The impact of a pay-for-performance system on timing to hip fracture surgery: experience from the Lazio Region (Italy)

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Abstract

Background

A tariff modulation mechanisms has been introduced in some Italian regions with the aim of reducing inappropriate admissions and improving quality of care. In response to a regional act, hospitals in Lazio adopted a clinical pathway for elderly patients with hip fracture and introduced a compensation system based on the quality of health care, as in a pay-for-performance model. The objective of the present study was to compare the proportion of surgery for hip fracture performed within 48 hours of admission among Lazio hospitals according to different payment systems, before and after the implementation of the regional act.

Methods

A retrospective cohort study of patients aged 65 years and over, residing in the Lazio region and admitted to an acute care hospital for hip fracture before (1 July 2008 - 30 June 2009) and after (1 July 2010 - 30 June 2011) the pay-for-performance act. The proportion of surgeries performed within 48 h of hospital arrival was calculated. An adjusted multivariate regression analysis was applied to assess the effect of hospital payment type on the likelihood of surgery within 48 h of hospital arrival.

Results

The share of patients with hip fracture that had surgery within 48 hours was 11.7% before the introduction of the pay-for-performance act and 22.2% after. The proportion of early hip fracture operations increased after the pay-for-performance act, regardless of hospital payment type. The largest increase of surgery within 48 h occurred in private hospitals (adjusted Relative Risk = 2.80, p < 0.001).

Conclusions

The introduction of a compensation system based on health care quality is associated with improved quality of care for elderly patients with hip fracture, especially in hospitals that only use the Diagnosis Related Group system.

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Most cited references 14

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Assessing quality using administrative data.

Lisa Iezzoni (1997)

Administrative data result from administering health care delivery, enrolling members into health insurance plans, and reimbursing for services. The primary producers of administrative data are the federal government, state governments, and private health care insurers. Although the clinical content of administrative data includes only the demographic characteristics and diagnoses of patients and codes for procedures, these data are often used to evaluate the quality of health care. Administrative data are readily available, are inexpensive to acquire, are computer readable, and typically encompass large populations. They have identified startling practice variations across small geographic areas and-supported research about outcomes of care. Many hospital report cards (which compare patient mortality rates) and physician profiles (which compare resource consumption) are derived from administrative data. However, gaps in clinical information and the billing context compromise the ability to derive valid quality appraisals from administrative data. With some exceptions, administrative data allow limited insight into the quality of processes of care, errors of omission or commission, and the appropriateness of care. In addition, questions about the accuracy and completeness of administrative data abound. Current administrative data are probably most useful as screening tools that highlight areas in which quality should be investigated in greater depth. The growing availability of electronic clinical information will change the nature of administrative data in the future, enhancing opportunities for quality measurement.

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Public reporting and pay for performance in hospital quality improvement.

Peter K Lindenauer, Denise Remus, Sheila Roman … (2007)

Public reporting and pay for performance are intended to accelerate improvements in hospital care, yet little is known about the benefits of these methods of providing incentives for improving care. We measured changes in adherence to 10 individual and 4 composite measures of quality over a period of 2 years at 613 hospitals that voluntarily reported information about the quality of care through a national public-reporting initiative, including 207 facilities that simultaneously participated in a pay-for-performance demonstration project funded by the Centers for Medicare and Medicaid Services; we then compared the pay-for-performance hospitals with the 406 hospitals with public reporting only (control hospitals). We used multivariable modeling to estimate the improvement attributable to financial incentives after adjusting for baseline performance and other hospital characteristics. As compared with the control group, pay-for-performance hospitals showed greater improvement in all composite measures of quality, including measures of care for heart failure, acute myocardial infarction, and pneumonia and a composite of 10 measures. Baseline performance was inversely associated with improvement; in pay-for-performance hospitals, the improvement in the composite of all 10 measures was 16.1% for hospitals in the lowest quintile of baseline performance and 1.9% for those in the highest quintile (P<0.001). After adjustments were made for differences in baseline performance and other hospital characteristics, pay for performance was associated with improvements ranging from 2.6 to 4.1% over the 2-year period. Hospitals engaged in both public reporting and pay for performance achieved modestly greater improvements in quality than did hospitals engaged only in public reporting. Additional research is required to determine whether different incentives would stimulate more improvement and whether the benefits of these programs outweigh their costs. 2007 Massachusetts Medical Society

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Association of timing of surgery for hip fracture and patient outcomes.

Megan McLaughlin, L. Kristopher Siu, Linda R. Morrison … (2004)

Previous studies of surgical timing in patients with hip fracture have yielded conflicting findings on mortality and have not focused on functional outcomes. To examine the association of timing of surgical repair of hip fracture with function and other outcomes. Prospective cohort study including analyses matching cases of early ( 24 hours) surgery with propensity scores and excluding patients who might not be candidates for early surgery. Four hospitals in the New York City metropolitan area. A total of 1206 patients aged 50 years or older admitted with hip fracture over 29 months, ending December 1999. Function (using the Functional Independence Measure), survival, pain, and length of stay (LOS). Of the patients treated with surgery (n = 1178), 33.8% had surgery within 24 hours. Earlier surgery was not associated with improved mortality (hazard ratio, 0.75; 95% confidence interval [CI], 0.52-1.08) or improved locomotion (difference of -0.04 points; 95% CI, -0.49 to 0.39). Earlier surgery was associated with fewer days of severe and very severe pain (difference of -0.22 days; 95% CI, -0.41 to -0.03) and shorter LOS by 1.94 days (P<.001), but postoperative pain and LOS after surgery did not differ. Analyses with propensity scores yielded similar results. When the cohort included only patients who were medically stable at admission and therefore eligible for early surgery, the results were unchanged except that early surgery was associated with fewer major complications (odds ratio, 0.26; 95% CI, 0.07-0.95). Early surgery was not associated with improved function or mortality, but it was associated with reduced pain and LOS and probably major complications among patients medically stable at admission. Additional research is needed on whether functional outcomes may be improved. In the meantime, patients with hip fracture who are medically stable should receive early surgery when possible.

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Author and article information

Contributors

Paola Colais

Luigi Pinnarelli

Danilo Fusco

Marina Davoli

Mario Braga

Carlo A Perucci

Journal

Journal ID (nlm-ta): BMC Health Serv Res

Journal ID (iso-abbrev): BMC Health Serv Res

Title: BMC Health Services Research

Publisher: BioMed Central

ISSN (Electronic): 1472-6963

Publication date Collection: 2013

Publication date (Electronic): 7 October 2013

Volume: 13

Page: 393

Affiliations

[1 ]Department of Epidemiology, Regional Health Service, Via Santa Costanza 53, Rome, Lazio Region 00198, Italy

[2 ]Department of Social and Economic Planning, Rome, Lazio Region, Italy

[3 ]National Agency of Regional Health Services, Rome, Italy

Article

Publisher ID: 1472-6963-13-393

DOI: 10.1186/1472-6963-13-393

PMC ID: 3852766

PubMed ID: 24099264

SO-VID: bec74536-4412-4b95-b479-3db8614acfc1

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The impact of a pay-for-performance system on timing to hip fracture surgery: experience from the Lazio Region (Italy)

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Abstract

Background

Methods

Results

Conclusions

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International Journal of Applied Technology in Medical Sciences

Most cited references 14

Assessing quality using administrative data.

Public reporting and pay for performance in hospital quality improvement.

Association of timing of surgery for hip fracture and patient outcomes.

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