CEDARS-SINAI MEDICAL CENTER

1. Top 10 Disparities

2. Equity Plan

HCAI All-Cause Unplanned 30-Day Hospital Readmission Rate
Preventing unplanned 30-day readmissions remains a strategic priority at Cedars-Sinai. Using stratified data, we routinely examine select readmission trends by stratified demographics to better understand population needs and guide targeted improvement efforts. Analysis from the HCAI Annual Health Equity Report highlighted higher 30-day readmission rates among (i) Medicare patients, (ii) Medicaid patients, (iii) adults ages 50—64, (iv) adults age 65+, (v) Black patients, (vi)Spanish language patients.

Our internal review points to several overlapping factors. Older adults face higher readmission risk due to greater clinical complexity. Readmission rate of Spanish speakers was also influenced by rates that increased with age. Within Medicare, our outcomes are disproportionately influenced by patients who are dual-eligible (Medicare + Medicaid) and have higher medical complexity and high socioeconomic barriers that complicate recovery. Differences observed among Black patients in the HCAI analysis are consistent with the impact of these same socioeconomic and structural factors independent of race itself.

To address these realities, Cedars-Sinai has strengthened care coordination and expanded supports that address medical and social needs. Key strategies include extended ambulatory case management, post-discharge pharmacist consultation, nursing home partnerships and community health workers navigation, with an emphasis on providing Spanish language concordance, where possible. Collectively, these initiatives have improved continuity of care and have resulted in the significant improvements observed over the past several years across all demographic categories.

In the upcoming year, our efforts will focus on further identification of factors associated with higher readmissions, with a particular focus on meeting linguistic and social needs. We will use our newly constructed dashboard to monitor performance and, guided by in-depth data analysis and root-cause assessment, expand how we integrate social, linguistic, and socioeconomic needs into care.


Agency for Healthcare Research and Quality (AHRQ) Quality Indicator Pneumonia Mortality Rate
Cedars-Sinai employs a systematic, data-driven approach to monitor, analyze and improve outcomes through continuous quality assessment and evidence-based interventions. Comprehensive mortality reviews are conducted as part of an ongoing commitment to delivering high-quality, safe and equitable care in alignment with HCAI and AHRQ quality indicators.
To address identification of differences in pneumonia-related mortality rates, efforts have been initiated to explore nosocomial aspiration pneumonia rates, as well as deepen our mortality reviews with a series of targeted next steps:
• Transitioning from a department-specific review to structured, multidisciplinary Mortality Review Team, aligning with best practices.
• Utilization of a four-phase mortality review toolkit to provide a structured framework for assessing contributing factors, identification of opportunities and implementation of corrective actions.
• Mobilization of a multidisciplinary team tasked with a clearly identified goal of conducting a gap analysis comparing current state practices to evidence-based best practices for reduction of nosocomial aspiration pneumonia, which will inform the development and implementation of targeted interventions by the end of the fiscal year.

AHRQ Patient Safety Indicator Death Rate among Surgical Inpatients with Serious Treatable Complications
Mortality data are systematically analyzed at Cedars-Sinai to identify patterns, trends and key drivers of patient outcomes. Through this approach, differences were identified within two distinct demographic groups—patients identifying as Asian and Medicare insurance. Further disaggregation of data revealed differences within the dual eligible population, providing visibility into unique risk profiles and care challenges.

To address disparate outcomes and death rates within the identified populations, a range of strategies have been implemented to both optimize processes and analyze data to better understand variability in outcomes among different groups, including the following:
• Implementation of a surgical outcomes dashboard with health equity stratification
• Incorporating Social Determinants of Health data into analyses of dual eligible patient populations
• Integrating standardized health equity stratification into root cause analyses to reveal populations that are disproportionately affected and to inform targeted interventions.

This integrated approach, combining demographic and social analyses with data-informed, team-based interventions, yielded measurable improvement in observed mortality rates within the Asian population—a 39% decrease from 2024 to 2025.

3. Structural Measures

4. Web Address for Equity Report

https://www.cedars-sinai.org

5. Download Equity Measures Report

Click on the link below to download the equity measures report.

6. Looking for Related Reports?

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