Publications by authors named "Josephine C Jacobs"

13 Publications

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Long-term care service mix in the Veterans Health Administration after home care expansion.

Health Serv Res 2021 Jun 3. Epub 2021 Jun 3.

Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina, USA.

Objective: To determine whether the Veterans Health Administration's (VHA) efforts to expand access to home- and community-based services (HCBS) after the 2001 Millennium Act significantly changed Veterans' utilization of institutional, paid home, and unpaid home care relative to a non-VHA user Medicare population that was not exposed to HCBS expansion efforts.

Data Sources: We used linkages between the Health and Retirement Study and VHA administrative data from 1998 until 2012.

Study Design: We conducted a retrospective-matched cohort study using coarsened exact matching to ensure balance on observable characteristics for VHA users (n = 943) and nonusers (n = 6106). We used a difference-in-differences approach with a person fixed-effects estimator.

Data Collection/extraction Methods: Individuals were eligible for inclusion in the analysis if they were age 65 or older and indicated that they were covered by Medicare insurance in 1998. Individuals were excluded if they were covered by Medicaid insurance at baseline. Individuals were considered exposed to VHA HCBS expansion efforts if they were enrolled in the VHA and used VHA services.

Principal Findings: Theory predicts that an increase in the public allocation of HCBS will decrease the utilization of its substitutes (e.g., institutional care and unpaid caregiving). We found that after the Millennium Act was passed, there were no observed differences between VHA users and nonusers in the probability of using institutional long-term care (0.7% points, 95% CI: -0.009, 0.022) or in receiving paid help with activities of daily living (0.06% points, 95% CI: -0.011, 0.0125). VHA users received more hours of unpaid care post-Millennium Act (1.48, 95% CI: -0.232, 3.187), though this effect was not significant once we introduced controls for mental health.

Conclusions: Our findings indicate that mandating access to HCBS services does not necessarily imply that access to these services will follow suit.
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June 2021

Estimating Costs of an Implementation Intervention.

Med Decis Making 2020 11 20;40(8):959-967. Epub 2020 Oct 20.

Center for Evaluation and Implementation Resources, US Department of Veterans Affairs (VA), Ann Arbor, MI, USA.

Health care systems frequently have to decide whether to implement interventions designed to reduce gaps in the quality of care. A lack of information on the cost of these interventions is often cited as a barrier to implementation. In this article, we describe methods for estimating the cost of implementing a complex intervention. We review methods related to the direct measurement of labor, supplies and space, information technology, and research costs. We also discuss several issues that affect cost estimates in implementation studies, including factor prices, fidelity, efficiency and scale of production, distribution, and sunk costs. We examine case studies for stroke and depression, where evidence-based treatments exist and yet gaps in the quality of care remain. Understanding the costs for implementing strategies to reduce these gaps and measuring them consistently will better inform decision makers about an intervention's likely effect on their budget and the expected costs to implement new interventions.
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November 2020

Observational Study of the Downstream Consequences of Inappropriate MRI of the Lumbar Spine.

J Gen Intern Med 2020 12 28;35(12):3605-3612. Epub 2020 Sep 28.

Health Economics Resource Center (HERC), VA Palo Alto Health Care System, Menlo Park, CA, USA.

Background: Contrary to guidelines, magnetic resonance imaging (MRI) is often ordered in the first 6 weeks of new episodes of uncomplicated non-specific low back pain.

Objective: To determine the downstream consequences of early imaging.

Design: Retrospective matched cohort study using data from electronic health records of primary care clinics of the U.S. Department of Veterans Affairs.

Participants: Patients seeking primary care for non-specific low back pain without a red flag condition or an encounter for low back pain in the prior 6 months (N = 405,965).

Exposure: MRI of the lumbar spine within 6 weeks of the initial primary care visit.

Main Measures: Covariates included patient demographics, health history in the prior year, and baseline pain. Outcomes were lumbar surgery, prescription opioid use, acute health care costs, and last pain score recorded within 1 year of the index visit.

Key Results: Early MRI was associated with more back surgery (1.48% vs. 0.12% in episodes without early MRI), greater use of prescription opioids (35.1% vs. 28.6%), a higher final pain score (3.99 vs. 3.87), and greater acute care costs ($8082 vs. $5560), p < 0.001 for all comparisons.

Limitations: Reliance on data gathered in normal clinical care and the potential for residual confounding despite the use of coarsened exact matching weights to adjust for baseline differences.

Conclusions: The association between early imaging and increased utilization was apparent even in a setting largely unaffected by incentives of fee-for-service care. Reduced imaging cost is only part of the motivation to improve adherence with guidelines for the use of MRI. Early scans are associated with excess surgery, higher costs for other care, and worse outcomes, including potential harms from prescription opioids.
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December 2020

Making connections: nationwide implementation of video telehealth tablets to address access barriers in veterans.

JAMIA Open 2019 Oct 5;2(3):323-329. Epub 2019 Aug 5.

Office of Connected Care/Telehealth Services, Veterans Health Administration.

Background: Video telehealth technology has the potential to enhance access for patients with clinical, social, and geographic barriers to care. We evaluated the implementation of a US Department of Veterans Affairs (VA) initiative to distribute tablets to high-need Veterans with access barriers.

Methods: In this mixed methods implementation study, we examined tablet adoption (ie, facility-level tablet distribution rates and patient-level tablet utilization rates) and reach (ie, sociodemographic and clinical characteristics of tablet recipients) between 5/1/16 and 9/30/17. Concurrently, we surveyed 68 facility telehealth coordinators to determine the most common implementation barriers and facilitators, and then conducted interviews with telehealth coordinators and regional leadership to identify strategies that facilitated tablet distribution and use.

Results: 86 VA facilities spanning all 18 geographic regions, distributed tablets to 6 745 patients. Recipients had an average age of 56 years, 53% lived in rural areas, 75% had a diagnosed mental illness, and they had a mean (SD) of 5 (3) chronic conditions. Approximately 4 in 5 tablet recipients used the tablet during the evaluation period. In multivariate logistic regression, tablet recipients were more likely to use their tablets if they were older and had fewer chronic conditions. Implementation barriers included insufficient training, staffing shortages, and provider disinterest (described as barriers by 59%, 55%, and 33% of respondents, respectively). Site readiness assessments, local champions, licensure modifications, and use of mandates and incentives were identified as strategies that may influence widespread implementation of home-based video telehealth.

Conclusion: VA's initiative to distribute video telehealth tablets to high-need patients appears to have successfully reached individuals with social and clinical access barriers. Implementation strategies that address staffing constraints and provider engagement may enhance the impact of such efforts.
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October 2019

Assessment of Primary Care Clinician Concordance With Guidelines for Use of Magnetic Resonance Imaging in Patients With Nonspecific Low Back Pain in the Veterans Affairs Health System.

JAMA Netw Open 2020 07 1;3(7):e2010343. Epub 2020 Jul 1.

Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California.

Importance: Magnetic responance imaging (MRI) of the lumbar spine that is not concordant with treatment guidelines for low back pain represents an unnecessary cost for US health plans and may be associated with adverse effects. Use of MRI in the US Department of Veterans Affairs (VA) primary care clinics remains unknown.

Objective: To assess the use of MRI scans during the first 6 weeks (early MRI scans) of episodes of nonspecific low back pain in VA primary care sites and to determine if historical concordance can identify clinicians and sites that are the least concordant with guidelines.

Design, Setting, And Participants: Retrospective cohort study of electronic health records from 944 VA primary care sites from the 3 years ending in 2016. Data were analyzed between January 2017 and August 2019. Participants were patients with new episodes of nonspecific low back pain and the primary care clinicians responsible for their care.

Exposures: MRI scans.

Main Outcomes And Measures: The proportion of early MRI scans at VA primary care clinics was assessed. Clinician concordance with published guidelines over 2 years was used to select clinicians expected to have low concordance in a third year.

Results: A total of 1 285 405 new episodes of nonspecific low back pain from 920 547 patients (mean [SD] age, 56.7 [15.8] years; 93.6% men) were attributed to 9098 clinicians (mean [SD] age, 52.1 [10.1] years; 55.7% women). An early MRI scan of the lumbar spine was performed in 31 132 of the episodes (2.42%; 95% CI, 2.40%-2.45%). Historical concordance was better than a random draw in selecting the 10% of clinicians who were subsequently the least concordant with published guidelines. For primary care clinicians, the area under the receiver operating characteristic curve was 0.683 (95% CI, 0.658-0.701). For primary care sites, the area was under this curve was 0.8035 (95% CI, 0.754-0.855). The 10% of clinicians with the least historical concordance were responsible for just 19.2% of the early MRI scans performed in the follow-up year.

Conclusions And Relevance: VA primary care clinics had low rates of use of early MRI scans. A history of low concordance with imaging guidelines was associated with subsequent low concordance but with limited potential to select clinicians most in need of interventions to implement guidelines.
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July 2020

Virtual Savings: Patient-Reported Time and Money Savings from a VA National Telehealth Tablet Initiative.

Telemed J E Health 2020 09 26;26(9):1178-1183. Epub 2019 Dec 26.

VA Center for Innovation to Implementation (Ci2i), Palo Alto Veterans Health Administration, Menlo Park, California, USA.

Virtual care holds promise for offering services to Veterans Affairs (VA) patients who have barriers to accessing care. In 2016, the VA began issuing video-enabled tablets to Veterans with geographic, clinical, and/or social barriers to in-person care. To complement a national evaluation of system-level implementation and effectiveness of these tablets, we sought to understand whether the VA-issued tablets generated money and/or time savings for patients. We distributed a survey to 2,120 Veterans who received tablets and administered a follow-up survey 3-6 months later. The final analysis included 594 and 399 patients who responded to questions about money and time savings, respectively. We used poststratification survey weighting methods to address potential selection and nonresponse bias. In multinomial logistic regressions and logistic regressions, we examined patient characteristics associated with reported money and time savings. A majority of survey respondents reported that the tablets saved them money (89%) and time (71%). Respondents were more likely to report monetary savings if they lived at a greater distance from the VA, if they experienced travel barriers, and if they did not have a mental health condition. Respondents were more likely to report time savings if they were <45 or ≥65 years of age, employed, and reported more overall technology experience. Findings may inform policy decisions regarding patient targeting and training as VA aims to expand its use of video telehealth technology.
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September 2020

Caregiving time costs and trade-offs: Gender differences in Sweden, the UK, and Canada.

SSM Popul Health 2019 Dec 17;9:100501. Epub 2019 Oct 17.

Lund University, Sweden.

Population ageing is putting pressure on pension systems and health care services, creating an imperative to extend working lives. At the same time, policy makers throughout Europe and North America are trying to expand the use of home care over institutional services. Thus, the number of people combining caregiving responsibilities with paid work is growing. We investigate the conflicts that arise from this by exploring the time costs of unpaid care and how caregiving time is traded off against time in paid work and leisure in three distinct policy contexts. We analyze how these tradeoffs differ for men and women (age 50-74), using time diary data from Sweden, the UK and Canada from 2000 to 2015. Results show that women provide more unpaid care in each country, but the impact of unpaid care on labor supply is similar for male and female caregivers. Caregivers in the UK and Canada, particularly those involved in intensive caregiving, reduce paid work in order to provide unpaid care. Caregivers in Sweden do not trade off time in paid work with time in caregiving, but they have less leisure time. Our findings support the idea that the more extensive social infrastructure for caring in Sweden may diminish the labor market effects of unpaid care, but highlight that throughout contexts, intensive caregivers make important labor and leisure tradeoffs. Respite care and financial support policies are important for caregivers who are decreasing labor and leisure time to provide unpaid care.
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December 2019

Increasing Mental Health Care Access, Continuity, and Efficiency for Veterans Through Telehealth With Video Tablets.

Psychiatr Serv 2019 11 5;70(11):976-982. Epub 2019 Aug 5.

U.S. Department of Veterans Affairs (VA) Health Economics Resource Center, Menlo Park, California (Jacobs); VA Center for Innovation to Implementation, Menlo Park (Blonigen, Kimerling, Slightam, Gregory, Gurmessa, Zulman); Department of Psychiatry and Behavioral Sciences (Blonigen) and Division of Primary Care and Population Health (Zulman), Stanford University School of Medicine, Stanford, California; VA National Center for Post-Traumatic Stress Disorder, Menlo Park (Kimerling).

Objective: In 2016, the Veterans Health Administration (VHA) began distributing video-enabled tablets to veterans with access barriers. This study evaluated the implementation of this initiative for veterans with mental health conditions, including the impact of tablet receipt on access to and continuity of mental health care, missed opportunities for care, and use of urgent care.

Methods: A retrospective matched cohort study was conducted, matching tablet recipients with diagnoses of mental disorders (N=728) to a comparison group (N=1,020) on the basis of sociodemographic characteristics, mental health utilization and diagnoses, and wireless coverage. A difference-in-differences approach was used to compare 6-month pre-post changes in number of psychotherapy and medication management visits, continuity of psychotherapy based on VHA's quality metric for mental health care continuity, missed opportunity rate (i.e., the proportion of mental health appointments that were missed or canceled), and probability of any and number of emergency department (ED) or urgent care visits.

Results: Compared with the matched control group, tablet recipients experienced an increase of 1.94 (p<0.001) psychotherapy encounters, an increase of 1.05 (p<0.001) medication management visits, an 18.54 percentage point (p<0.001) increase in their likelihood of receiving recommended mental health care necessary for continuity of care, and a 20.24 percentage point (p<.001) decrease in their missed opportunity rate in the 6-month period following receipt of tablets (or the index date for the matched sample). No significant differences in ED or urgent care use were found.

Conclusions: Distributing video-enabled tablets to veterans with mental health conditions appeared to improve access to and continuity of mental health services while also improving clinical efficiency by decreasing missed opportunities for care.
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November 2019

Economic Spillover Effects of Intensive Unpaid Caregiving.

Pharmacoeconomics 2019 04;37(4):553-562

RAND Corporation, 1200 South Hayes St, Arlington, VA, 22202-5050, USA.

Background: Growing evidence has documented economic spillover effects experienced by intensive caregivers across the lifecycle. These spillover effects are rarely incorporated in economic analyses of health interventions. When these costs are captured, it is shown that commonly applied methods for valuing caregiver time may be underestimating the true opportunity costs of informal care. We explore how intensive caregiving is associated with economic outcomes for caregivers aged 18 years and older.

Methods: We used the cross-sectional 2013 RAND Survey of Military and Veteran Caregivers, a survey of 3876 caregivers and non-caregivers aged 18 years and older to conduct multivariable analyses and calculate average marginal effects, focusing on the association between intensive caregiving (i.e., providing ≥ 20 h of weekly care) and six economic outcomes: schooling, labor force participation, taking unpaid time off of work, cutting back work hours, quitting a job, and early retirement.

Results: Intensive caregivers are 13 percentage points (95% confidence interval [CI] 8-18) less likely to be employed than non-caregivers. Intensive caregivers are 3 percentage points (95% CI 0.5-5) more likely to cut back schooling, 6 percentage points (95% CI 2-10) more likely to take unpaid time off of work, 4 percentage points (95% CI 0.1-9) more likely to cut back work hours, 12 percentage points (95% CI 8-15) more likely to quit a job, and 5 percentage points (95% CI 2-7) more likely to retire early due to caregiving responsibilities relative to non-intensive caregivers.

Conclusions: Despite the difficulty of quantifying the true opportunity costs of informal care, policy makers and researchers need to understand these costs. The higher the opportunity costs of unpaid care provision, the less likely it is that caregivers will provide this care and the less economically attractive this 'free' source of care is from a societal perspective.
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April 2019

Emergent Challenges in Determining Costs for Economic Evaluations.

Pharmacoeconomics 2017 02;35(2):129-139

VA Health Economics Resource Center, 795 Willow Rd. (152), Menlo Park, CA, 94025, USA.

This paper describes methods of determining costs for economic evaluations of healthcare and considers how cost determination is being affected by recent developments in healthcare. The literature was reviewed to identify the strengths and weaknesses of the four principal methods of cost determination: micro-costing, activity-based costing, charge-based costing, and gross costing. A scoping review was conducted to identify key trends in healthcare delivery and to identify costing issues associated with these changes. Existing guidelines provide information on how to implement various costing methods. Bottom-up costing is needed when accuracy is paramount, but top-down approaches are often the only feasible approach. We describe six healthcare trends that have important implications for costing methodology: (1) reform in payment mechanisms; (2) care delivery in less restrictive settings; (3) the growth of telehealth interventions; (4) the proliferation of new technology; (5) patient privacy concerns; and (6) growing efforts to implement guidelines. Some costs are difficult to measure and have been overlooked. These include physician services for inpatients, facility costs for outpatient services, the cost of developing treatment innovations, patient and caregiver costs, and the indirect costs of organizational interventions. Standardized methods are needed to determine social welfare and productivity costs. In the future, cost determination will be facilitated by technological advances but hindered by the shift to capitated payment, to the provision of care in less restrictive settings, and by heightened concern for medical record privacy.
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February 2017

Cardiovascular Disease Risk Awareness and Its Association With Preventive Health Behaviors: Evidence From a Sample of Canadian Workplaces.

J Occup Environ Med 2016 05;58(5):459-65

Ivey Business School, Western University (Drs Jacobs, Rouse, Zaric); School of Health Studies, Western University, Arthur & Sonia Labatt Health Sciences Building (Dr Burke); Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada (Dr Sarma).

Objective: The aim of this study was to determine Canadian workers' level of awareness about their cardiovascular disease (CVD) risk factors and the association between CVD risk awareness and health behaviors.

Methods: We used cross-sectional data to compare awareness of CVD risk factors with biometric measures from a workplace screening clinic (n = 320). We assessed the association between risk factor awareness and self-reported health behaviors using logistic regression analyses.

Results: Overall, 39.5% of workers did not know at least one of their CVD risk factors. These individuals were less likely to meet recommended physical activity levels and to consume three daily servings of fruits and vegetables, and more likely to report weekly fast food consumption.

Conclusions: This study highlights a lack of awareness about cholesterol levels and demonstrates a negative association between low CVD awareness and preventive health behaviors.
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May 2016

Caregiving intensity and retirement status in Canada.

Soc Sci Med 2014 Feb 3;102:74-82. Epub 2013 Dec 3.

Institute of Health Policy, Management, and Evaluation, University of Toronto, 155 College St., Toronto M5T 3M6, Canada. Electronic address:

A number of OECD countries have implemented policies encouraging longer labour force participation in tandem with policies encouraging informal care provision in the community. To better understand how these policies may affect the available pool of caregivers and labour force participants, we need more evidence about how informal caregiving is related to retirement status and timing. We assessed the association between caregiving intensity and retirement status for individuals aged 55 to 69 using the Canadian 2007 General Social Survey, a cross-sectional survey with 23,404 individuals. We used multinomial logistic regressions to determine whether providing different intensities of informal care (i.e. hours of weekly care) was significantly associated with the likelihood that an individual was fully retired, had retired and returned to work, had never retired and was working part-time or full-time, or was a labour market non-participant. We found that higher intensity caregiving was associated with being fully retired (relative to working full-time) for men and women (relative risk ratios, 2.93 and 2.04, respectively). For women, high intensity caregiving was also associated with working part-time (1.84) and being a labour force non-participant (1.99). Male and female high intensity caregivers were more likely to be retired before age 65. Our results highlight the importance of measuring caregiving intensity and multiple paths to retirement, which are often overlooked in the caregiving and retirement literature. They also indicate that a policy context encouraging both later retirement and more informal care may not be reasonable without flexible work arrangement options.
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February 2014

The fiscal impact of informal caregiving to home care recipients in Canada: how the intensity of care influences costs and benefits to government.

Soc Sci Med 2013 Mar 5;81:102-9. Epub 2013 Jan 5.

Institute of Health Policy, Management, and Evaluation, University of Toronto, 155 College St., Toronto, Canada M5T 3M6.

The objective of this study was to estimate the annual costs and consequences of unpaid caregiving by Canadians from a government perspective. We estimated these costs both at the individual and population levels for caregivers aged 45 and older. We conducted a cost-benefit analysis where we considered the costs of unpaid caregiving to be potential losses in income tax revenues and changes in social assistance payments and the potential benefit of reduced paid care expenditures. Our costing methods were based on multivariate analyses using the 2007 General Social Survey, a cross-sectional survey of 23,404 individuals. We determined the differential probability of employment, wages, and hours worked by caregivers of varying intensity versus non-caregivers. We also used multivariate analysis to determine how receiving different intensities of unpaid care impacted both the probability of receiving paid care and the weekly hours of paid care received. At the lowest intensities of caregiving, there was a net benefit to government from caregiving, at both the individual and population levels. At the population level, the net benefit to government was estimated to be $4.4 billion for caregivers providing less than five hours of weekly care. At the highest intensity of caregiving, there was a net cost to government of $641 million. Our overall findings were robust to a number of changes applied in our sensitivity analysis. We found that the factor with the greatest impact on cost was the probability of labour force participation. As the biggest cost driver appears to be the higher likelihood of intense caregivers dropping out of the labour force, government policies that enable intense caregivers to balance caregiving with employment may help to mitigate these losses.
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March 2013