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

David Metcalfe, Cheryl K Zogg, Andrew Judge, Daniel C Perry, Belinda J Gabbe, Keith Willet, Matthew Costa

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

72 Citations (Scopus)
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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.
Original languageEnglish
Pages (from-to)1015-1023
Number of pages9
JournalBone and Joint Journal
Issue number8
Early online date31 Jul 2019
Publication statusPublished - 1 Aug 2019


  • Hip fracture
  • Best practice tariff
  • Pay-for-performance


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