SAN ANTONIO REGIONAL 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) | 65 and older | 15.6% | 18 to 34 | 5.3% | 3.00 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 15.0% | 18 to 34 | 5.3% | 2.80 |
|
3.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 12.7% | 18 to 34 | 5.3% | 2.40 |
|
4.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 16.7% | Private | 7.4% | 2.30 |
|
5.
HCAI 30-Day readmission
|
Preferred Language | Spanish Language | 15.0% | English Language | 13.4% | 2.20 |
|
6.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 13.5% | Private | 7.4% | 1.80 |
|
7.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 17.0% | Asian | 9.8% | 1.70 |
|
8.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 14.2% | Asian | 9.8% | 1.50 |
|
9.
AHRQ pneumonia mortality rate
|
Age (excluding maternal measures) | 65 and older | 95.9% | 50 to 64 | 72.4% | 1.30 |
|
10.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Hispanic or Latino | 12.8% | Asian | 9.8% | 1.30 |
2. Equity Plan
Readmission has been one of our top priorities for the last year and it continues to be one for the next year as well. SARH implemented a multi - disciplinary task force. It was sponsored by our Chief Population Health Officer and Co-chaired by Chief Nursing Officer.
Nursing departments played a major role by bringing in issues and gaps that were seen on the floor, to everyone's attention.
Based on the gap analysis, our Performance Improvement team's focus in 2025 has been on improving education handed out to patients admitted for AMI, COPD, CHF , Pneumonia and Cardiac procedures.
* Pharmacy department introduced Meds - to - Beds to reduce preventable readmissions especially due to medication non - compliance.
* We have our in - house DME Closet Dispensing process which is facilitated by Case Management and the medical equipment company. CM is responsible for maintaining the par levels.
All Cause Readmissions for CY 2025 have been in the 30th percentile when compared nationwide. It is projected to improve and move upto the 50th percentile in 2026.
This has been made possible due to improvements seen in Condition Specific areas like HF, AMI and COPD.
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.