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

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 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 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

• 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.

• 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.

• Pragmatism, inevitable trade-offs, and wise constrained-resource decisions are required for Triple Aim success.

Keywords

extreme prematurity - Triple Aim - quality improvement - morbidity metric

Authors' Contributions

J.W.K. conceptualized and designed the original idea and illustration of the investigation; designed the outcomes metrics analysis; helped in data collection process, tabular and figure displays, as well as all data storage and integrity; supervised the QI collaboration and overall agreement with the individual NICU and group outcomes measurements; participated in the manuscript preparation and final version; and obtained approval from the Vermont Oxford Network Publications Committee before submission.

L.W. designed the outcomes metrics analysis; helped in data collection process, tabular and figure displays, as well as ensuring all data storage and integrity; participated in the manuscript preparation and final version; and obtained approval from the Vermont Oxford Network Publications Committee before submission.

M.D. supervised the QI collaboration and overall agreement with the individual NICU and group outcomes measurements, participated in the manuscript preparation and final version, and obtained approval from the Vermont Oxford Network Publications Committee before submission.

All three coauthors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Note

The Vermont Oxford Network had no role in the concept, design, analysis, or formulation of this research report. The discussion and views belong solely to the coauthors and do not represent the opinions of the Vermont Oxford Network.

Publication History

Received: 20 June 2022

Accepted: 12 December 2022

Accepted Manuscript online:
20 December 2022

Article published online:
01 February 2023

• References

• 1 Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood) 2008; 27 (03) 759-769
• 2 Mery G, Majumder S, Brown A, Dobrow MJ. What do we mean when we talk about the Triple Aim? A systematic review of evolving definitions and adaptations of the framework at the health system level. Health Policy 2017; 121 (06) 629-636
• 3 Shah A, Aurelio M, Frasquilho F, Fradgley R. Quality improvement in practice – part three: achieving the triple aim through the systematic application of quality improvement. Br J Healthcare Improvement 2021;
• 4 Institute of Medicine, National Academy of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. In: Briere R. ed. Washington DC: National Academy Press; 2001
• 5 Rawlins MD. Cost, effectiveness, and value. How to judge?. JAMA 2016; 316 (14) 1447-1448
• 6 Shah V, Warre R, Lee SK. Quality improvement initiatives in neonatal intensive care unit networks: achievements and challenges. Acad Pediatr 2013; 13 (6, suppl): S75-S83
• 7 Dukhovny D, Pursley DM, Kirpalani HM, Horbar JH, Zupancic JAF. Evidence, quality, and waste: solving the value equation in neonatology. Pediatrics 2016; 137 (03) e20150312
• 8 Donahue KE, Reid A, Baxley EG. et al. Triple aim is triply tough: can you focus on three things at once?. Fam Med 2018; 50 (03) 179-187
• 9 Hendrikx RJP, Drewes HW, Spreeuwenberg M, Ruwaard D, Struijs JN, Baan CA. Which Triple Aim related measures are being used to evaluate population management initiatives? An international comparative analysis. Health Policy 2016; 120 (05) 471-485
• 10 Ralston SL, Brady PW, Kemper AR. Do we really need scholarly quality improvement?. JAMA Pediatr 2019; 173 (05) 413-414
• 11 Djulbegovic B, Bennett CL, Guyatt G. A unifying framework for improving health care. J Eval Clin Pract 2019; 25 (03) 358-362
• 12 Buntin MB. Confronting challenges in the US healthcare system. JAMA 2021; 325 (14) 1399-1400
• 13 Emanuel EJ. The near-term future of healthcare reform. JAMA 2021; 325 (14) 1394-1397
• 14 Beam AL, Fried I, Palmer N. et al. Estimates of healthcare spending for preterm and low-birthweight infants in a commercially insured population: 2008-2016. J Perinatol 2020; 40 (07) 1091-1099
• 15 Myrhaug HT, Brurberg KG, Hov L, Markestad T. Survival and impairment of extremely premature infants: a meta-analysis. Pediatrics 2019; 143 (02) e20180933
• 16 Nakanishi H, Suenaga H, Uchiyama A, Kono Y, Kusuda S. Neonatal Research Network, Japan. Trends in the neurodevelopmental outcomes among preterm infants from 2003-2012: a retrospective cohort study in Japan. J Perinatol 2018; 38 (07) 917-928
• 17 Marlow N, Ni Y, Lancaster R. et al. No change in neurodevelopment at 11 years after extremely preterm birth. Arch Dis Child Fetal Neonatal Ed 2021; 106 (04) 418-424
• 18 Lui K, Lee SK, Kusuda S. et al; International Network for Evaluation of Outcomes (iNeo) of neonates Investigators. Trends in outcomes for neonates born very preterm and very low birth weight in 11 high-income countries. J Pediatr 2019; 215: 32-40.e14
• 19 Morsing E, Lundgren P, Hård AL. et al. Neurodevelopmental disorders and somatic diagnoses in a national cohort of children born before 24 weeks of gestation. Acta Paediatr 2022; 111 (06) 1167-1175
• 20 Kaempf J, Morris M, Steffen E, Wang L, Dunn M. Continued improvement in morbidity reduction in extremely premature infants. Arch Dis Child Fetal Neonatal Ed 2021; 106 (03) 265-270
• 21 Allotey J, Zamora J, Cheong-See F. et al. Cognitive, motor, behavioural and academic performances of children born preterm: a meta-analysis and systematic review involving 64 061 children. BJOG 2018; 125 (01) 16-25
• 22 Burnett AC, Anderson PJ, Lee KJ, Roberts G, Doyle LW, Cheong JLY. Victorian Infant Collaborative Study Group. Trends in executive functioning in extremely preterm children across 3 birth eras. Pediatrics 2018; 141 (01) e20171958
• 23 Ding S, Lemyre B, Daboval T, Barrowman N, Moore GP. A meta-analysis of neurodevelopmental outcomes at 4–10 years in children born at 22–25 weeks gestation. Acta Paediatr 2018; 108 (07) 1237-1244
• 24 Twilhaar ES, Wade RM, de Kieviet JF, van Goudoever JB, van Elburg RM, Oosterlaan J. Cognitive outcomes of children born extremely or vey preterm since the 1990s and associated risk factors: a meta-analysis and meta-regression. JAMA Pediatr 2018; 172 (04) 361-367
• 25 Kaempf JW, Zupancic JAF, Wang L, Grunkemeier GL. A risk-adjusted, composite outcomes score and resource utilization metrics for very low-birth-weight infants. JAMA Pediatr 2015; 169 (05) 459-465
• 26 Kaempf JW, Wang L, Dunn M. Using a composite morbidity score and cultural survey to explore characteristics of high proficiency neonatal intensive care units. Arch Dis Child Fetal Neonatal Ed 2019; 104 (01) F13-F17
• 27 Kaempf JW, Morris M, Austin J, Steffen E, Wang L, Dunn M. Sustained quality improvement collaboration and composite morbidity reduction in extremely low gestational age newborns. Acta Paediatr 2019; 108 (12) 2199-2207
• 28 Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed.. San Francisco, CA: Jossey-Bass Publishers; 2009
• 29 Vermont Oxford Network. Vermont Oxford Network Database Manual of Operations. Release 23.0. Burlington: Vermont; 2019
• 30 Schmidt B, Roberts RS, Davis PG. et al; Caffeine for Apnea of Prematurity (CAP) Trial Investigators, Caffeine for Apnea of Prematurity CAP Trial Investigators. Prediction of late death or disability at age 5 years using a count of 3 neonatal morbidities in very low birth weight infants. J Pediatr 2015; 167 (05) 982-6.e2
• 31 Holsti A, Serenius F, Farooqi A. Impact of major neonatal morbidities on adolescents born at 23-25 weeks of gestation. Acta Paediatr 2018; 107 (11) 1893-1901
• 32 Asztalos EV, Church PT, Riley P, Fajardo C, Shah PS. Neonatal factors associated with a good neurodevelopmental outcome in very preterm infants. Am J Perinatol 2016; 34 (04) 388-396
• 33 Petrou S, Abangma G, Johnson S, Wolke D, Marlow N. Costs and health utilities associated with extremely preterm birth: evidence from the EPICure study. Value Health 2009; 12 (08) 1124-1134
• 34 Petrou S, You HH, Kwon J. Economic consequences of preterm birth: a systematic review of the literature (2009–2017). Arch Dis Child 2018; 104 (05) 456-465
• 35 Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academies Press; 2012
• 36 Shrank WH, Rogstad TL, Parekh N. Waste in the US health care system estimated costs and potential for savings. JAMA 2019; 322 (15) 1501-1509
• 37 Nightingale Internet Reporting System. Burlington, Vermont: Vermont Oxford Network; 2020
• 38 Marmot M. The health gap: the challenge of an unequal world. Lancet 2015; 386 (10011): 2442-2444
• 39 Edwards EM, Greenberg LT, Ehret DEY, Lorch SA, Horbar JD. Discharge age and weight for very preterm infants: 2005–2018. Pediatrics 2021; 147 (02) e2020016006
• 40 Waitzman NJ, Jalali A, Grosse SD. Preterm birth lifetime costs in the United States in 2016: an update. Semin Perinatol 2021; 45 (03) 151390
• 41 Obucina M, Harris N, Fitzgerald JA. et al. The application of triple aim framework in the context of primary healthcare: a systematic literature review. Health Policy 2018; 122 (08) 900-907
• 42 Kissick WL. Medicine's Dilemmas: Infinite Needs Versus Finite Resources. New Haven, CT: Yale University Press; 1994. ISBN 0–300–05964–7.
• 43 Braithwaite J. Changing how we think about healthcare improvement. BMJ 2018; 361: k2014
• 44 Silverman WA. Restraining the unsustainable. Pediatrics 2003; 111 (03) 672-674
• 45 Berwick DM. Moral choices for today's physician. JAMA 2020; 323 (17) 1708-1709
• 46 Chua KP, Conti RM, Freed GL. Appropriately framing child health care spending a prerequisite for value improvement. JAMA 2018; 319 (11) 1087-1088
• 47 Watkins PL, Dagle JM, Bell EF, Colaizy TT. Outcomes at 18 to 22 months of corrected age for infants born at 22 to 25 weeks of gestation in a center practicing active management. J Pediatr 2020; 217: 52-58e1
• 48 Backes CH, Rivera BK, Pavlek L. et al. Proactive neonatal treatment at 22 weeks of gestation: a systematic review and meta-analysis. Am J Obstet Gynecol 2021; 224 (02) 158-174
• 49 Thurow LC. Learning to say “no”. N Engl J Med 1984; 311 (24) 1569-1572
• 50 Figueroa JF, Wadhera RK, Jha AK. Eliminating wasteful health care spending – is the United States simply spinning its wheels?. JAMA Cardiol 2020; 5 (01) 9-10
• 51 Callahan D. False Hopes: Overcoming the Obstacles to a Sustainable Affordable Medicine. New Brunswick, NJ: Rutgers University Press; 1999
• 52 Ubel PA, Rosenthal MB. Beyond nudges – when improving health calls for greater assertiveness. N Engl J Med 2019; 380 (04) 309-311
• 53 Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med 2014; 12 (06) 573-576
• 54 Nundy S, Cooper LA, Mate KS. A quintuple aim for health care improvement: a new imperative to advance health equity. JAMA 2022; 327 (06) 521-522
• 55 Djulbegovic B, Bennett CL, Guyatt G. Failure to place evidence at the centre of quality improvement remains a major barrier for advances in quality improvement. J Eval Clin Pract 2019; 25 (03) 369-372