Learning from England’s Best Practice Tariff: Process Measure Pay-for-Performance Can Improve Hip Fracture Outcomes

Objective: 

The objective of this study was to evaluate England's Best Practice Tariff (BPT) and consider potential implications for Medicare patients should the US adopt a similar plan.

Summary Background Data: 

Since the beginning of the Affordable Care Act, Medicare has renewed efforts to improve the outcomes of older adults through introduction of an expanding set of alternative-payment models. Among trauma patients, recommended arrangements met with mixed success given concerns about the heterogeneous nature of trauma patients and resulting outcome variation. A novel approach taken for hip fractures in England could offer a viable alternative.

Methods: 

Linear regression, interrupted time-series, difference-in-difference, and counterfactual models of 2000–2016 Medicare (US), HES-APC (England) death certificate-linked claims (≥65y) were used to: track US hip fracture trends, look at changes in English hip fracture trends before-and-after BPT implementation, compare changes in US-versus-English mortality, and estimate total/theoretical lives saved.

Results: 

806,036 English and 3,221,109 US hospitalizations were included. Following BPT implementation, England's 30-day mortality decreased by 2.6 percentage-points (95%CI: 1.7–3.5) from a baseline of 9.9% (relative reduction 26.3%). 90- and 365-day mortality decreased by 5.6 and 5.4 percentage-points. 30/90/365-day readmissions also declined with a concurrent shortening of hospital length-of-stay. From 2000–2016, US outcomes were stagnant (p > 0.05), resulting in an inversion of the countries’ mortality and > 38,000 potential annual US lives saved.

Conclusions: 

Process measure pay-for-performance led to significant improvements in English hip fracture outcomes. As efforts to improve US older adult health continue to increase, there are important lessons to be learned from a successful initiative like the BPT.