What drives hospital performance? The impact of comparative outcome evaluation of patients admitted for hip fracture in two Italian regions

BACKGROUND: From 2006 to 2007 Lazio and Tuscany, two Italian regions, released data about hospital performance and implemented strategic programmes aimed at improving the quality of hospital care. Furthermore, different pay-for-performance systems were introduced: the hospital's performance determined the DRG (Diagnosis-Related Group) reimbursement rate for Lazio providers while in Tuscany the chief executive officer's compensation was linked to the hospital's performance. The authors evaluated the impact of the Lazio and Tuscany programmes on quality of healthcare for orthopaedic patients compared with other Italian regions. METHODS: The proportion of older patients admitted with hip fractures who had surgery within 48 h and the median waiting time for surgical treatment of fractures of the tibia or fibula were estimated separately for Lazio, Tuscany and other Italian regions for two periods: 2006-2007 and 2008-2009. Risk-adjusted proportions were obtained using the direct standardisation method and a multivariate logistic regression was performed taking into account age, gender and comorbidity status. RESULTS: The proportion of hip operations performed within 48 h was increased by 34% for Lazio (p<0.001) and 46% for Tuscany (p<0.001) and reduced by 3% in other Italian regions (p<0.001). To assess for possible adverse consequences, such as increased waiting times for other orthopaedic procedures, the authors monitored time to surgery for tibia or fibula fractures. There were no significant differences in the median time to surgery for tibia or fibula fractures between the two periods. CONCLUSIONS: The Lazio and Tuscany programmes appeared to have a positive impact on quality of care for older patients admitted with hip fracture without having a negative impact on other orthopaedic interventions. The results highlight the need for continuous quality improvement by repeating the evaluation process and by combining the performance system with a management strategy.