ANTELOPE VALLEY MEDICAL CENTER
1. Top 10 Disparities
The following table lists the ten largest health equity disparities identified for this reporting period.
Disparities for each hospital equity measure are identified by comparing the rate ratios by stratification groups. Rate ratios are calculated differently for measures with preferred low rates and those with preferred high rates. Rate ratios are calculated after applying the California Health and Human Services Agency's "Data De-Identification Guidelines (DDG)," dated September 23, 2016.
The table below highlights the ten widest health equity disparities identified by hospitals and hospital systems during this reporting period. Measure names have been shortened for display purposes. To view each measure in full, please download the complete Hospital Equity Report using the link below.
| Measure | Stratification | Stratification Group | Stratification Group Rate | Reference Group | Reference Rate | Rate Ratio |
|---|---|---|---|---|---|---|
|
1.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 16.0% | 18 to 34 | 4.7% | 3.40 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 15.2% | 18 to 34 | 4.7% | 3.20 |
|
3.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 16.7% | Private | 6.0% | 2.80 |
|
4.
AHRQ pneumonia mortality rate
|
Race and/or Ethnicity | White | 124.1% | Black or African American | 100.6% | 2.50 |
|
5.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 14.3% | Asian | 6.1% | 2.30 |
|
6.
AHRQ pneumonia mortality rate
|
Race and/or Ethnicity | Hispanic or Latino | 116.4% | Black or African American | 100.6% | 2.30 |
|
7.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 13.5% | Asian | 6.1% | 2.20 |
|
8.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Multiracial and/or Multiethnic (two or more races) | 13.2% | Asian | 6.1% | 2.00 |
|
9.
AHRQ pneumonia mortality rate
|
Expected Payor | Medicare | 144.6% | Medicaid | 72.2% | 2.00 |
|
10.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 9.2% | 18 to 34 | 4.7% | 1.90 |
2. Equity Plan
1. Targeted Readmission Reduction Strategies
Disparities in 30-day readmission rates by age, race/ethnicity, and payer type suggest a need for:
Enhanced discharge planning and follow-up for older adults and Medicare patients.
Culturally responsive care coordination for racial/ethnic groups with higher readmission rates.
Increased access to outpatient support and transitional care services.
2. Improve Pneumonia Outcomes
Higher pneumonia mortality rates among White and Hispanic patients and Medicare recipients indicate:
Review and standardize pneumonia treatment protocols across all demographics.
Strengthen early detection and intervention strategies.
Provide staff training on implicit bias and culturally competent care.
3. Data-Driven Quality Improvement
Use stratified data to monitor progress and refine interventions.
Engage multidisciplinary teams to analyze root causes of disparities.
Incorporate patient feedback to guide improvements.
4. Community Engagement and Education
Partner with community organizations to address social determinants of health.
Provide education on chronic disease management, especially for high-risk populations.
Expand outreach to underserved groups to improve access and trust.
5. Staff Training and Accountability
Train staff on equity-focused care practices.
Ensure accountability through performance metrics tied to disparity reduction.
3. Structural Measures
| Centers for Medicare & Medicaid Services (CMS) Hospital Commitment to Health Equity Structural (HCHE) Measure | Yes/No |
|---|---|
Our hospital system strategic plan identifies priority populations who currently experience health disparities |
Yes |
Our hospital system strategic plan identifies healthcare equity goals and discrete action steps to achieve these goals |
Yes |
Our hospital system strategic plan outlines specific resources that have been dedicated to achieving our equity goals |
Yes |
Our hospital system strategic plan describes our approach for engaging key stakeholders, such as community-based organizations |
Yes |
Our hospital strategic plan identifies healthcare equity goals and discrete action steps to achieve these goals |
Yes |
Our hospital system has training for staff in culturally sensitive collection of demographics and/or social determinant of health information |
Yes |
Our hospital system inputs demographic and/or social determinant of health information collected from patients into structured, interoperable data elements using a certified EHR technology |
Yes |
Our hospital system stratifies key performance indicators by demographic and/or social determinants of health variables to identify equity gaps and includes this information in hospital performance dashboards |
Yes |
Our hospital system participates in local, regional or national quality improvement activities focused on reducing health disparities |
Yes |
Our hospital system senior leadership, including chief executives and the entire hospital board of trustees, annually reviews our strategic plan for achieving health equity |
Yes |
Our hospital system senior leadership, including chief executives and the entire hospital board of trustees, annually reviews key performance indicators stratified by demographic and/or social factors |
Yes |
5. Download Equity Measures Report
Click on the link below to download the equity measures report.
Click on the link below to download all equity measures reports.