The Triple Aim Quality Improvement Gold Standard Illustrated as Extremely Premature Infant Care.

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Publication Date


Publication Title

American journal of perinatology


oregon; psvmc


OBJECTIVES: The Triple Aim is widely regarded as the quality improvement gold standard - enhance population health, lower costs, better individual care. There have been no large-scale, sustained demonstrations of such improvement in healthcare. Illustrating the Triple Aim using relevant extremely premature infant outcomes might highlight interwoven proficiency and efficiency complexities that impede sustained value progress.

STUDY DESIGN: Ten long-term collaborating neonatal intensive care units (NICU) in the Vermont Oxford Network (VON) calculated the Triple Aim in 23 0/7 to 27 6/7-week infants using three surrogate measures: 1) population health/x-axis - eight major morbidity rates as a composite, risk-adjusted metric, 2) cost/y-axis - total hospital length of stay, and 3) individual care/z-axis - mortality, then illustrated this relationship as a sphere within a 3-dimensional cube. Results 3,706 infants born 1.01.2014 to 12.31.2019, mean (SD) gestational age 25.7 (1.4) weeks, birth weight 803 (208) grams were analyzed. Triple Aim 3-axis cube positions varied inconsistently comparing NICUs. Each NICUs' sphere illustrated mixed x- and z-axis movement (clinical proficiency), and y-axis movement (cost efficiency). No NICU demonstrated the theoretically ideal Triple Aim improvement in all three axes. Backward movement in at least one axis occurred in eight NICUs. The whole-group Triple Aim sphere moved forward along the x-axis (better morbidities metric) but moved backward in the y-axis length of stay and z-axis mortality measurements.

CONCLUSIONS: Illustrating the Triple Aim gold standard as extreme prematurity outcomes reveals complexities inherent to simultaneous attempts at improving interwoven quality and cost outcomes. Lack of progress using relevant Triple Aim parameters from our well-established collaboration highlights the difficulties prioritizing competing outcomes, variable potentially-better-practice applications amongst NICUs, unmeasured biologic interactions, and obscured cultural-environmental contexts that all likely affect care. Triple Aim excellence, if even remotely possible, will necessitate scalable, evidence-based methodologies, pragmatism regarding inevitable trade-offs, and wise constrained-resource decisions.

Clinical Institute

Women & Children