An improvement in the proportion of patients receiving early surgery for hip fracture after the introduction of the pay-for-performance act was observed in cases remunerated through all hospital payment types. However, the largest increase of surgery within 48 h was observed for private hospitals. This improvement resulted in a strong reduction of the diversity of the interval from admission to surgery across hospital types. In the period preceding the introduction of the pay-for-performance act, the patients admitted to private hospitals had the lowest likelihood of receiving surgical intervention for hip fracture within 48 h, while less than one-half of the likelihood was observed in public and teaching hospitals. During the period after the introduction of the pay-for-performance act, public hospitals still exhibited the greatest proportion of patients receiving hip surgery within 48 h; however, the greatest increase was observed in local health unit and private hospitals.
In Italy, the National Health System provides equal access to healthcare for all citizens and residents through a mixture of public and private services. In the Lazio region (5.7 million inhabitants and healthcare budget of 1.1 million euros/year) there are 41 private and public hospitals that perform hip surgery (Table 2). The hospitals are very different in size, and serve areas that differ for age composition and distribution of diseases .
Our results seem to confirm the hypothesis that the introduction of a compensation system based on quality of health care, such as the pay-for-performance model, is associated with improved quality of care for elderly patients with hip fracture. This finding is especially true for hospitals entirely paid by the DRG system, as shown in a study that compared the quality improvement programs in Lazio and Toscana .
The impact of pay-for-performance in the Lazio region can be related to the fact that the hospitals had plenty of room for improvement from baseline , given the low proportion of patients receiving surgery within 48 hours .
Even if the evidence of the pay-for-performance model effectiveness remains weak , its implementation was a necessary measure to improve the performance of the health care systems in Lazio and in other Italian regions. The compensation system of a pay-for-performance needs to be linked with important clinical outcomes [19–21], in Lazio hospital remuneration was related to the proportion of hip surgery performed within 48 hours. The Lazio regional act was aimed at implementing the pay-for-performance model uniformly to all providers in the region so that its effects were not diluted , however it is noteworthy that the pay-for-performance model could have an impact at the hospital level rather than at the individual or team level [17, 19, 22]. Furthermore, healthcare providers could have affected the impact of pay-for-performance program as different ownership types might have implemented different incentives related to the uptake of the pay-for-performance model .
The increase of interventions performed within 48 h of admission may be due to the development of programs for public release. In 2007, P.Re.Val.E [5, 6] was conducted with the aim of improving the quality of health care; in 2008, the Agency for Public Health of Lazio designed a clinical pathway for elderly patients with hip fracture. The impact of these programs on the quality of health care for orthopedic patients compared with other Italian regions was evaluated in a recent study . Overall, there is no clear evidence regarding an association between public reporting and improved quality of care, even though some studies suggest that public reporting may motivate quality improvement activities [24, 25]. A previous study found little evidence of an association between the introduction of result-based payment and a change in the quality of care. In this study, Farrar et al. used three variables to measure quality: in-hospital mortality, 30-day postsurgical mortality, and emergency readmission after treatment for hip fracture . Finally, the improvement of quality of health care for elderly patients admitted for hip fracture may be associated with the “announcement effect” of the regulatory act on the Lazio providers.
There are other differences among Lazio hospitals that could affect the capacity of reacting to the changing payment methods. The differences in the management of elderly patients with hip fracture in hospitals depends on the different distribution of elective or emergency patients and the relative waiting time to surgery and on the clinical practices of the hospital specialties. The distribution of socio-economic characteristics of elderly patients with hip fracture could be different among Lazio hospitals and there is evidence that more disadvantaged people could experience longer waiting times . However, the socioeconomic inequalities in the waiting times for surgery were reduced in Lazio region after the implementation of P.Re.Val.E. .
The strengths of this study include the before-after design, the large data sample available for analysis, the validated algorithm for cohort selection and variable definitions, and the robust outcome. However, the limitations should also be considered. The study relies entirely on administrative data and, despite the broad and valued use of administrative data for health care research, hospital discharge data have several limitations that have been recognized repeatedly . In addition, although several covariates were included in the models to adjust for differences in patient characteristics, unmeasurable or unmeasured covariates that might affect the likelihood of intervention within 48 h of admission may not have been taken into account. However, the lack of major differences between the crude and adjusted proportion of patients receiving surgery within 48 h and the homogeneity of results by hospital payment type suggest that these covariates may not affect results. Furthermore, different coding practices across hospitals and misclassification of comorbidity are unlikely to be associated with hospital payment type.