Does achieving the best practice tariff improve outcomes in hip fracture patients? An observational cohort study

Abstract

ObjectivesTo determine if the introduction of the best practice tariff (BPT) has improved survival of the elderly hip fracture population, or if achieving BPT results in improved survival for an individual.SettingA single university-affiliated teaching hospital.Participants2541 patients aged over 60 admitted with a neck of femur fracture between 2008 and 2010 and from 2012 to 2014 were included, to create two cohorts of patients, before and after the introduction of BPT. The post-BPT cohort was divided into two groups, those who achieved the criteria and those who did not.Primary and secondary outcome measuresPrimary outcomes of interest were differences in mortality across cohorts. Secondary analysis was performed to identify associations between individual BPT criteria and mortality.ResultsThe introduction of BPT did not significantly alter overall 30-mortality in the hip fracture population (8.3% pre-BPT vs 10.0% post-BPT; p=0.128). Neither was there a significant reduction in length of stay (15 days (IQR 9–21) pre-BPT vs 14 days (IQR 11–22); p=0.236). However, the introduction of BPT was associated with a reduction in the time from admission to theatre (median 44 hours pre-BPT (IQR 24–44) vs 23 hours post-BPT (IQR 17–30); p<0.005). 30-day mortality in those who achieved BPT was significantly lower (6.0% vs 21.0% in those who did not achieve-BPT; p<0.005). There was a survival benefit at 1 year for those who achieved BPT (28.6% vs 42.0% did not achieve-BPT; p<0.005). Multivariate logistic regression revealed that of the BPT criteria, AMT monitoring and expedited surgery were the only BPT criteria that significantly influenced survival.ConclusionsThe introduction of the BPT has not led to a demonstrable improvement in outcomes at organisational level, though other factors may have confounded any benefits. However, patients where BPT criteria are met appear to have improved outcomes.

The Effect of Simple Cost Effective Interventions in Improving Enhanced Recovery in Neck of Femur Fracture Care

“…A 2017 observational cohort study by Oakley et al based on 2541 patients aged over 60 admitted to a trauma centre with neck of femur fractures, found that there was a reduction in 30-day mortality from 21% in those who did not meet the BPT criteria to 6% in those who did. This was also reflected in longer-term survival figures, with a one-year mortality rate of 28.6% in those who met the tariff criteria and 42% in those who did not [ 10 ]. Since March 2012, the published NHFD 30-day mortality rates have reduced from 8.2% to 6% in April 2020 [ 11 ].…”

Interdisciplinary care of hip fractures.

“…According to best practice reimbursement for patients with hip fractures in England, there is currently a requirement of an orthogeriatric approach including the assessment of osteoporosis to obtain the highest refund. This is also about to be established in several other countries, probably because such a "reward" delivers better outcomes [13].…”

Frailty in orthopaedics: is age relevant?

“…This may well represent that the frailest patients have a delay to theatre due to a complicating medical issue which also increased their risk of mortality. There has not been a profound “improvement in outcomes at organisational level” due to the introduction of the BPT [25] . The BPT's age criteria and lack of acknowledgement of frailty could be a factor in why there has not been a significant impact on overall outcomes before and after its introduction.…”