Open Access Research article

The impact of a pay-for-performance system on timing to hip fracture surgery: experience from the Lazio Region (Italy)

Paola Colais1*, Luigi Pinnarelli1, Danilo Fusco1, Marina Davoli1, Mario Braga2 and Carlo A Perucci3

Author Affiliations

1 Department of Epidemiology, Regional Health Service, Via Santa Costanza 53, Rome, Lazio Region 00198, Italy

2 Department of Social and Economic Planning, Rome, Lazio Region, Italy

3 National Agency of Regional Health Services, Rome, Italy

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BMC Health Services Research 2013, 13:393  doi:10.1186/1472-6963-13-393

Published: 7 October 2013



A tariff modulation mechanisms has been introduced in some Italian regions with the aim of reducing inappropriate admissions and improving quality of care. In response to a regional act, hospitals in Lazio adopted a clinical pathway for elderly patients with hip fracture and introduced a compensation system based on the quality of health care, as in a pay-for-performance model. The objective of the present study was to compare the proportion of surgery for hip fracture performed within 48 hours of admission among Lazio hospitals according to different payment systems, before and after the implementation of the regional act.


A retrospective cohort study of patients aged 65 years and over, residing in the Lazio region and admitted to an acute care hospital for hip fracture before (1 July 2008 - 30 June 2009) and after (1 July 2010 - 30 June 2011) the pay-for-performance act. The proportion of surgeries performed within 48 h of hospital arrival was calculated. An adjusted multivariate regression analysis was applied to assess the effect of hospital payment type on the likelihood of surgery within 48 h of hospital arrival.


The share of patients with hip fracture that had surgery within 48 hours was 11.7% before the introduction of the pay-for-performance act and 22.2% after. The proportion of early hip fracture operations increased after the pay-for-performance act, regardless of hospital payment type. The largest increase of surgery within 48 h occurred in private hospitals (adjusted Relative Risk = 2.80, p < 0.001).


The introduction of a compensation system based on health care quality is associated with improved quality of care for elderly patients with hip fracture, especially in hospitals that only use the Diagnosis Related Group system.

Pay-for-performance; Hip fracture; Surgery; Information systems