PARADISE VALLEY HOSPITAL
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 | 20.1% | 18 to 34 | 10.4% | 1.90 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 19.5% | 18 to 34 | 10.4% | 1.90 |
|
3.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 17.5% | 18 to 34 | 10.4% | 1.70 |
|
4.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 18.9% | Private | 13.5% | 1.40 |
|
5.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 18.5% | Private | 13.5% | 1.40 |
|
6.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 20.2% | Hispanic or Latino | 15.6% | 1.30 |
|
7.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 19.7% | Hispanic or Latino | 15.6% | 1.30 |
|
8.
HCAI 30-Day readmission NOBH
|
Sex Assigned at Birth | Male | 16.6% | Female | 13.4% | 1.30 |
|
9.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 19.5% | Female | 16.0% | 1.20 |
|
10.
AHRQ pneumonia mortality rate
|
Sex Assigned at Birth | Male | 121.2% | Female | 100.0% | 1.20 |
2. Equity Plan
Overview and Performance Data: The report identifies significant disparities in the HCAI All-Cause Unplanned 30-Day Hospital Readmission Rate, with a lower rate being the preferred outcome. The most notable gaps are seen across age groups, where patients aged 50 to 64 (20.1%) and 35 to 49 (19.5%) have nearly double the readmission rates compared to those aged 18 to 34 (10.4%). Older adults (65+) also show elevated rates at 17.3%. Insurance type plays a key role, with Medicare (18.9%) and Medicaid (18.5%) patients experiencing higher readmissions than those with private insurance (13.5%). These disparities suggest that age and payer type significantly influence post-discharge outcomes and may reflect differences in access to follow-up care or chronic disease burden.
Further disparities are evident in race, ethnicity, and gender. White (20.2%) and Black/African American (19.7%) patients have higher readmission rates compared to Hispanic/Latino patients (15.6%). Additionally, males show consistently higher readmission rates than females, both overall (19.3% vs 15.9%) and among those without behavioral health diagnoses (16.6% vs 13.4%). These findings highlight the need for targeted quality improvement initiatives to address systemic inequities and improve care transitions, particularly for older adults, publicly insured patients, and specific racial and gender groups. By addressing these disparities, Paradise Valley Hospital can enhance patient outcomes and reduce avoidable readmissions.
Based on the Agency for Healthcare Research and Quality (AHRQ) Quality Indicator Pneumonia mortality rates are higher for male with a disparity rate 121.2 compared to female reference group. Pneumonia mortality rate is higher in the age group of 65yrs plus.
Program and Practices:
Pneumonia vaccination screening program specifically for the age group of 65yrs plus at the time of admission
Emphasize the patients over the age group of 65yrs to receive the pneumonia vaccine
Educate the patient to use the incentive Spirometer to increase the lungs tidal volume, prevent mucus build up and pneumonia
Educate the patient and family to modify the lifestyle and habits like smoking cessation to prevent the risk of pneumonia
Social worker consultation for smoking cessation for the patient have the habit of smoking
Free classes for community through center for health promotion: free exercise classes, mall walk program
Pneumonia vaccine offered to the age group of 65yrs and above
Monitoring of the use of VAP bundle for the patients in Ventilator
Appropriate airway and ventilator management in the patients in ICU to prevent ventilator associate pneumonia 9VAP)
Physicians review the pneumonia mortality cases associated with sepsis, severity of illness (SOI) AND Risk of mortality (ROM) cases
Initiate the code sepsis protocol to identify the sepsis cases early and provide 3hours,6hours bundle to prevent severe sepsis and septic shock
Respiratory Therapy team review and consulted with pulmonologists to initiate respiratory treatment for pneumonia patients
Measurable Objectives:
- Reduce 10% of patient pneumonia mortality rate compared to 2025 by Q4 FY2026.
Timeframe:
- All initiatives are underway or launching in Q1 FY2026, with quarterly evaluations and full implementation by Q4 FY2026.
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.