Multilevel Examination of Hospital Participation in the Healthcare Equality Index (HEI): The Role of Geographic Location and State Health Care Policies

The Healthcare Equality Index (HEI) evaluates compliance with LGBTQ+ (lesbian, gay, bisexual, transgender, queer or questioning, and other sexual and gender diverse individuals) inclusion in U.S. health care facilities and is associated with greater patient satisfaction. We examined how hospitals' metropolitan location and state-level LGBTQ+ health care policies are associated with voluntary HEI participation and performance. This cross-sectional study analyzed 6,120 U.S. hospitals from the 2022 American Hospital Association Annual Survey. Multilevel logistic regression assessed the relationship and varying impact of metropolitan status and state policies on HEI participation and HEI Leader status (highest performance). State policies had a stronger positive association with nonmetropolitan hospitals. Each additional policy increased HEI participation odds by 58% for nonmetropolitan hospitals (adjusted odds ratio [aOR] = 1.58; 95% confidence interval [CI] = 1.19, 2.10) and 21% for metropolitan hospitals (aOR = 1.21; 95% CI = 1.02, 1.43). No significant associations with HEI Leader status were observed. Strengthening LGBTQ+ inclusive state policies may encourage hospitals, particularly in nonmetropolitan areas, to adopt LGBTQ+ inclusion initiatives.