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

Cheryl K Zogg*, David Metcalfe, Andrew Judge, Daniel C Perry, Matthew L Costa, Belinda J Gabbe, Andrew J Schoenfeld, Kimberly A Davis, Zara Cooper, Judith H Lichtman

*Corresponding author for this work

Research output: Contribution to journalArticle (Academic Journal)peer-review

7 Citations (Scopus)
68 Downloads (Pure)



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.


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.


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.


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.

Original languageEnglish
JournalAnnals of Surgery
Early online date22 Jan 2021
Publication statusE-pub ahead of print - 22 Jan 2021


  • older adult
  • Medicare
  • hip fracture
  • trauma
  • pay-for-performance
  • process measure
  • mortality


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