Pay-for-Performance and Hip Fracture Outcomes:An interrupted time series and difference-in-differences analysis in England and Scotland

AimsHip fractures are associated with high morbidity, mortality and healthcare cost. One strategy for improving outcomes is to incentivize hospitals to provide better quality 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 secular control.MethodsWe undertook an interrupted time series study with data from all patients aged >60 with hip fractures in England (2000-2018) using the Hospital Episode Statistics Admitted Patient Care dataset linked to national death registrations. Difference-in-differences (DID) analyses incorporating equivalent data from the Scottish Morbidity Record was used to control for secular trends. The outcomes were 30- and 365-day mortality, 30-day readmission, time to operation, and acute hospital length of stay.ResultsThere were 1,037,860 hip fracture patients in England and 116,594 in Scotland. Both 30- (DID -1.7%, 95% CI -2.0% to -1.2%) and 365-day (-1.9%, -2.5% to -1.3%) mortality fell in England post-intervention when compared to outcomes in Scotland. There were 7,600 fewer deaths between 2010 and 2016 that could be attributed to interventions driven by pay-forperformance. A pre-existing annual trend towards increased 30-day readmissions in England was halted post-intervention. Significant reductions were observed in time to operation and length of stay.ConclusionsThis study provides evidence that a pay-for-performance program improved hip fracture outcomes in England