Applying the Triple Aim to the Quality Agenda for Anticoagulation Care

T he Institute for Healthcare Improvement’s Triple Aim Framework has been gaining ground since its launch in 2008 as an innovative vision for health system reform. The framework articulates a set of goals in which health system costs and healthcare quality must be balanced against the needs of the population and improved health outcomes for all. Since its inception, this balanced approach to health and healthcare has been a source of debate, striking a nerve amongst healthcare leaders, clinicians providing care, and the patients whose healthcare needs must be met. Is it truly feasible to reduce costs while improving the patient care experience? Can we move away from the deeply ingrained biomedical model to an evolved one that espouses the principles of population health and health equity? Since 2008, a groundswell of health organizations in the United States and Canada have been taking up the vision of the Triple Aim with increasing momentum. To provide guidance to organizations pursing the balanced Triple Aim approach, Berwick et al identified three preconditions for success. First, Berwick et al called upon the need for the “existence of an ‘integrator’, able to focus and coordinate services to help the population on all three dimensions at once.” A successful integrator is positioned within the healthcare system to help make connections between communities and their community resources, between patients and their providers of care, and amongst insular health organizations to ensure a successful continuum of care. Second, the population of concern must be defined. As Berwick et al pointed out, “a population need not be geographic” ; instead a population or subpopulation is often best defined as a group of individuals with a specific set of needs that must be addressed in order to provide the highest quality care. Third, Berwick et al suggested that budget constraints and clear policy levers must be identified that insist upon principles of health equity. It is the fundamental goal of equity that becomes a lens for understanding quality and access to care to ensure the optimal patient experience. Over the last decade, these three Triple Aim preconditions— the role of the successful integrator, the defined population, and equitable care—have been examined in the anticoagulation therapy and management research. The literature, however, remains somewhat unbalanced in favor of the first two preconditions while leaving the issue of equity relatively unexplored. A considerable body of research has focused on optimal ‘integrative’ models for oral anticoagulant management, by exploring cost effectiveness, quality of care, and patient outcomes for anticoagulation services in physician offices, in dedicated anticoagulation clinics, and in patient self management. A second stream of research has focused on defining the appropriate patient population for oral anticoagulation therapy based on specific clinical needs. This research has demonstrated that oral anticoagulants are highly efficacious for patients with conditions such as valvular heart disease, atrial fibrillation, and venous thrombo-embolism. The final Triple Aim precondition that is grounded in equitable care for all, however, remains the least well studied. In order to achieve a balance in the anticoagulationmanagement literature that supports all three preconditions for the Triple Aim, a further examination of equity in access and quality of care is required. In this issue of JAHA, Rodriguez and colleagues provide an important contribution to the equity and quality literature by examining potential disparities in care amongst limited English proficient patients at an Anticoagulant Management Clinic at the Massachusetts General Hospital from 2009 to 2010. Given that approximately 20% of the US population now speaks a language other than English at home, and the fact that limited English proficiency has been associated with poor anticoagulation control, the issue of language barriers and their contribution to inequitable anticoagulantmanagement is increasingly important. Warfarin, a commonly prescribed anticoagulant, has a narrow therapeutic range that requires careful monitoring and management. Poor medication management can have particularly dire consequences if anticoagulant complications The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association. From the Department of Population Health, University of Ottawa, Ottawa, Ontario, Canada; and the Canadian Institute for Health Information, Ottawa, Ontario, Canada. Correspondence to: Deborah Cohen, MA, PhD Candidate, 35 Soho Crescent, Ottawa, ON, Canada. E-mail: [email protected] J Am Heart Assoc. 2013;2:e000377 doi: 10.1161/JAHA.113.000377. a 2013 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell. This is an Open Access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.