Within a high risk stratum, the average person’s risk of experiencing the Triple Fail event will be higher than the average population risk. As a result, a higher proportion of individuals in these groups could benefit from preventive care. In other words, this stratum would have a higher positive predictive value, which in turn would increase the cost-effectiveness of the preventive intervention, all other things being equal. However, the stratified approach is beset by a number of challenges, principally those relating to the ethical aspects of risk stratification, which are described below.23
The stratified approach to the Triple Aim described in this article includes three phases. A planning phase would involve conducting an opportunity analysis, developing predictive models and impact ability (also known as intervene ability) models. The latter are models that seek to identify subgroups of high-risk people who are most likely to engage with and respond to various preventive interventions, such as case management. The planning phase would also include an ethical review to ensure its compliance with our adaptation of James Wilson and Gunner Jungner’s prerequisites, described below.
An operational phase would use the predictive models and impact ability models to identify high-opportunity patients—those who are both at risk and amenable to an intervention—and offer them preventive interventions. An ongoing feedback phase would refine the predictive models and impact ability models—for example, by prioritizing patients with characteristics similar to those of patients who responded well to the intervention.