Article Text

Download PDFPDF
What drives hospital performance? The impact of comparative outcome evaluation of patients admitted for hip fracture in two Italian regions
  1. Luigi Pinnarelli1,
  2. Sabina Nuti2,
  3. Chiara Sorge1,
  4. Marina Davoli1,
  5. Danilo Fusco1,
  6. Nera Agabiti1,
  7. Milena Vainieri2,
  8. Carlo A Perucci3
  1. 1Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
  2. 2Management and Health Laboratory, Istituto di Management, Scuola Superiore Sant'Anna, Pisa, Italy
  3. 3National Agency for Regional Health Services, Rome, Italy
  1. Correspondence to Dr Luigi Pinnarelli, Via di Santa Costanza 53, 00198 Rome, Italy; pinnarelli{at}


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.

  • Outcome assessment
  • disclosure
  • hospitals
  • patient care
  • orthopaedics
  • clinical practice guidelines
  • evidence-based medicine
  • performance measures
  • pay for performance
  • quality improvement
  • statistics
  • report cards
  • quality measurement
  • pharmacoepidemiology
  • performance measures
  • management
  • health policy

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Funding This study was supported by National Outcome Programme, Ministry of Health, Italy.

  • Competing interests None.

  • Ethics approval Any necessary ethics committee approval has been secured for the study reported.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Data sharing statement Additional data are available on request from the corresponding author.