Evaluating the effect of the Best Practice Tariff for hip fracture on health inequalities

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Datasets: + Bespoke Cohort: MPS_ID Linkage; + Civil Registrations of Death - Secondary Care Cut; + Emergency Care Data Set (ECDS)

Objective for processing

The objective Centre for Health Economics (CHE), based at University of this York, requires access to NHS England data for the purposes of research is into the extent to assess which the cost-effectiveness introduction of the hip fracture Best Practice Tariff (BPT) from an NHS perspective by measuring its impact on process quality and outcomes and comparing it to its cost implications. The research is funded by NHS England, who will use this information to review, and potentially, change the way it implements financial incentives to improve patient care. To this end, the University of York, Centre for Health Economics (CHE) will explore how the introduction of the fragility hip fracture BPT in English NHS hospitals in April 2010 and subsequent changes to it and the national tariff have affected: design, affect health inequalities in this patient population. 1. Achievement on the incentivized process quality standards, In this research project, CHE researchers will use data from the National Hip Fracture Database (NHFD) (part of the Falls and Fragility Fracture Audit Programme commissioned by the Healthcare Quality Improvement Partnership (HQIP) and administered by the Royal College of Physicians (RCP)) for the period 01 April 2008 to 31 March 2020 (approximately 600,000 admissions). The data will be used to examine whether the BPT introduction, and subsequent amendments to its design, had different effects on incentivised clinical behaviours across socioeconomic groups (as defined by the Index of Multiple Deprivation) and how this affects population health and health inequalities. Any changes in clinical behaviour is likely to have an impact on long-term healthcare utilisation and morbidity, which affect how health benefits are distributed across socio-economic groups. 2. Patients’ health outcomes (i.e. mortality and quality adjusted life years) and the occurrence of adverse events (infections, readmissions), The following NHS England data will be accessed: 3. Cost to the purchaser of care. • Hospital Episode Statistics Admitted Patient Care, Accident & Emergency and Outpatients Furthermore, to explore why producers may respond differently to the BPT, CHE will explore: • Emergency Care Data set (ECDS) (replacement product for Hospital Episode Statistics Accident & Emergency 2019/20 onwards) 4. How the BPT has affected providers’ unit costs, • Civil Registration Mortality 5. How improvements on specific quality standards correlate with patients' health outcomes, • a bridge file enabling linkage between de-identified NHFD records to pseudonymised HES/mortality extract (currently held) 6. How improvements on specific quality standards correlate with costs and how this relationship changes as achievement levels improve, Long-term health care utilisation and patient survival beyond the initial hospital stay are not recorded in the NHFD and can only be assessed through routine HES data linked to Civil Registration data. The data will be used to examine whether the effect of incentivised care processes on these long-term outcomes differs by socio-economic status of the patients affected. Access to HES-Civil Registration (Deaths) data linked to NHFD data is necessary to achieve the stated research objectives, which cannot be achieved in other ways. 7. Which elements of the BPT for hip fracture are the hardest to achieve (i.e. their level) and offer most scope for improvement (i.e. provider variability in average achievement), The level of the data requested will be pseudonymised but identifying data will be supplied to NHS England in order to facilitate the linkage of NHFD data and linked pseudonymised HES-Civil Registration mortality data which the CHE already holds under a separate Data Sharing Agreement (ref: DARS-NIC-84254-J2G1Q which will be superseded by DARS-NIC-667040-B5T1X-v0 within the next 12 months). 8. Whether providers with a positive profit margin (tariff and BPT bonus net of unit costs) are more responsive to the BPT than those with a negative profit margin. The data will be limited to data for all patients treated for fragility hip fracture in English NHS hospitals between 01 April 2011 and 31st March 2020 and whose care was documented in the NHFD. This time period is required to examine the effect of changes to the BPT design introduced at different time points, to maximise statistical power to obtain precise estimates of the associations of interest, and to examine whether these statistical associations change over time. The data covers patients treated in all areas of England, in line with the scope of the BPT and the data captured in the NHFD. In outlining the justification for processing under GDPR: is Article 6 (1)(e) - "processing is necessary for the performance of a task in the public interest or in the exercise of official authority vested in the controller". It is in the public interest to determine the economic implications of implementation of NHS processes and look at the patient improvement that this has brought also. Furthermore, justification for using Article 9 (2)(j) - "processing is necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes" is given in the fact that this is a piece of research undertaken by a University. Data on patients treated for hip fracture between April 2008 and March 2011 will not be used because NHFD does not contain sufficient person identifiers to permit linkage for these patients. CHE will analyse data for patients with a fragility hip fracture admitted to hospital in England (i.e. those subject to the BPT) and in Wales (not subject to the BPT) to establish the causal effect of the financial incentives on care patterns. The data held under this agreement will permit linking HES data for patients treated in England to mortality data and resource use data (e.g. hospital admissions, A&E attendances). This linkage is necessary to establish how changes in care pattern affect resource use and outcomes. The data will be limited to information on patient socio-demographic characteristics, medical history, admission and discharge modalities of the care episode (e.g. start/end of A&E attendance; discharge date from hospital ward) as well as diagnostic and procedure codes to describe the care provided. CHE is the sole data controller and data processor. NHS England funds this work but does not control the scope or conduct of the research work. The HES/Civil Registration mortality data will be linked to two other datasets: CHE's proposed research project differs from previous evaluations of the BPT in that it evaluates both short- and long-term effects of the introduction of the BPT and explicitly links improvements in process quality to outcomes and costs. This allows, for the first time, a full evaluation of the cost-effectiveness of the BPT. 1) Price data from the National Tariff Payment System published by NHS England The project ended in Dec 2018. CHE's plan to publish the results of the project in a high-impact international journal. As there is usually a significant time delay between submitting the paper and its acceptance, CHE need to retain the data for a longer period, to accommodate potential reviewers' comments. 2) Area-level information from the English Indices of Deprivation. The price data will be used to construct expenditure profiles for patients over specific time frames (e.g. expenditure per year after the hip fracture admission). The Indices of Deprivation data will be used to group patients into five socio-economic deprivation quintile groups. The NHFD does not collect data on patients’ history of care prior to the index hip fracture admission. Patient and public involvement in the study occurred at early stages of the process, namely the design of the research and will continue throughout the study. As the overall project examines the health inequality impacts of a range of current health policies, the study team recruited members of the public rather than users of specific services. The study have public representatives involved in the project who have advised on the selection of this topic and the research methods. Members of the public were involved in the design of the overall research proposal, including the number and nature of the case studies, of which this specific proposal to examine the inequality impact of best practice tariffs for hip fracture is one. One of these members of the public also attended a stakeholder workshop to discuss the relevance and priority of examining the health inequality impacts of the best practice tariff for hip fracture. Members of the public will advise on interpretation and dissemination once the analysis is complete. During meetings that have been undertaken so far, all participants expressed that they thought the proposed research would provide social value, and that the use of confidential patient information without consent was appropriate. Pseudonymised HES and Mortality data will be analysed from 01/04/2009 to 31/03/2022 for patients that were treated for a hip fracture between 01/04/2011 until 31/03/2020. CHE will link NHFD to HES / Civil Registration mortality data from up to two years prior to the hip fracture care episode to construct measures of historic care utilisation (e.g. number of hospitalisations in the year prior to the hip fracture) and frailty scores for the purpose of case-mix adjustment. This is why CHE plans to link NHFD data (with the earliest recorded admission in April 2011 for which sufficient personal information is recorded in NHFD to permit linkage to HES) to HES/Civil Registration mortality data from April 2009. Work by Street et al. (2021, The Lancet Healthy Longevity) shows that a two-year time window is optimal for capturing frailty using administrative data. HES records for patients that cannot be linked to NHFD are excluded to minimise data flow. The University of York is the sole data controller as they are the organisation responsible for ensuring that the data will only be processed for the purpose described above. Amazon Web Services supply Cloud Services for the University of York and are therefore a data processor. They supply support to the system, but do not access data. Therefore, any access to the data held under this Agreement would be considered a breach of the Agreement. This includes granting of access to the databases containing the data. The research has received funding from the National Institute for Health Research Policy Research Programme. Crown Informatics (on behalf of the Royal College of Physicians (RCP) commissioned by Healthcare Quality Improvement Partnership (HQIP)) provides data from the National hip fracture audit database to NHS England. These data were collected as part of a clinical audit that HQIP has commissioned RCP to conduct. CHE at University of York, processes data under the following legal bases: Article 6(1)(e) of the GDPR (lawfulness of processing): processing is necessary for the performance of a task carried out in the public interest or in the exercise of official authority vested in the controller Article 9(2)(j) of the GDPR (Processing of special categories of personal data): processing is necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) based on Union or Member State law which shall be proportionate to the aim pursued, respect the right to data protection and provide for suitable and specific measures to safeguard the fundamental rights and the interests of the data subject. The processing of personal data, including special category data, is necessary to carry out research that serves the public interest, to inform policy and practice with the goal of improving health and well-being.

Processing activities

All organisations party to this agreement must comply with the Data Sharing Framework Contract requirements, including those regarding the use (and purposes of that use) by “Personnel” (as defined within the Data Sharing Framework Contract ie: employees, agents and contractors of the Data Recipient who may have access to that data)” CHE already holds pseudonymised HES data (Admitted Patient Care (APC) 1997/98 to 2021/22, Outpatient care (OP) 2003/04 to 2021/22, Accident & Emergency care (A&E) 2007/08 to 2019/20, Emergency Care Data set (ECDS) 2018/19 - 2021/22 , Civil Registration (Deaths) - Secondary Care Cut 1998/99 - 2021/22) for the relevant years under an existing agreement with NHS England [DARS-NIC-84254-J2G1Q superseded by DARS-NIC-667040-B5T1X-v0 within the next 12 months]. These data do not need to be resupplied. The University of York’s CHE holds a set of pseudonymised HES data for the years 1989/90 to 2015/16 plus vital status at 7, 30, 90 and 365 days post-date of admission derived from mortality data. This data was provided under a separate Data Sharing Agreement DARS-NIC-84254-J2G1Q. CHE extracted and utilised a subset of this data for use in this project. Once extracted, the subset was not be relinked with the ‘master’ dataset. NHS England will derive a bridge file by mapping person-identifiable data from the NHFD to person-identifiable data held in Personal Demographics Service (PDS). The Royal College of Physicians (RCP) holds the NHFD at Crown Informatics. Crown Informatics will extract the identifiers of each patient whose data is held in the NHFD and will assign a unique patient ID to each patient (NHFD ID). The NHFD ID will be released to CHE as part of the audit dataset released under the HQIP DSA. Crown Informatics will not release patient identifiers to CHE. The Royal College of Physicians (RCP) hold the National Hip Fracture Database (NHFD) at Crown Informatics. Crown Informatics extracted the identifiers of each patient whose data was held in the NHFD and assigned a unique patient ID to each patient (ID#1). This ID was not present in the NHFD and will not be retained by RCP once transferred. Crown Informatics (on behalf of RCP) provide to NHS England a file containing the patient identifiers (NHS Number, Date of Birth, Postcode & Sex) plus the unique patient NHFD ID for all patients treated in English hospitals between April 2011 and March 2020. No clinical data from the NHFD is supplied to NHS England. Crown Informatics (on behalf of RCP) securely transferred a file containing the patient identifiers (NHS Number, DoB, Postcode & Sex) plus the unique patient ID (ID#1) to NHS Digital. No clinical data from the NHFD was supplied to NHS Digital. NHS England will use the patient identifiers to extract the matching HES IDs (or Token-Person ID; depending on the date of data release). NHS England will produce a patient-level bridge file that matches the NHFD ID with the encrypted HES ID [using the same encryption algorithm as used for DARS-NIC-84254-J2G1Q superseded by DARS-NIC-667040-B5T1X-v0 within the next 12 months] and supply this file to CHE. NHS England will not release any patient identifiers (i.e. NHS Number, Date of Birth, Postcode & Sex) received from Crown Informatics. NHS Digital linked the identifiers to its HES patient index and extracted the matching HESIDs (ID#2). The HESIDs were encrypted using the same encryption key as used for DARS-NIC-84254-J2G1Q [a seperate agreement issued to the University of York]. Crown Informatics will flow pseudonymised NHFD data containing the unique NHFD ID to CHE. Crown Informatics will then destroy any record of the unique NHFD ID that could be used to re-link that ID to identifiers held in the NHFD. NHS Digital produced a bridging file matching the NHFD ID (ID#1) with the encrypted HESID (ID#2). Additionally NHS Digital assigned to each patient a unique study ID (ID#3) that is not common to the data supplied under DARS-NIC-84254-J2G1Q [the other DSA]. NHS Digital supplied the bridging file to CHE. CHE will link NHFD and the linked HES-Civil Registration mortality data using the supplied bridge file. CHE will then create a new study ID in the merged dataset and delete the NHFD ID and encrypted HES ID to prevent future re-identification of individuals or re-linkage of datasets. The linked dataset will be held and maintained separately to the data provided to CHE under DARS-NIC-84254-J2G1Q (superseded by DARS-NIC-667040-B5T1X-v0 within the next 12 months). Crown Informatics flowed pseudonymised NHFD data containing the unique NHFD ID (ID#1). Crown Informatics will then destroy any record of the unique NHFD ID (ID#1) that could be used to relink that ID to identifiers held in the NHFD. NHS Digital will require HQIP to ensure that ID#1 is destroyed by Crown Informatics once the audit data has flowed to the University of York and NHS Digital could seek confirmation from HQIP that this condition has been imposed. Data storage: CHE used the encrypted HESID (ID#2) to extract the relevant pseudonymised HES + ONS/derived mortality data from the ‘master’ dataset. Data will only be stored on the University of York Data Safe Haven (DSH) and backup locations (onsite at University of York, and offsite at Amazon Web Services). CHE used the bridging file to link HES data (and linked derivations) to the pseudonymised NHFD data. The data under this Agreement will only be processed by substantive employees of University of York. CHE then removed from the linked dataset both the NHFD ID (ID#1) and the encrypted HESID (ID#2) leaving only the unique study ID (ID#3) as a remaining patient identifier ensuring the data was pseudonymised and could not be relinked back to identifiers by CHE, RCP, or Crown Informatics. Data will not be accessed or processed by any other third party not mentioned in this Agreement. Access is granted for each project only to the individuals associated with that project under authorised user names. Such access is controlled and recorded by the CHE Data Governance Group, following the strict processes of CHE and the Data Safe Haven (DSH). The linked dataset is held and maintained separately to the data provided to CHE under DARS-NIC-84254-J2G1Q and will not be linked with any other data. CHE does not require and will not attempt to re-identify individuals. Guidance on confidentiality and data protection is provided to staff from University of York Information Security and Data Protection policies, CHE policies, CHE induction, as well as through University mandatory online training (Information Security Awareness and Data Protection - GDPR). Completion of the training, every 12 months, is a requirement for access to the Data Safe Haven. Users of the Data Safe Haven must sign a user agreement, confirming they are aware of the applicable policies (University of York and Data Safe Haven) and their personal responsibilities towards maintaining the security of the Data Safe Haven and the information stored within it. Once signed, a DSH User Agreement applies to all projects and data within the Data Safe Haven. This is a retrospective observational study using a regression-based case-control approach. The cost-effectiveness of the hip fracture BPT will be evaluated using an interrupted time series approach, as well as a difference-in-difference approach with non-English providers that are not subject to the BPT (but are included in NHFD) as a control group. All substantive employees granted access to data held by CHE for research purposes are required to sign a Non-Disclosure Confidentiality Data Processing Agreement, confirming that they will read, act and adhere to CHE and University of York policies, in addition to the applicable Data Sharing Agreement and the Data Sharing Framework Contract. All analyses will employ appropriate econometric techniques such as Hierarchical Generalised Linear Modelling to isolate the effect of BPT achievement from that of patient characteristics (i.e. case-mix). These models are appropriate for the non-normal distribution of outcomes and clustering of patients in providers. Data quality and completeness will be assessed prior to analysis. If more than 5% of data on key outcome or explanatory variables are missing CHE will employ multiple imputation techniques to address the effect of the missing data. Changes in mortality will be translated into quality-adjusted life years (QALYs) using life expectancy data, population health related quality of life (HRQoL) data, and utility values from the UK general public. This will allow CHE to express all patient health outcomes in terms of a common metric, QALYs. The cost of care to the purchaser will be calculated as the sum of HRG base tariff payment for hip fracture treatment, BPT bonus and cost of additional activity in post-acute care not covered by the BPT, including A&E attendances, outpatient appointments, and emergency readmissions. The costs to hospitals and other providers of delivering care according to BPT requirements will be assessed using reference cost data and length of stay data. Cost-effectiveness will be calculated as incremental cost per QALY. CHE will determine the probability that the hip fracture BPT is cost-effective over a range of different valuations for a unit gain in QALY. Authorised users Only substantive employees of CHE will have access to the data and will access the data only for the purpose set out in this application. There will be no data linkage undertaken with NHS Digital data provided under this agreement that is not already noted in the agreement. Data will only be accessed and processed by substantive employees of The University of York and will not be accessed or processed by any other third parties not mentioned in this agreement. All individuals involved in data processing are substantive employees of the University of York and have been throughout the duration of the project.

Expected output

CHE has provided quarterly reports and will provide regular updates to the project stakeholder group and defined policy contacts in the Department of Health & Social Care and NHS England for the duration of the project as part of CHE's stakeholder engagement process, with a final report submitted in December 2018. Results were further disseminated to NHS England and NHS Improvement through a seminar held at NHS England, Leeds on the 27th March 2019. process. CHE are now in the process of converting the report into two scientific articles for publication in peer-reviewed international journals in order to disseminate our findings to the wider scientific community and the general population. CHE expect to submit one paper for publication by September 2019, and another by December 2019. CHE further anticipate request for revisions as part of the scientific review process, which requires continued access to the underlying data until approximately April 2020. The primary output from this research project is a scientific report to the funder (target date December 2023). CHE also plans to publish two articles in scientific journals 1) on the impact of the BPT on inequalities in receipt of BPT-conform care across different SES groups (target date December 2023; based solely on NHFD data) and 2) on the impact of the BPT on population health inequalities, taking into account the effect on health outcomes for hip fracture patients and the distribution of opportunity costs of NHS expenditure (target date December 2023; based on data released under this agreement). The target journals for these publications are the British Medical Journal (BMJ) and Health Economics. In these articles, CHE will report the methodology of the research project and summarise the main findings and policy conclusions. Broadly speaking, one paper will describe the results of an evaluation of whether the BPT for fragility hip fracture care has improved adherence to best practice standards. The second paper will describe the results of a cost-effectiveness evaluation that seeks to establish whether any improvements in adherence to best practice generate sufficient patient health benefits to offset any additional costs to the NHS. CHE researchers are also planning to disseminate the findings from the work through lay summaries such as newsletters and blogs, and conference and seminar presentations to academic, policy, professional and public audiences. Specifically, they plan to present their work at the International Health Economics Association meeting, the Society for Medical Decision Making meeting, and the Health Economists’ Study Group meeting (i.e. the UK health economics association). CHE has a long-established track record in delivery of policy research that utilises HES data, as recognized by the award of the Queen’s Anniversary Prize in 2007. Examples of recent publications that have employed HES data can be found here http://www.york.ac.uk/che/publications/in-house/ The publication of the papers in peer-reviewed journals will be accompanied by additional communication activities, such as short summary pieces in CHE's Centre's quarterly newsletter, which reaches a large number of stakeholders in the NHS and academia, conference presentations (e.g. a presentation has been scheduled at the International Health Economics Association conference in Basel, July 2019) and media engagement facilitated by the University of York media team. CHE will publish only summary statistics of the data and estimated quantities (means, standard errors, regression coefficients) but will not publish individual-level data in any form. All outputs will be aggregated with small numbers suppressed in line with the HES Analysis Guide. CHE will publish only descriptive statistics of the data and estimated quantities (means, standard errors, regression coefficients) but will not publish individual-level data in any form. All outputs will be aggregated with small numbers suppressed in line with the HES Analysis Guide. The NHS needs to ensure that it uses its limited resources cost-effectively. Furthermore, under the Health and Social Care Act 2012, the Department of Health & Social Care and its arm’s-length bodies received explicit duties to reduce inequalities in England with respect to population benefits from the health service. These duties reflect the preferences for health equity of the general population, who fund the NHS through their tax contributions. This study will provide decision-makers in the English NHS with information on the population health and health inequality impacts of pay-for-performance models such as the fragility hip fracture BPT. It is hoped this information will inform future designs of pay-for-performance arrangements in the English NHS, which are expected to improve population health and/or reduce inequalities. Given the expected timing of the project report in December 2022, the work may inform payment models for the financial year 2024/25. The data are requested for the purpose of evaluating the cost-effectiveness of the BPT for fragility hip fracture as part of a research project commissioned by NHS England. The outputs generated from the data will also contribute to a final PhD thesis as part of PhD project. The PhD student is a full-time employee of the University of York who currently pursues PhD studies as part of an NIHR fellowship. There are plans to include some of the research outputs that have been generated while working on the NHS England commissioned evaluation as part of the final PhD thesis. In this way, the study supports PhD research work; although this is not its primary aim nor did this motivate the initial data request. The planned outputs included in the PhD thesis are taken from the evaluation conducted for NHS England and do not originate from any new or additional research outside the scope of the NHS England evaluation. The outputs reported in the PhD thesis will consist of summary tables, sets of regression coefficients describing statistical associations between variables, and graphs such as bar charts, forest plots and time series plots of average values. The purposes of these outputs are to illustrate the methodological contribution of the work and to highlight the policy implications arising from the results. No patient-level information that may permit re-identification will be disclosed as part of these outputs. All outputs will be aggregated with small numbers suppressed in line with the HES analysis guide.

Expected measurable benefits

[2 paragraphs unchanged] Financial incentives, such as those provided by the BPT, have the potential [26 words unchanged] to increased NHS spending without benefit to patients targeted by the incentive. Furthermore, this This additional NHS spending draws resources away from other areas of NHS care, creating losses in patient benefit. The current evidence base is insufficient to help inform decisions about future refinements and roll-out Even if these incentives work, they might still favour the provision of BPT tariffs. If BPTs are not cost-effective, then the associated resources might be better invested elsewhere. care for specific patient populations, thereby increasing or decreasing population health inequalities. It is therefore in the public interest to generate and disseminate information on the effectiveness cost-effectiveness and health inequality impact of the BPT for fragility hip fracture as proposed here. Previously, CHE's comprehensive review and evaluation of the effectiveness and cost-effectiveness of the hip fracture BPT helps ensure the efficient use of resources in the NHS, by demonstrating a) whether the BPT has changed provider behaviour, and b) whether the benefits of the programme measured by patient health outcomes outweigh its opportunity cost. It also illustrates areas for further improvement which policymakers might target as part of future revisions of the BPT. Based on our previous research, NHS England, England / Improvement, who are responsible for the design of the BPTs, BPTs and have obligations to tackle health inequalities under the Health & Social Care Act 2012, may decide to stop, change or continue the current BPT for fragility [14 words unchanged] provision of health care affecting about 60,000 hip fracture patients a year. These improvements can be measured through adherence rates reported Results from this research are expected to emerge from December 2022 onwards and may therefore inform the design of reimbursement rules in NHFD. the English NHS from financial year 2024/25 at the earliest. The mortality data disseminated under this agreement allows linking data from the National Hip Fracture Dataset (NHFD) to Hospital Episode Statistics (HES) by means of a bridging file. The linked data are essential to relate changes in clinical behaviour measured in NHFD to resource use (care episodes measured in HES) and health outcomes (survival, as derived from mortality information provided alongside the HES dataset). The data disseminated under this agreement are therefore required to answer the research question mentioned above. The main work, commissioned by NHS England under a variation to contract to the DHSC' Policy Research Unit in the Economics of Health and Social Care, has now concluded and the findings of the work have been reported to NHS England. The results of CHE's evaluation suggest that the existing BPT has been cost-effective, i.e. it has improved patients survival chances at a small increase in overall costs that are easily set off by the additional benefits. CHE also made suggestions on how the BPT could be re-designed to generate further benefits. The purpose of this extension request is to retain data access while CHE seek to disseminate the results to the academic, medical and policy communities and to other interested stakeholders, such as patient organisations. This dissemination is important to ensure that CHE's recommendations feed into practice and generate further patient health benefits.

Benefits reported

CHE have performed a comprehensive review and evaluation of the Best Practice Tariff for hip fracture. CHE results shows the scheme has been successful overall, both in terms of the uptake as well as by directly increasing patients benefit by improving outcomes. CHE are currently writing up the results and preparing manuscript for publication. Yielded Benefits is not a requirement for new applications. CHE's work and results have been discussed at regular meetings with NHS England, who are very supportive of CHE's work. It is expected that the final results of CHE's research will directly impact the future development of the BPT tariff for hip fracture. Due to the timing of the final report, the findings of this project are likely to feed into the development of the 2020/21 NHS Tariff at the earliest.

Text removed is struck through; text added is underlined. Unchanged paragraphs are summarised rather than repeated.

Processing activities

[2 paragraphs unchanged] The Royal College of Physicians (RCP) hold the National Hip Fracture Database [20 words unchanged] assigned a unique patient ID to each patient (ID#1). This ID was note not present in the NHFD and will not be retained by RCP once transferred. [19 paragraphs unchanged]

Unchanged: Objective for processing, Expected output, Expected measurable benefits, Benefits reported.