PDF icon Download PDF
Am J Perinatol 2024; 41(S 01): e1172-e1182
DOI: 10.1055/a-2001-8844
Original Article

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

Joseph W. Kaempf
1   Providence St. Vincent Medical Center, Women and Children's Services, Medical Data and Research Center, Portland, Oregon
,
Lian Wang
1   Providence St. Vincent Medical Center, Women and Children's Services, Medical Data and Research Center, Portland, Oregon
,
Michael Dunn
2   Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
› Author Affiliations
Funding The manuscript preparation was supported by Women and Children's Services, Providence Health System, Portland, OR, as part of Joseph W. Kaempf's role as Medical Director of Value, Research, and Innovation. Providence Health System had no role in the design and conduct of the study, collection, analysis, interpretation of the data, preparation of the manuscript, nor the decision to submit the manuscript for publication.
› Further Information
Also available ateRefHebammen
   Permissions and Reprints
Preview

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

  • 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.


Supplementary Material



Publication History

Received: 20 June 2022

Accepted: 12 December 2022

Accepted Manuscript online:
20 December 2022

Article published online:
01 February 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA