COLLEGE HOSPITAL COSTA MESA
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) | 50 to 64 | 19.3% | 35 to 49 | 12.1% | 1.60 |
|
2.
HCAI 30-Day readmission
|
Expected Payor | Private | 19.2% | Medicaid | 13.0% | 1.50 |
|
3.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 14.7% | Hispanic or Latino | 13.3% | 1.10 |
|
4.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Female | 14.7% | Male | 13.7% | 1.10 |
2. Equity Plan
College Hospital Costa Mesa's Equity Report identified four key disparities related to 30-day hospital-wide all-cause unplanned readmissions, including higher rates among patients aged 50–64, those with private insurance, White patients, and female patients. To address these disparities, we will continue to implement individualized treatment plans that have been shown to benefit our patient population and enhance discharge planning tailored to each patient's needs. This includes evaluating legal holds when applicable and ensuring patients receive appropriate prescriptions at discharge to support medication adherence, which can reduce readmissions. Risk Management will track and report readmission data by these disparity groups to the Patient Safety and Quality Committees and other medical staff meetings to ensure group dynamic discussions and transparency. Our measurable objective for 2026 is to reduce 30-day unplanned readmissions by identifying at-risk patients, strengthening discharge support, and monitoring outcomes through stratified reporting to ensure equity-focused improvements.
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 |
4. Web Address for Equity Report
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.