Stratified approach helps dodge 'Triple Fail' pitfalls

As healthcare systems focus on the “Triple Aim” of improving patients’ experience of care, advancing population health and lowering per capita costs, they must beware of “Triple Fail” events, which represent a failure to meet all three goals—a risk more prevalent among certain patient groups than others, according to an article published in Health Affairs.

“New financial and quality rules are giving hospitals and accountable care organizations incentives to prevent Triple Fail events such as avoidable readmissions,” wrote Geraint Lewis, MD, MPH, of the National Health Service, London, and colleagues. “However, many such organizations are relying on population strategies to achieve these goals, including better care coordination and improvements in information technology. Ultimately, success will probably require targeting specific subpopulations as well.”

Aside from hospital readmissions, other Triple Fail events listed by the authors include untimely nursing home admissions, inappropriate initiations of hemodialysis and surgeries for low back pain in patients not offered decision support. These and other Triple Fail events are costly and result in suboptimal outcomes and patient experiences.

Using preventive care to achieve the Triple Aim has largely consisted of population and targeted strategies, explained the authors. The population strategy lowers risk within an entire population through broad initiatives, while targeted strategies focus efforts on identifying high-risk individuals and offering interventions.

Lewis and colleagues argue that a third strategy, the stratified approach, can combine the strengths of both the population and targeted strategies. “This third approach is best adopted by organizations with responsibility for a population’s health, such as accountable care organizations. It involves analyzing medical claims, pharmacy claims, electronic health record information, and other administrative data to predict individuals’ risks of different Triple Fail events. The organization would next estimate each person’s likely response to a range of preventive programs and then assign people to different interventions according to their likely benefit.”

Each stratified subpopulation would be more homogenous than the population at large, and those in a high-risk stratum would represent a group with a high cost-effectiveness for preventive interventions. Because large scale screening efforts bring their own physical and psychological risks, the authors recommend that Triple Fail events targeted for a stratified approach should represent an important health problem.

Other recommendations offered by Lewis and colleagues for promoting appropriate use of the stratified approach to the Triple Aim include:

• Use pilot programs to compare approaches;
• Reduce time lag between the occurrence of Triple Fail contributing factors and availability of data recording such occurences;
• Conduct an ethical review of the design and implementation of predictive models; and
• Expand database indicators to cover more potentially adverse events.