Data,” policymakers and practitioners are in need of a new set of analytical tools to comprehensively understand the social, behavioral, and environmental factors that shape population health in cities. Systems science, an interdisciplinary field that draws concepts, theories, and evidence from fields such as computer science, engineering, social planning, economics, psychology, and epidemiology, has shown promise in providing practical conceptual and analytical approaches that can be used to solve urban health problems. This chapter describes the level of complexity that characterizes urban health problems and provides an overview of systems science features and methods that have shown great promise to address urban health challenges. We provide two specific examples to showcase systems science thinking: one using a system dynamics model to prioritize interventions that involve multiple social determinants of health in Toronto, Canada, and the other using an agent-based model to evaluate the impact of different food policies on dietary behaviors in NewYork City. These examples suggest that systems science has the potential to foster collaboration among researchers, practitioners, and policymakers from different disciplines to evaluate interconnected data and address challenging urban health problems.
Telementoring Primary Care Clinicians to Improve Geriatric Mental Health CareFisher, E., Hasselberg, M., Conwell, Y., Weiss, L., Padrón, N. A., Tiernan, E., Karuza, J., Donath, J., & Pagan, J.
Journal titlePopulation Health Management
Page(s)342-347Health care delivery and payment systems are moving rapidly toward value-based care. To be successful in this new environment, providers must consistently deliver high-quality, evidence-based, and coordinated care to patients. This study assesses whether Project ECHO® (Extension for Community Healthcare Outcomes) GEMH (geriatric mental health) - a remote learning and mentoring program - is an effective strategy to address geriatric mental health challenges in rural and underserved communities. Thirty-three teleECHO clinic sessions connecting a team of specialists to 54 primary care and case management spoke sites (approximately 154 participants) were conducted in 10 New York counties from late 2014 to early 2016. The curriculum consisted of case presentations and didactic lessons on best practices related to geriatric mental health care. Twenty-six interviews with program participants were conducted to explore changes in geriatric mental health care knowledge and treatment practices. Health insurance claims data were analyzed to assess changes in health care utilization and costs before and after program implementation. Findings from interviews suggest that the program led to improvements in clinician geriatric mental health care knowledge and treatment practices. Claims data analysis suggests that emergency room costs decreased for patients with mental health diagnoses. Patients without a mental health diagnosis had more outpatient visits and higher prescription and outpatient costs. Telementoring programs such as Project ECHO GEMH may effectively build the capacity of frontline clinicians to deliver high-quality, evidence-based care to older adults with mental health conditions and may contribute to the transformation of health care delivery systems from volume to value.
Using systems science to inform population health strategies in local health departments: A case study in San Antonio, TexasLi, Y., Padrón, N. A., Mangla, A. T., Russo, P. G., Schlenker, T., & Pagan, J.
Journal titlePublic Health Reports
Page(s)549-555Objectives: Because of state and federal health care reform, local health departments play an increasingly prominent role leading and coordinating disease prevention programs in the United States. This case study shows how a local health department working in chronic disease prevention and management can use systems science and evidence-based decision making to inform program selection, implementation, and assessment; enhance engagement with local health systems and organizations; and possibly optimize health care delivery and population health. Methods: The authors built a systems-science agent-based simulation model of diabetes progression for the San Antonio Metropolitan Health District, a local health department, to simulate health and cost outcomes for the population of San Antonio for a 20-year period (2015-2034) using 2 scenarios: 1 in which hemoglobin A1c (HbA1c) values for a population were similar to the current distribution of values in San Antonio, and the other with a hypothetical 1-percentage-point reduction in HbA1c values. Results: They projected that a 1-percentage-point reduction in HbA1c would lead to a decrease in the 20-year prevalence of end-stage renal disease from 1.7% to 0.9%, lower extremity amputation from 4.6% to 2.9%, blindness from 15.1% to 10.7%, myocardial infarction from 23.8% to 17.9%, and stroke from 9.8% to 7.2%. They estimated annual direct medical cost savings (in 2015 US dollars) from reducing HbA1c by 1 percentage point ranging from $6842 (myocardial infarction) to $39 800 (endstage renal disease) for each averted case of diabetes complications. Conclusions: Local health departments could benefit from the use of systems science and evidence-based decision making to estimate public health program effectiveness and costs, calculate return on investment, and develop a business case for adopting programs.
Who does not reduce their sodium intake despite being advised to do so? A population segmentation analysisLi, Y., Berenson, J., Moran, A. E., & Pagan, J.
Journal titlePreventive Medicine
Page(s)77-79Excessive sodium intake is linked to an increased risk for hypertension and cardiovascular disease. Although health care providers and other health professionals frequently provide counseling on healthful levels of sodium consumption, many people who consume sodium in excess of recommend levels still do not watch or reduce their sodium intake. In this study, we used a population segmentation approach to identify profiles of adults who are not watching or reducing their sodium intake despite been advised to do so. We analyzed sodium intake data in 125,764 respondents sampled in 15 states, the District of Columbia and Puerto Rico through the Behavioral Risk Factor Surveillance System to identify and segment adults into subgroups according to differences in sodium intake behaviors. We found that about 16% of adults did not watch or reduce their sodium intake despite been told to do so by a health professional. This proportion varied substantially across the 25 different population subgroups identified. For example, about 44% of adults 18 to 44 years of age who live in West Virginia were not reducing their sodium intake whereas only about 7.2% of black adults 65 years of age and older with diabetes were not reducing their sodium intake. Population segmentation identifies subpopulations most likely to benefit from targeted and intensive public health and clinical interventions. In the case of sodium consumption, population segmentation can guide public health practitioners and policymakers to design programs and interventions that change sodium intake in people who are resistant to behavior change.
Agent-based modeling of chronic diseases: A narrative review and future research directionsLi, Y., Lawley, M. A., Siscovick, D. S., Zhang, D., & Pagan, J.
Journal titlePreventing chronic disease
Issue5The United States is experiencing an epidemic of chronic disease. As the US population ages, health care providers and policy makers urgently need decision models that provide systematic, credible prediction regarding the prevention and treatment of chronic diseases to improve population health management and medical decision-making. Agent-based modeling is a promising systems science approach that can model complex interactions and processes related to chronic health conditions, such as adaptive behaviors, feedback loops, and contextual effects. This article introduces agent-based modeling by providing a narrative review of agent-based models of chronic disease and identifying the characteristics of various chronic health conditions that must be taken into account to build effective clinical- and policy-relevant models. We also identify barriers to adopting agent-based models to study chronic diseases. Finally, we discuss future research directions of agent-based modeling applied to problems related to specific chronic health conditions.
An agent-based model for ideal cardiovascular healthLi, Y., Kong, N., Lawley, M. A., & Pagan, J.
Patient-Centered Medical Home Features and Health Care Expenditures of Medicare Beneficiaries with Chronic Disease DyadsPhilpot, L. M., Stockbridge, E. L., Padrón, N. A., & Pagan, J.
Journal titlePopulation Health Management
Page(s)206-211Three out of 4 Medicare beneficiaries have multiple chronic conditions, and managing the care of this growing population can be complex and costly because of care coordination challenges. This study assesses how different elements of the patient-centered medical home (PCMH) model may impact the health care expenditures of Medicare beneficiaries with the most prevalent chronic disease dyads (ie, co-occurring high cholesterol and high blood pressure, high cholesterol and heart disease, high cholesterol and diabetes, high cholesterol and arthritis, heart disease and high blood pressure). Data from the 2007-2011 Medical Expenditure Panel Survey suggest that increased access to PCMH features may differentially impact the distribution of health care expenditures across health care service categories depending on the combination of chronic conditions experienced by each beneficiary. For example, having no difficulty contacting a provider after regular hours was associated with significantly lower outpatient expenditures for beneficiaries with high cholesterol and diabetes (n = 635; P = 0.038), but it was associated with significantly higher inpatient expenditures for beneficiaries with high blood pressure and high cholesterol (n = 1599; P = 0.015), and no significant differences in expenditures in any category for beneficiaries with high blood pressure and heart disease (n = 1018; P > 0.05 for all categories). However, average total health care expenditures are largely unaffected by implementing the PCMH features considered. Understanding how the needs of Medicare beneficiaries with multiple chronic conditions can be met through the adoption of the PCMH model is important not only to be able to provide high-quality care but also to control costs. (Population Health Management 2016;19:206-211)
Social Norms and the Consumption of Fruits and Vegetables across New York City NeighborhoodsLi, Y., Zhang, D., & Pagan, J.
Journal titleJournal of Urban Health
Page(s)244-255Consumption of fruits and vegetables is associated with a lower risk of developing many chronic health conditions such as diabetes and cardiovascular disease. While five or more servings of fruits and vegetables per day are recommended, only 50 % of New York City (NYC) residents consume two or more servings per day. In addition, there is wide variation in dietary behaviors across different neighborhoods in NYC. Using a validated agent-based model and data from 34 NYC neighborhoods, we simulate how a mass media and nutrition education campaign strengthening positive social norms about food consumption may potentially increase the proportion of the population who consume two or more servings of fruits and vegetables per day in NYC. We found that the proposed intervention results in substantial increases in daily fruit and vegetable consumption, but the campaign may be less effective in neighborhoods with relatively low education levels or a relatively high proportion of male residents. A well-designed, validated agent-based model has the potential to provide insights on the impact of an intervention targeting social norms before it is implemented and shed light on the important neighborhood factors that may affect the efficacy of the intervention.
Advancing the use of evidence-based decision-making in local health departments with systems science methodologiesLi, Y., Kong, N., Lawley, M., Weiss, L., & Pagan, J.
Journal titleAmerican Journal of Public Health
Page(s)S217-S222Objectives: We assessed how systems science methodologies might be used to bridge resource gaps at local health departments (LHDs) so that they might better implement evidence-based decision-making (EBDM) to address population health challenges. Methods: We used the New York Academy of Medicine Cardiovascular Health Simulation Model to evaluate the results of a hypothetical program that would reduce the proportion of people smoking, eating fewer than 5 fruits and vegetables per day, being physically active less than 150 minutes per week, and who had a body mass index (BMI) of 25 kg/m2 or greater. We used survey data from the Behavioral Risk Factor Surveillance System to evaluate health outcomes and validate simulation results. Results: Smoking rates and the proportion of the population with a BMI of 25 kg/m2 or greater would have decreased significantly with implementation of the hypothetical program (P < .001). Two areas would have experienced a statistically significant reduction in the local population with diabetes between 2007 and 2027 (P < .05). Conclusions: The use of systems science methodologies might be a novel and efficient way to systematically address a number of EBDM adoption barriers at LHDs.
Chronic pain and health care spending: An analysis of longitudinal data from the medical expenditure panel surveyStockbridge, E. L., Suzuki, S., & Pagan, J.
Journal titleHealth Services Research
Page(s)847-870Objective To estimate average incremental health care expenditures associated with chronic pain by health care service category, expanding on prior research that focused on specific pain conditions instead of general pain, excluded low levels of pain, or did not incorporate pain duration. Data Source Medical Expenditure Panel Survey (MEPS) data (2008-2011; N = 26,671). Study Design Differences in annual expenditures for adults at different levels of pain that interferes with normal work, as measured by the SF-12, were estimated using recycled predictions from two-part logit-generalized linear regression models. Principal Findings "A little bit" of chronic pain-related interference was associated with a $2,498 increase in total adjusted expenditures over no pain interference (p <.0001) and a $1,008 increase over nonchronic pain interference (p =.0001). Moderate and severe chronic pain-related interference was associated with a $3,707 and $5,804 increase in expenditures over no pain interference and a $2,218 and $4,315 increase over nonchronic interference, respectively (p <.0001). Expenditure increases were most pronounced for inpatient and hospital outpatient expenditures compared to other types of health care expenditures. Conclusions Chronic pain limitations are associated with higher health care expenditures. Results underscore the substantial cost of pain to the health care system.
Cost-Effectiveness Analysis of a Colonoscopy Screening Navigator Program Designed for Hispanic MenWilson, F. A., Villarreal, R., Stimpson, J. P., & Pagan, J.
Journal titleJournal of Cancer Education
Page(s)260-267Although Hispanic men are at higher risk of developing colon cancer compared to non-Hispanic white men, colonoscopy screening among Hispanic men is much lower than among non-Hispanic white men. University Health System (UHS) in San Antonio, Texas, instituted a Colorectal Cancer Male Navigation (CCMN) Program in 2011 specifically designed for Hispanic men. The CCMN Program contacted 461 Hispanic men 50 years of age and older to participate over a 2-year period. Of these age-eligible men, 370 were screened for CRC after being contacted by the navigator. Using participant and program data, a Markov model was constructed to determine the cost-effectiveness of the CCMN Program. An average 50-year-old Hispanic male who participates in the CCMN Program will have 0.3 more quality-adjusted life-years (QALYs) compared to a similar male receiving usual care. Life expectancy is also predicted to increase by 6 months for participants compared to non-participants. The program results in net health care savings of $1,148 per participant ($424,760 for the 370 CCMN Program participants). The incremental cost-effectiveness ratio is estimated at $3,765 per QALY in favor of the navigation program. Interventions to reduce disparities in CRC screening across ethnic groups are needed, and this is one of the first studies to evaluate the economic benefit of a patient navigator program specifically designed for an urban population of Hispanic men. A colorectal cancer screening intervention which relies on patient navigators trained to address the unique needs of the targeted population (language barriers, transportation and scheduling assistance, colon cancer, and screening knowledge) can substantially increase the likelihood of screening and improve quality of life in a cost-effective manner.