WEST ANAHEIM 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.
AHRQ pneumonia mortality rate
|
Race and/or Ethnicity | Asian | 144.6% | White | 48.2% | 3.00 |
|
2.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 18.6% | Private | 8.7% | 2.20 |
|
3.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 15.5% | Private | 8.7% | 1.80 |
|
4.
AHRQ pneumonia mortality rate
|
Race and/or Ethnicity | Asian | 144.6% | White | 48.2% | 1.70 |
|
5.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 17.6% | 18 to 34 | 11.4% | 1.50 |
|
6.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 17.2% | 18 to 34 | 11.4% | 1.50 |
|
7.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 16.3% | 18 to 34 | 11.4% | 1.40 |
|
8.
AHRQ pneumonia mortality rate
|
Sex Assigned at Birth | Male | 98.4% | Female | 69.8% | 1.40 |
|
9.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 20.4% | Hispanic or Latino | 14.7% | 1.40 |
|
10.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 17.6% | Hispanic or Latino | 14.7% | 1.20 |
2. Equity Plan
West Anaheim Medical Center is committed to delivering high-quality, cost-effective, and patient-centered healthcare with compassion, dignity, and respect for every patient and family. A key priority is addressing disparities in all-cause unplanned 30-day hospital readmissions and 30-day pneumonia mortality
Identified Disparities
Analysis of outcomes demonstrates significant variation in readmissions and mortality by age, gender, race, and payor type
Key findings include
Race/Ethnicity
Asian patients experience 144.6% higher pneumonia mortality compared to White patients (48.2%)
Hispanic patients have 83.3% higher pneumonia mortality compared to White patients (48.2%)
African American patients have 18.5% higher 30-day unplanned readmissions compared to Hispanic patients (1.5%)
White patients have 15.2% higher 30-day unplanned readmissions compared to Hispanic patients (12.4%)
Payor Type
Medicare patients (15.8%) and Medi-Cal patients (13.6%) have higher 30-day unplanned readmissions compared to private insurance (7.6% and 1.8%, respectively)
Age & Gender
Patients aged 50 to 64 years have 15.2% higher 30-day unplanned readmissions compared to patients aged 18 to 34 years (10.7%)
Male patients demonstrate 98.4% higher pneumonia mortality compared to female patients (69.8%)
Patients greater than or equal to 65 years have 14.6% higher 30-day unplanned readmissions compared to those aged 18 to 34 years (10.7%)
Patients aged 35 to 49 years show 13.4% higher 30-day unplanned readmissions compared to those aged 18 to 34 years (10.7%)
Facility Objectives
1.Reduce Unplanned Readmissions
Achieve a 10% reduction in all-cause unplanned 30-day hospital readmissions for each disparity group within 12 months
2.Strengthen Post-Discharge Support
Conduct targeted post-discharge phone calls for patients with pneumonia or pneumonia as a secondary diagnosis
Sample at least 10% of pneumonia discharges for follow-up by the case management team
Assess continuity of care, including appointments, medications, durable medical equipment, home health, and other post-discharge needs
3.Enhance Case Management Oversight
Hold weekly interdisciplinary case management meetings (case managers, clinical directors, providers) to review patients meeting disparity criteria
Identify barriers to care and close gaps by linking patients to community resources and support services
4.Mortality Review and Quality Oversight
Perform 100% retrospective review of pneumonia inpatient mortality cases to identify clinical and social determinants influencing outcomes
Reviews will be conducted by the quality management department and physician reviewers
Findings and improvement opportunities will be discussed with case management and social services teams
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.