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Negative Association of Hospital Efficiency Under Increasing Geographic Elevation on Acute Myocardial Infarction In-Patient Mortality

Devaraj, Srikant; Patel, Pankaj, C.

The Journal for Healthcare Quality (JHQ): January/February 2018 - Volume 40 - Issue 1 - p 9–18
doi: 10.1097/JHQ.0000000000000061
Original Article

Although variation in-patient outcomes based on hospitals' geographic location has been studied, altitude of hospitals above sea level may also affect patient outcomes. Possibly, because of negative physical and psychological effects of altitude on hospital employees, hospital efficiency may decline at higher altitudes. Greater focus on hospital efficiency, despite decreasing efficiency at higher altitudes, could increase demands on hospital employees and further deteriorate patient outcomes. Using data envelopment analysis on a sample of 840 hospital-year observations representing 95,504 patients with acute myocardial infarction (AMI) in the United States, and controlling for patient, hospital, and county characteristics and controlling for hospital, state, and year fixed effects, we find support for the negative association between hospital altitude and efficiency; for 1 percentage point increase in efficiency and every 1,000 feet increase in altitude above the sea level, the mortality of patients with AMI increases by 0.66 percentage points. The findings have implications for hospital performance at increasing geographic elevation and introduces to the literature the notion of “health economics of elevation,” to suggest that elevation of a hospital may be an important criterion for consideration for policy makers and insurance firms.

For more information on this article, contact Srikant Devaraj at

The authors declare no conflict of interest.

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© 2018 National Association for Healthcare Quality
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