A study published in 2019 in Bone and Joint Journal finds that the implementation of pay for performance Best Practice Tariff (BPT) in England, United Kingdom (UK) in 2010 resulted in 7600 fewer deaths between 2010 and 2016. Additional results included significant reductions which were observed in the time to operation and length of stay (LOS) and a pre-existing annual trend towards increased 30-day re-admissions in England was halted post-intervention.
The BPT was implemented following a national clinical audit being established in England and Wales in 2007 with the aim of improving hip fracture outcomes. 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. The BPT scheme was introduced a number of years later and paid hospitals a supplement for each patient whose care satisfied six of the reported clinical standards, such as surgery within 36 hours. The improvements in LOS and re-admission suggest substantial resource savings attributable to the BPT in addition to reduced mortality. The BPT itself did not require a substantial investment.
The study notes that there were a number of other changes that could account for improved outcomes over time across the UK, including publication of clinical guidelines, increasing recognition of the need for early surgery and postoperative rehabilitation, and the emergence of orthogeriatrics as a medical subspecialty dedicated to caring for elderly patients with a fracture.
Matt Costa, Professor of Orthopaedic Trauma and one of the researchers involved with the study, noted that: “The success of the BPT was part of a comprehensive initiative that began with setting up clinical guidelines and using the national clinical audit to identify issues and design quality improvement processes. Data was easily accessible, being provided through online visual dashboards and in publicly accessible reports.” He further stated that “Once the structure was in place to improve performance, BPTs provided additional impetus that helped clinicians and hospital leaders to create business cases that justified local investment in hip fracture services.”
Implementation of the BPT was associated with a marked and sustained improvement in outcomes, however needs to be built on clinical standards and a reporting system that allows hospitals to identify and address their weaknesses.
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