Facility Level Research Articles

Employment status of older nursing staff aged 55 years and older in care facilities: A nationwide cross-sectional study in Japan.

An aging nursing workforce requires addressing shortages due to retirement. This nationwide descriptive cross-sectional study in Japan clarified the employment status of older nursing staff aged ≥ 55 years by facility type during January-March 2022. Questionnaires were sent to 8,000 nursing directors, with 1,658 valid responses (response rate: 20.7%). Descriptive statistics and Kruskal-Wallis or χ2 tests analyzed inter-facility differences. A violin plot depicted the proportion of older nursing staff across facilities by age group, and generalized estimating equation (GEE) models examined associated factors at the facility level. Older nursing staff's distribution differed significantly across age groups (p < 0.01), from 0% to 100% within the same facility type. Some facilities had high percentages of staff working beyond retirement age. GEE results showed higher percentages of full-time employees and nurses were negatively associated with the percentage of older nursing staff across most facility types (p < 0.05). For those aged ≥ 65 years, the total population was positively associated with employment in bedded clinics (coef. = 0.07, 95% CI: 0.01 to 0.14, p = 0.03), but negatively associated with the total population (coef. = -0.06, 95% CI: -0.10 to -0.01, p = 0.02) and percentage of the population aged ≥ 65 (coef. = -0.76, 95% CI: -1.43 to -0.08, p = 0.03) in long-term care insurance facilities. Working conditions and environments should be improvement to potentially retain older nursing staff. Job seekers should be matched with managers' needs in facilities with a higher proportion of older nursing staff to ensure a sustainable workforce.

Finding the Missing Men with Tuberculosis: A Participatory Approach to Identify Priority Interventions in Uganda.

Gender impacts exposure and vulnerability to TB, evidenced by a higher prevalence of both TB disease and missed TB diagnoses among men, who significantly contribute to new TB infections. We present the formative research phase of a study which used participatory methods to identify gender-specific interventions for systematic screening of TB among men in Uganda. Health facility level data was collected at four Ugandan general hospitals (Kawolo, Gombe, Mityana, and Nakaseke) among 70 TB stakeholders, including healthcare workers, TB survivors, policymakers, and researchers. Using health seeking pathways, they delineated and compared men's ideal and actual step-by-step TB health seeking processes to identify barriers to TB care. The stepping stones method, depicting barriers as a 'river' and each 'steppingstone' as a solution, was employed to identify interventions which would help link men with TB symptoms to care. These insights were then synthesized in a co-analysis meeting with 17 participants including representatives from each health facility to develop a consensus on proposed interventions. Data across locations revealed the actual TB care pathway diverted from the ideal pathway due to health system, community, health worker and individual level barriers such as delayed health seeking, unfavourable facility operating hours and long waiting times that conflicted with men's work schedules. Stakeholders proposed to address these barriers through the introduction of male-specific services; integrated TB services that prioritize X-ray screening for men with cough; healthcare worker training modules on integrated male-friendly services; training and supporting TB champions to deliver health education to people seeking care; and engagement of private practitioners to screen for TB. In conclusion, our participatory co-design approach facilitated dialogue, learning, and consensus between different health actors on context-specific, person-centred TB interventions for men in Uganda. The acceptability, effectiveness and cost effectiveness of the package will now be evaluated in a pilot study.

Implementation of the WHO Standards to assess quality of paediatric care at the facility level using service users’ perspective as source of data: a multicentre quality improvement study in Italy

ObjectivesThere is little experience in the use of the WHO Standards for improving the quality of care (QOC) for children at the facility level. We describe the use of 75...

Evaluation of the WHO standards to assess quality of care for children with acute respiratory infections: findings of a baseline multicentre assessment (CHOICE) in Italy

BackgroundExperience is lacking on the implementation of the WHO standards for improving the quality of care (QOC) for children at facility level. We describe the use of 10 prioritised WHO...

Implementation of the WHO standards to assess the quality of care for children with acute diarrhoea: findings of a multicentre study (CHOICE) in Italy

BackgroundThere is no documented experience in the use of the WHO standards for improving the quality of care (QOC) for children at the facility level. We describe the use of...

An approach to integrated management of diabetes in tuberculosis patients: Availability and readiness of the health facilities of Bangladesh.

Comorbidity of diabetes mellitus and tuberculosis (TB) is a major public health concern in low- and middle-income countries including Bangladesh. An integrated approach is required for adequate management of diabetes mellitus and TB. The objective of the present study was to investigate the availability and readiness of the TB care centers of Bangladesh toward diabetic patients' management. The present study was conducted based on existing data obtained from the Bangladesh Health Facility Survey (BHFS) 2017. Data collected from a total of 303 facilities providing TB services were retrieved. The outcome variables of the present study were availability and readiness of the TB health facilities for providing diabetes mellitus service. Readiness was measured for four domains: staff and guidelines, equipment, diagnostic facility and basic medicine. The independent variables were: facility level, management authority and location of the facility. Binary and multiple logistic regression models were constructed for both the outcome variables (availability and readiness) to find out their predictors. Services for diabetes mellitus were available in 68% of the TB facilities while high readiness was present in 36% of the facilities. For domain-specific readiness index, readiness for the domains of staff and guidelines, equipment, diagnostic facility and basic medicine was reported in 46%, 96%, 38% and 25% facilities respectively. In the logistic regression model, availability of diabetes mellitus services was better in primary level (aOR 2.62, 95% CI 1.78-4.77) and secondary level (aOR 3.26, 95% CI 1.82-9.05) facilities than community facilities. Similarly, readiness of diabetes mellitus care was also better in these facilities (aOR 2.55, 95% CI 1.05-4.71 for primary and aOR 2.75, 95% CI 1.80-4.32 for secondary facilities). Besides, private TB facilities had better availability (aOR 2.84, 95% CI 1.75-5.89) and readiness (aOR 2.52, 95% CI 1.32-4.29) for diabetes mellitus care. Availability and readiness for providing diabetes mellitus services in TB care providing facilities in Bangladesh is inadequate.

Expert assessment of the state and problems of implementation of health technology assessment in Ukraine

Health Technology Assessment (HTA) is widely used worldwide as a transparent tool for determining the value of both new and existing medical technologies (MTs), including drugs, medical devices, vaccines, and other interventions. The use of the independent expertise results allows to make reasonable decisions on the feasibility of using the medicinal products (market authorization, inclusion in protocols and relevant regulatory lists), as well as pricing, reimbursement and procurement. HTA affects the access and affordability of MTs, thereby contributing to the efficiency of medical care and the rational use of resources. In our opinion, the limited use of НТА in Ukraine is primarily due to the low level of awareness of the professional community about НТА and its role in providing decision support at various levels of government. An expert survey was conducted to study the current state, problems, and prospects for the development of НТА in Ukraine. There were 77 respondents who were divided into three groups (developers, users, and informed persons) according to the level of involvement in the НТА sphere. According to the survey results, more than half of the respondents consider OMT as a professional expert activity related to the preparation of high-level evidence. The rest of the respondents classify HTA as a field of scientific research that is currently not sufficiently integrated into practical health care and decision-making. The majority of respondents see the main purpose of the HTA as identifying the safest medical technologies with proven efficacy and economic feasibility for inclusion in standards and regulatory lists. Among the main problems of HTA development at the current stage, experts identify the following: lack of a formed professional environment, insufficient awareness of potential stakeholders, unresolved issue of using HTA results, especially at the level of healthcare facilities. At the same time, a comparison of the survey results with the data of previous studies shows an increase in awareness and understanding of the importance of implementing HTA in medical and pharmaceutical practice at different levels of government. To improve the implementation of HTA in the national practice of health care, it is proposed to strengthen the educational and informational component and ensure the publicity of the processes and use of HTA results in decision-making at the state, regional and local levels.

Health worker perspectives on barriers and facilitators of tuberculosis investigation coverage among index case contacts in rural Southwestern Uganda: a qualitative study

BackgroundIn 2012, the World Health Organization recommended screening and investigation of contacts of index tuberculosis patients as a strategy to accelerate detection of tuberculosis (TB) cases. Nine years after the adoption of this recommendation, coverage of TB contact investigations in Uganda remains low. The objective of this study was to examine health care providers’ perceptions of factors influencing coverage of TB contact investigations in three selected rural health facilities in Mbarara district, southwestern Uganda.MethodsThis study identified provider opinions on the barriers and facilitators to implementation of TB contact investigation using the Consolidated Framework for Implementation Research. Using an exploratory qualitative study design, semi-structured interviews with 19 health workers involved in the TB program at district, health facility and community levels were conducted from April 2020 and July 2020. Analysis was conducted inductively using reflexive thematic analysis in six iterative steps: familiarizing with the data, creating initial codes, searching for themes, reviewing themes, developing theme definitions, and writing the report.ResultsNineteen health care workers participated in this study which translates to a 100% response rate. These included two district TB and leprosy supervisors, five nurses, five clinical officers, six village health team members and one laboratory technician. The three themes that emerged from the analysis were intervention-related, health system and contextual factors. Health system-related barriers included inadequate or delayed government funding for the TB program, shortage of human resources, insufficient personal protective equipment, and a stock-out of supplies such as Xpert MTB cartridges. Contextual barriers included steep terrain, poverty or low income, and the stigma associated with TB and COVID-19. Facilitators comprised increased knowledge and understanding of the intervention, performance review and on-the-job training of health workers.ConclusionsThis study found that most of the factors affecting TB contact investigations in this rural community were related to health system constraints such as inadequate or delayed funding and human resource shortages. This can be addressed by strengthening the foundational elements of the health system - health financing and human resources - to establish a comprehensive TB control program that will enable the efficient identification of missing TB patients.

The quality of routine data for measuring facility-based maternal mortality in public and private health facilities in Kampala City, Uganda

BackgroundRoutine health facility data are an important source of health information in resource-limited settings. Regular quality assessments are necessary to improve the reliability of routine data for different purposes, including estimating facility-based maternal mortality. This study aimed to assess the quality of routine data on deliveries, livebirths and maternal deaths in Kampala City, Uganda.MethodsWe reviewed routine health facility data from the district health information system (DHIS2) for 2016 to 2021. This time period included an upgrade of DHIS2, resulting in two datasets (2016–2019 and 2020–2021) that were managed separately. We analysed data for all facilities that reported at least one delivery in any of the six years, and for a subset of facilities designated to provide emergency obstetric care (EmOC). We adapted the World Health Organization data quality review framework to assess completeness and internal consistency of the three data elements, using 2019 and 2021 as reference years. Primary data were collected to verify reporting accuracy in four purposively selected EmOC facilities. Data were disaggregated by facility level and ownership.ResultsWe included 255 facilities from 2016 to 2019 and 247 from 2020 to 2021; of which 30% were EmOC facilities. The overall completeness of data for deliveries and livebirths ranged between 53% and 55%, while it was < 2% for maternal deaths (98% of monthly values were zero). Among EmOC facilities, completeness was higher for deliveries and livebirths at 80%; and was < 6% for maternal deaths. For the whole sample, the prevalence of outliers for all three data elements was < 2%. Inconsistencies over time were mostly observed for maternal deaths, with the highest difference of 96% occurring in 2021.ConclusionsRoutine data from childbirth facilities in Kampala were generally suboptimal, but the quality was better in EmOC facilities. Given likely underreporting of maternal deaths, further efforts to verify and count all facility-related maternal deaths are essential to accurately estimate facility-based maternal mortality. Data reliability could be enhanced by improving reporting practices in EmOC facilities and streamlining reporting processes in private-for-profit facilities. Further qualitative studies should identify critical points where data are compromised, and data quality assessments should consider service delivery standards.

Impact of federal antipsychotic use policy in nursing homes on new diagnoses for approved indications in dementia residents.

Federal policies targeting antipsychotic use among nursing home (NH) residents may have increased reporting of diagnoses for approved uses, including schizophrenia, Tourette's syndrome, and Huntington's Disease (called "exclusionary diagnoses" because they exclude residents from the antipsychotic quality metric). We assessed changes in new exclusionary diagnoses among long-stay NH admissions specifically with dementia following federal policies. Retrospective, quarterly, interrupted time-series analysis (2009-2018) of new long-stay NH residents with dementia and no exclusionary diagnoses reported before NH admission. The National Partnership and the addition of facility level antipsychotic use to the Five Star Quality Rating system were key time exposures. Outcome was quarterly facility level predicted percentage of exclusionary diagnoses within 2 years of admission stratified by NH characteristics. For 264,095 long-stay admissions, mean percentage of new exclusionary diagnoses was 2.2% before the Partnership. After the Partnership, there was an unadjusted increase in the percentage over time (slope change, 0.044, p = 0.018), but the percentage never exceeded 2.9%. The Partnership contributed to a one-time decrease in diagnoses in NHs with an intermediate percentage of Black residents (-1.29%, p = 0.004). Before the Partnership, diagnoses were increasing among not-for-profit relative to for-profit NHs (0.044; p = 0.012), but after the Partnership, the pattern reversed. For-profit NHs saw an increase (+0.034, p = 0.002); not-for-profit NHs experienced a decrease (-0.014, p = 0.039). Quality Rating modifications had no significant effect. Exclusionary diagnosis reporting among long-stay NH residents with dementia, the group most at risk from antipsychotics, did not increase in response to federal policies. Evaluation of reasons for the observed increase in exclusionary diagnoses among non-dementia NH residents is warranted along with continued attention to how to incentivize the appropriate use of medications in residents with dementia that is crucial for high-quality NH care.

Midwives’ descriptions of policies on access to maternity health services in North West Province, South Africa

The study sought to explore and describe the various policies regarding access to Maternity health care services in the North West Province, South Africa, through the lens of midwives. Legal and ethical frameworks guide maternity healthcare services to ensure such a service's quality, safety, and standardization. A qualitative, descriptive, explorative research design was followed. Nine purposefully sampled midwives participated in a one-on-one in-depth interview. Data were analyzed using Collaizi's descriptive method based on the emerging themes and categories. One overarching theme with six categories emerged from the data. From the overarching perspective, it was evident that midwives were dissatisfied with the ambiguity of various policies guiding patients' access to Maternity healthcare services. To a certain extent, the admission policy was inconsistent with the patient's rights and constitution of the land on access to health. The ambiguity of admission position led to uncontrolled movements of self-referred patients to clinical facilities. The ambiguity of the transfer policy contributed to challenges during interfacility transfers of referred patients from lower levels of care facilities and vice versa. In addition, the policy on escorts of patients was unspecific about the healthcare personnel required to escort complicated patients in transit, which caused care interruptions. The study findings highlight the Midwives' concerns regarding various policies of access to maternity health services, and the marked ineffectiveness of controlling patients' movement into facilities could be the reason for overcrowding, inadvertently causing a decline in the quality of maternity healthcare services. The study findings may alert policymakers to be cautious and ensure that policies are succinct and consistent with other related laws.

Postnatal quality of care measures for mothers and newborns at home: A scoping review.

The postnatal period is one of the most critical periods in the lives of mothers and newborns. Yet, the postnatal period remains the most neglected period along the maternal health care continuum. Globally, measures assessing quality of postnatal care (PNC) often focus on care at health facility level, the provision of home-based PNC and associated quality of care measures seem largely overlooked. This scoping review aims to give an overview of the literature on measures assessing quality of PNC for mothers and newborns in a home-based setting. This review was conducted according to the Arksey and O'Malley's methodology for scoping reviews. Three electronic bibliographic databases were searched together with a grey literature search. Two reviewers independently screened the identified articles. All data on home-based PNC measures were extracted and mapped according to the 2022 World Health Organization PNC Guideline recommendations in three categories: i) maternal care, ii) newborn care, iii) health system and health promotion interventions. Several additional quality of care domains, characterizing home-based PNC, were identified: i) social and emotional empowerment, ii) assessment of the home setting, iii) early breastfeeding, iv) health education and counseling, v) personal hygiene and prevention of infections, vi) referral to health facility when necessary, vii) thermal care, viii) parent-child relationship and ix) promote economic self-sufficiency. This review illustrates that home-based PNC has a very broad spectrum of care and plays a vital role in improving maternal and newborn health and well-being. In addition, there is a clear need for more research on the optimal timing and content of home-based care in the postnatal period for maximizing its potential.

Designing Novel Physiologic Monitor Displays for Combat Medics.

Combat medics who are responsible for the care of injured warfighters face challenges from their reliance on medical alarms that exceed the noise levels recommended by the WHO. This is because the elevated noise levels in military facilities, particularly from vehicular units and weaponry, compromise the combat medics' effectiveness and attentiveness to medical alarms. We previously designed a graphical ("configural") display to communicate patients' vital signs and found that when the configural display and traditional numerical display were concurrently presented to participants, it produced the fastest identification of patient vital signs and triggered the fewest number of alarms. This study used eye tracking to assess how participants direct visual attention to and engage with concurrently presented numerical and configural vital sign displays. We recruited 30 undergraduate students with normal hearing and vision for this study. Subjects were tasked with monitoring a simulated patient's vital signals using simultaneously presented numerical and configural vital sign displays. Concurrently, they performed an N-back task to simulate the multitasking required in a military environment. We manipulated the eccentricity and display position of the numerical and configural displays through 4 orientations, with each orientation being used in a monitoring block lasting 12 minutes. Continuous eye tracking was utilized to collect physiological data about participant display preference. We used eye tracking to analyze several metrics: Total display viewing time, total viewing time percentage, number of dwells (groups of eye fixations), mean fixations per dwell, and fixation patterns during an emergency event. Participants spent more time looking at the configural display than the numerical display during nominal monitoring and emergency events. During emergencies, the percentage of time individuals spent looking at the configural display increased from 30 to 50%, while there was no corresponding increase in the participants' looking at the numerical display. When there were 2 concurrent emergency events instead of 1, total viewing time did not increase, suggesting that participants did not need to change their viewing strategy when the emergency situation complexity increased. Also, during emergencies, participants directed nearly half of their fixations to the configural display during the first 2 seconds of an emergency, while only directing fewer than 5% of fixations to the numerical display during that same period. The average response time for an emergency event was around 2 seconds, which suggests that participants obtained relevant information from the configural display in this time period. We found that when a patient monitor contains both a configural display and a numerical display, participants look at the configural display. Furthermore, during time-sensitive situations, participants utilize the configural display to provide important information. We suggest this because the configural display integrates the relevant vital signs into one display. These findings provide justification for pursuing integrated vital sign displays to efficiently communicate patient conditions in complex environments. On the battlefield, swift decision-making is essential, as combat medics must minimize the time required to assess and act in critical situations.

Determinants of translating routine health information system data into action in Mozambique: a qualitative study

IntroductionRoutine health information systems (RHISs) are an essential source of data to inform decisions and actions around health facility performance, but RHIS data use is often limited in low and...

An Integrated Photonic Biosensing Platform for Pathogen Detection in Aquaculture.

Aquaculture is expected to play a vital role in solving the challenge of sustainably providing the growing world population with healthy and nutritious food. Pathogen outbreaks are a major risk for the sector, so early detection and a timely response are crucial. This can be enabled by monitoring the pathogen levels in aquaculture facilities. This paper describes a photonic biosensing platform based on silicon nitride waveguide technology with integrated active components, which could be used for such applications. Compared to the state of the art, the current system presents improvements in terms of miniaturization of the Photonic Integrated Circuit (PIC) and the development of wafer-level processes for hybrid integration of active components and for material-selective chemical and biological surface modification. Furthermore, scalable processes for integrating the PIC in a microfluidic cartridge were developed, as well as a prototype desktop readout instrument. Three bacterial aquaculture pathogens (Aeromonas salmonicida, Vagococcus salmoninarum, and Yersinia ruckeri) were selected for assay development. DNA biomarkers were identified, corresponding primer-probe sets designed, and qPCR assays developed. The biomarker for Aeromonas was also detected using the hybrid PIC platform. This is the first successful demonstration of biosensing on the hybrid PIC platform.

A hospital-based survey assessing the health facility-level factors that contribute to delayed diagnosis of cervical cancer; patients views

Background In Kenya, Cervical Cancer is the 2nd commonly diagnosed type of cancer and the leading cause of cancer-related death among women. Globally, more than 50% of Cervical Cancer diagnoses are made late, with this proportion rising to 80% in developing countries. Poor Health systems can cause delays in diagnosis; thus, this study focused on determining the health facility level factors that contribute to delayed diagnosis among Cervical Cancer patients at Kenyatta National Hospital (KNH). Methods An analytical cross-sectional mixed method study was adopted to collect data on hospital and referral experiences from 139 Cervical Cancer patients systematically sampled at the KNH, using a semi-structured questionnaire. Associations between stage at diagnosis and hospital and referral experience were tested using a logistic regression model at a 95% Confidence Interval. Results 86 (61.9%) patients were diagnosed with advanced stages III and IV. The potential predictors for delayed diagnosis were a higher number of hospital referrals (p =0.000), facing referral challenges (p =0.041), longer time taken for diagnosis appointment (p =0.059), and longer time taken for diagnostic results (p =0.007) in the bivariate analysis. A higher number of hospital referrals (p =0.001) and longer time taken for diagnostic results (p =0.025) were significantly associated with delayed diagnosis of cervical cancer in the multivariate logistic regression test model. Referral challenges include misdiagnosis, cost of diagnosis, and prolonged diagnosis appointments. The study concluded that the advanced stage at presentation for most patients was due to poor health and referral systems, inadequate medical personnel, and diagnostic equipment. Conclusion This study recommends improving referral systems and encouraging partnerships to decentralize diagnostic centers and equipment and to train more experts on Cervical Cancer.

Integrating SARS-CoV-2 rapid antigen testing in maternal, neonatal and child health, HIV, and TB clinics in Kenya and Cameroon: outcomes from the Catalysing COVID-19 Action Project

IntroductionEarly diagnosis of SARS-CoV-2 infection is key to preventing severe disease and poor outcomes in vulnerable populations, such as pregnant women and people living with HIV or diagnosed with tuberculosis...

Learning From Countries on Measuring and Defining Community-Based Resilience in Health Systems: Voices From Nepal, Sierra Leone, Liberia, and Ethiopia

Background: The best approach for defining and measuring community health care resilience in times of crisis remains elusive. We aimed to synthesise definitions and indicators of resilience from countries who had recently undergone shocks (i.e., outbreaks and natural disasters). Methods: We purposively selected four countries that had recently or were currently experiencing a shock: Nepal, Ethiopia, Sierra Leone, and Liberia. Focus group discussions and key informant interviews were conducted with participants at the community, facility, district, sub-national, national, and international levels. Interviews and discussions were translated and transcribed verbatim. Data were open coded in ATLAS.ti using a grounded theory approach and were thematically collated to a pre-specified framework. Results: A total of 486 people participated in the study (n=378 community members, n=108 non-community members). Emergent themes defining community-based health system resilience included: the importance of communities, health system characteristics, learning from shocks, preventing and preparing for shocks, and considerations for sustainability and intersectoral engagement. Participants identified 193 potential indicators for measuring resilience, which fell into the domains of: 1) preparedness, 2) response and recovery, 3) communities, 4) health systems, and 5) intersectoral engagement. Conclusion: Despite varying definitions and understanding of the concept of resilience, community-centred responses to shocks were key in building resilience. Further insight is needed into how the definitions and indicators identified in this study compare to other shocks and contexts and can be used to further our understanding of health system resilience. Metrics and definitions could assist policy makers, researchers, and practitioners in evaluating the readiness of systems to respond to shocks and to allow comparability across health systems. We must build health systems that can continue to function and ensure quality, equity, community-focused care, and engagement, regardless of the pressures put upon them and ensure they are linked to strong primary health care.

Exploring The Disparity of Public Facilities in The Central Java Province

The significant difference between the number of public facilities in regencies/cities and the number of public facilities in Central Java Province, which is feared to result in high inequality, is the focus of this study. The objective of this research is to determine the level of inequality in public facilities and the factors that influence the inequality of public facilities in Central Java Province. Secondary data is utilized and analyzed using the Modified Williamson Index approach and Multiple Regression Analysis. The variables employed include population growth rate, transfer income, and the Human Development Index (HDI). The analysis of the Modified Williamson Index reveals an inequality level of public facilities in Central Java Province of 0.21. The highest level of inequality in public facilities is found in Cilacap Regency, Boyolali Regency, and Kebumen Regency. The factors influencing the inequality of public facilities include the significant variable of transfer income in relation to the level of inequality in public facilities. However, the variables of population growth rate and the Human Development Index (HDI) are not significant factors in relation to the inequality of public facilities.

Methods for Estimating Costs for Stays at Inpatient Rehabilitation Facilities and Long-Term Care Hospitals

ObjectiveTo describe and compare 3 methods for estimating stay-level Medicare facility (Part A) costs using claims and cost report data for inpatient rehabilitation facilities (IRFs) and long-term care hospitals (LTCHs), the 2 hospital-based postacute care providers. DesignWe calculated stay-level facility costs using different methods. Method 1 used routine costs per day and ancillary cost-to-charge ratios. Method 2 used routine and ancillary cost-to-charge ratios (freestanding IRFs and LTCHs only). Method 3 used facility-specific operating cost-to-charge ratios from the Provider Specific File. For each method, we compared the costs with payments and charges at the claim and facility levels and examined facility margins. SettingData are from 1619 providers, including 266 freestanding IRFs, 909 IRF units, and 444 LTCHs. ParticipantsThe analyses included 239,284 claims from 2014, of which 86,118 claims were from freestanding IRFs, 92,799 claims were from IRF units, and 60,367 claims were from LTCHs. InterventionsNot applicable. Main Outcome MeasuresCosts and payments in 2014 United States Dollars. ResultsFor freestanding IRFs, the mean facility stay-level costs were calculated to be $13,610 (method 1), $13,575 (method 2), and $13,783 (method 3). For IRF units, the mean facility stay-level costs were $17,385 (method 1) and $19,093 (method 3). For LTCHs, the mean facility stay-level costs were $36,362 (method 1), $36,407 (method 2), and $37,056 (method 3). ConclusionsThe 3 methods resulted in small differences in facility mean stay-level costs. Using the facility-level cost-to-charge ratio (method 3) is the least resource-intensive method. Although more resource-intensive, using routine cost per day and ancillary cost-to-charge ratios (method 1) for cost calculations allows for differentiation in costs across patients based on differences in the mix of services used. As policymakers consider postacute care payment reforms, cost, rather than charge or payment data, needs to be calculated and the results of the methods compared.