Pay for performance and hip fracture outcomes

Abstract

Hip fracture is a leading cause of death and disability among the elderly worldwide. 1,2 The incidence is rising as populations age, and there are now over 1.6 million hip fractures globally each year. 1 In the United Kingdom alone, there are 70 000 cases annually at a cost of £2 billion. 3 Pay-for-performance initiatives are increasingly used to improve outcomes. 4-6 These schemes link healthcare payments to quality metrics in order to incentivize providers to improve the quality or efficiency of care. 7 There is mixed evidence about whether these initiatives can truly drive improvements in healthcare. 4,6 There is evidence that they can modestly improve care. However, few pay-for-performance schemes have been shown to positively affect outcomes. 6 A national clinical audit was established in England and Wales in 2007 with the aim of improving hip fracture outcomes. 8 This programme included a National Hip Fracture Database (NHFD) and support for local clinical teams to improve the quality of care provided to elderly patients with a hip fracture. In 2010, the NHFD was the basis for a pay-for-performance initiative, called the 'Best Practice Tariff' (BPT). The BPT scheme paid hospitals a supplement for each patient whose care satisfied six clinical standards, such as surgery within 36 hours. 9 Cases satisfying these standards, which have evolved over time (Supplementary Table i), were identified from data submitted to the NHFD. Importantly, Scottish hospitals did not participate in the NHFD and were not subject to the BPT. Aims Hip fractures are associated with high morbidity, mortality, and costs. One strategy for improving outcomes is to incentivize hospitals to provide better quality of care. We aimed to determine whether a pay-for-performance initiative affected hip fracture outcomes in England by using Scotland, which did not participate in the scheme, as a control. Materials and Methods We undertook an interrupted time series study with data from all patients aged more than 60 years with a hip fracture in England (2000 to 2018) using the Hospital Episode Statistics Admitted Patient Care (HES APC) data set linked to national death registrations. Difference-indifferences (DID) analysis incorporating equivalent data from the Scottish Morbidity Record was used to control for secular trends. The outcomes were 30-day and 365-day mortality, 30-day re-admission, time to operation, and acute length of stay. Results There were 1 037 860 patients with a hip fracture in England and 116 594 in Scotland. Both 30-day (DID-1.7%; 95% confidence interval (CI)-2.0 to-1.2) and 365-day (-1.9%; 95% CI-2.5 to-1.3) mortality fell in England post-intervention when compared with outcomes in Scotland. There were 7600 fewer deaths between 2010 and 2016 that could be attributed to interventions driven by pay-for-performance. A pre-existing annual trend towards increased 30-day re-admissions in England was halted post-intervention. Significant reductions were observed in the time to operation and length of stay. Conclusion This study provides evidence that a pay-for-performance programme improved the outcomes after a hip fracture in England.