UCI HEALTH-LOS ALAMITOS
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
|
Expected Payor | Medicaid | 15.5% | Private | 7.7% | 2.00 |
|
2.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 12.3% | Private | 7.7% | 1.60 |
|
3.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Native Hawaiian or Pacific Islander | 17.1% | White | 11.6% | 1.50 |
|
4.
HCAI 30-Day readmission NOBH
|
Sex Assigned at Birth | Male | 13.3% | Female | 9.1% | 1.50 |
|
5.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 12.3% | 35 to 49 | 8.8% | 1.40 |
|
6.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 13.7% | Female | 10.0% | 1.40 |
|
7.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 18 to 34 | 11.9% | 35 to 49 | 8.8% | 1.40 |
|
8.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 11.9% | 35 to 49 | 8.8% | 1.40 |
|
9.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 13.8% | White | 11.6% | 1.20 |
|
10.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Asian | 13.3% | White | 11.6% | 1.20 |
2. Equity Plan
We have identified the top disparities using a rate ratio methodology in which the value illustrates how much higher the rates are for a given patient population stratification in comparison to another. For instance, a rate ratio of 1.5 would indicate that the former comparison group is 50% more likely to have the specified event when compared to the latter.
We recognize important limitations in the current method of identifying disparities. The performance metrics are not risk-adjusted, meaning they do not account for expected variation by age or other clinical factors. Because younger patients generally experience fewer complications and hospitalizations, observed differences in readmission rates by age group likely reflect, in part, underlying differences in patient risk profiles rather than inequitable care. Consequently, it is not unexpected that there are disparities involving higher readmission rates among older age groups compared to younger patients.
Disparity: Readmission rates for Medicaid vs Private (1) and Medicare vs Private (2) payors demonstrated by a rate ratio of 1.9 and 1.7, respectively.
Disparity: Readmission rates for Native Hawaiian or Pacific Islander vs Hispanic or Latino (3) and Black or African American vs Hispanic or Latino (4) patients demonstrated by a rate ratio of 1.5 and 1.2, respectively.
Disparity: Readmission rates between ages 18 to 34 vs 35-49 (5), 65+ vs 35-49 (6), and 50-64 vs 35-49 (7) age ranges which all have rate ratios of 1.4.
Disparity: Readmission rates when filtered to behavioral health diagnosis of ' No Behavioral Health Diagnosis ' show a rate ratio of 1.4 for Male vs Female (8) when stratified by Sex Assigned at Birth. And a readmission rate ratio of 1.3 for Male vs Female (9) when stratified by Sex Assigned at Birth.
Disparity: Pneumonia mortality rate ratio of 1.2 for Female vs Male (10) when stratified by Sex Assigned at Birth.
Action plan: The Quality Department conducts reviews of hospital readmissions to assess appropriateness of care and identify any provider management concerns. Cases requiring further evaluation are referred to Peer Review. In addition, readmission data are regularly shared with the Quality Council to support multidisciplinary collaboration and identify opportunities for improvement.
Moving forward, a dedicated workgroup representing multiple disciplines will be established to conduct a deeper analysis of readmission data, identify disparities, and develop targeted strategies with measurable countermeasures. This may include evaluating discharge planning processes through a health literacy lens to ensure patient education materials and discharge instructions are accessible and culturally responsive.
In order to address the disparity regarding mortality, we will perform a comprehensive analysis of practices to uncover contributing factors. This analysis will include stratification by race, sex, ethnicity, age, language, socioeconomic factors and other demographic characteristics. We will also consider developing process maps to better understand workflows.
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.