Abstract
Objectives The Triple Aim is widely regarded as the quality improvement gold standard that enhances
population health, lowers costs, and betters 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 calculated the Triple Aim in 230/7 to 276/7-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 three-dimensional cube.
Results Three thousand seven hundred six infants born between January 1, 2014 and December
31, 2019, with mean (standard deviation) gestational age of 25.7 (1.4) weeks and birth
weight of 803 (208) grams were analyzed. Triple Aim three-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.
Conclusion 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.
Key Points
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The Triple Aim gold standard is elusive. There is no demonstration of sustained, large-scale
success in healthcare and our quality improvement network has previously published
benchmark extreme prematuritymorbidity improvements.
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Extreme prematurity outcomes illustrated as the Triple Aim show uneven results in
relevant surrogate parameters and Triple Aim achievement, if even possible, will necessitate
evidence-based methodologies that are scalable.
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Pragmatism, inevitable trade-offs, and wise constrained-resource decisions are required
for Triple Aim success.
Keywords
extreme prematurity - Triple Aim - quality improvement - morbidity metric
