LOS ANGELES COUNTY OLIVE VIEW-UCLA 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 | 18.2% | 18 to 34 | 10.1% | 1.80 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 17.5% | 18 to 34 | 10.1% | 1.70 |
|
3.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 16.4% | 18 to 34 | 10.1% | 1.60 |
|
4.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 19.2% | Private | 12.2% | 1.60 |
|
5.
HCAI 30-Day readmission NOBH
|
Sex Assigned at Birth | Male | 15.2% | Female | 11.4% | 1.30 |
|
6.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 15.8% | Private | 12.2% | 1.30 |
|
7.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 18.6% | Hispanic or Latino | 15.9% | 1.20 |
|
8.
CMQCC breast milk feeding
|
Age (for maternal measures only) | 30 to 39 | 55.5% | 18 to 29 | 64.0% | 1.20 |
|
9.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 18.6% | Hispanic or Latino | 15.9% | 1.10 |
|
10.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Asian | 16.8% | Hispanic or Latino | 15.9% | 1.00 |
2. Equity Plan
Of the top 10 disparities we identified in our preliminary report, 9 are readmissions disparities and 4 are linked directly with age. Older patients are more likely to be readmitted compared to the 18-34 age group. Although we never expect the readmission rate of our geriatric populations to be equal to that of our 18-34 group, in 2026 we are working towards becoming an age-friendly hospital, which involves multiple interventions in the IHI "5Ms" framework to improve care for older adults, including improving the medication reconciliation process, documenting goals of care and ensuring discharge instructions and follow up plans are clear. As we implement these interventions, we plan to measure numerous quality markers including 7 and 30-day readmissions to see if our rates decline.
When we break readmissions along race and ethnicity lines, we see that Asian, White and Black patients are all more likely to be readmitted compared to Hispanic or Latino patients. We plan to do additional investigation about why this disparity exists. In the past, we have found that because the majority of our admitted patients identify as Latino, rates of various quality measures in other groups have significant variation due to a small sample size. By performing a qualitative review of the reasons for readmission in these minority groups we hope to gain some insight about the root causes of these higher readmission rates.
Finally, there is a disparity in readmissions between Medicaid patients and patients with private insurance. As a patient-centered medical home that primarily serves patients on Medicaid, we know that our patients face numerous social drivers of health that can lead to readmission. We also know that privately insured patients are less likely to return to our hospital after an incident admission, since they are not typically a part of our health system, so their readmissions may simply not be captured in our data. We already have numerous programs dedicated to preventing readmission in our Medicaid patients, including: the Next Day and Urgent Care clinics which provide same day access to patients with urgent needs after discharge, a transition-of-care pharmacist that reviews high complexity patients to the discharge medication plan is followed, same-week access to the patient's own primary care physician and RN care managers that follow patients with multiple hospitalizations. We will continue to improve these programs to address this disparity.
The only disparity identified in our top 10 outside of the readmissions rates was the exclusive breast milk feeding measure, which was lower in patients in the 30-39 year old range compared to patients in the 18-29 year old range. Again, this may be due to relatively small numbers of patients in each of these groups, but in 2026 we plan to trend this data carefully and work with our award-winning Obstetrics and Lactation team to ensure patients have access to the support they need to breastfeed when possible.
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.