CEDARS-SINAI

CEDARS-SINAI HEALTH SYSTEM

Reporting Organization
CEDARS-SINAI HEALTH SYSTEM
Report Period
01/01/2024 – 12/31/2024
Hospital / Hospital System
Hospital System
Report Type
General Acute Care Hospital

Hospitals

Hospital Count: 3

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 NOBH
Expected Payor Medicare 14.5% Other 4.0% 3.70
2. HCAI 30-Day readmission
Expected Payor Medicare 15.0% Other 5.2% 2.90
3. CMQCC breast milk feeding
Preferred Language Spanish Language 25.0% Other/Unknown 65.4% 2.60
4. HCAI 30-Day readmission NOBH
Expected Payor Medicaid 10.2% Other 4.0% 2.60
5. AHRQ PSI surgical death rate
Race and/or Ethnicity Asian 175.8% Black or African American 138.7% 2.50
6. HCAI 30-Day readmission
Expected Payor Medicaid 12.7% Other 5.2% 2.50
7. HCAI 30-Day readmission NOBH
Age (excluding maternal measures) 65 and older 13.5% 18 to 34 6.1% 2.20
8. AHRQ PSI surgical death rate
Race and/or Ethnicity White 148.8% Black or African American 138.7% 2.10
9. AHRQ PSI surgical death rate
Expected Payor Medicaid 144.0% Private 94.0% 2.10
10. AHRQ PSI surgical death rate
Race and/or Ethnicity Hispanic or Latino 138.9% Black or African American 138.7% 2.00

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2. Equity Plan

HCAI All-Cause Unplanned 30-Day Hospital Readmission Rate, stratified by behavioral health diagnosis (No Behavioral Health Diagnosis) & HCAI All-Cause Unplanned 30-Day Hospital Readmission Rate
Reducing readmissions begins with strengthening transitions of care across ED and inpatient settings. Because most unplanned readmissions enter through the ED, efforts emphasize early identification of high-risk patients, enhanced case management, improved discharge planning, and stronger coordination with skilled nursing facilities. Inpatient strategies include ensuring access to a 30-day supply of medications, scheduling follow-up within 7 days, refining discharge planning to address transitional needs, expanding disease-specific education, and linking Medicaid members to their Managed Care Plans for ECM and community supports. Stratified data show higher readmission rates among Medicare and Medicaid patients and adults ages 50—64 and 65+, largely due to clinical complexity and socioeconomic barriers. In response, Cedars-Sinai Health System (CSHS) expanded ambulatory case management for up to 90 days, initiated pharmacist follow-up consultations, increased use of "Transition Home" clinic visits, integrated Community Health Workers, and strengthened SNF partnerships. These approaches have improved continuity, reduced preventable readmissions, and enhanced recovery. CSHS will continue refining strategies to better address clinical, social, and navigation needs.
AHRQ PSI Death Rate among Surgical Inpatients with Serious Treatable Complications
Reducing surgical mortality requires a coordinated, equity-focused strategy centered on older adults and Medicare-covered patients, who experience higher risk due to age, functional status, and comorbidity. CSHS conducts structured, multidisciplinary mortality reviews to identify patterns, drivers of variation, and opportunities to strengthen reliability. Systemwide improvements include creation of a surgical outcomes dashboard integrating demographics with postoperative measures (mortality, LOS index, readmissions, ICU use, return to OR), incorporation of SDoH into reviews, and use of standardized equity stratification when feasible. Culturally responsive education and enhanced nursing training further support earlier detection of deterioration and timely escalation. Huntington Health launched a multi-year mortality-reduction plan (January 2025–June 2026) focused on older adults and Medicare patients. Key interventions include improving diagnostic accuracy and follow-up for pneumonia patients, activating a comprehensive ED "Code Sepsis" protocol with continuous monitoring, and expanding community outreach for older adults and caregivers.

CMQCC Exclusive Breast Milk Feeding
Exclusive breastfeeding is a key determinant of infant health, reducing infections, chronic disease, and readmissions. Systemwide analyses identified lower exclusive breastfeeding rates among Spanish-speaking patients, highlighting disparities related to language access and context. To strengthen equitable breastfeeding support, CSHS expanded multilingual, responsive interventions. Inpatient actions include identifying disparities by race/ethnicity and language, comparing intended feeding goals with discharge outcomes, providing stratified data to prenatal providers, supporting skin-to-skin and early breastfeeding after cesarean births, and reviewing outcomes by pediatric provider. Outpatient strategies include examining disparities in attendance at no-cost antenatal breastfeeding classes, expanding lactation educators from communities experiencing lower rates, increasing Spanish and Mandarin offerings, and sharing stratified data with outpatient pediatric practices. These actions aim to ensure all families receive accessible, individualized feeding support.
California Maternal Quality Care Collaborative NTSV Cesarean Birth Rate
Reducing NTSV cesarean births is a systemwide quality and equity priority, as lower rates improve maternal outcomes and reduce future risks. Evidence shows higher cesarean rates among patients with limited English proficiency and historically marginalized groups. CSHS applies standardized labor guidelines, continuous labor support, shared decision-making, and early recognition of labor dystocia. A key innovation is reporting nurse-specific cesarean rates, launched in 2020, which strengthened accountability and contributed to improvement from 25.7% to 22.0%. Equity-focused strategies include stratifying NTSV rates by demographic factors, standardizing patient education about labor expectations, expanding culturally aligned doula support, strengthening escalation processes for prolonged labor, and integrating NTSV metrics into unit-level dashboards. These efforts advance safe, equitable maternity care and reduce preventable primary cesarean deliveries.

3. Web Address for Equity Report

https://www.cedars-sinai.org

4. Download Equity Measures Report

Click on the link below to download the equity measures report.

Hospital Equity Measures Report Download

Click on the link below to download all equity measures reports.