An investigation of air pollution-induced temperature sensitivity and susceptibility to heat-related hospitalization in the Medicare population

Background: With rising temperatures and an aging US population, understanding how to prevent heat-related illness among older Americans will be an increasingly critical objective. Despite biological plausibility, no study to date has investigated how exposure to fine particulate matter air pollution (PM$_{2.5}$) may contribute to risk of heat-related hospitalization. Methods: We identified Medicare fee-for-service beneficiaries who experienced a heat-related hospitalization between 2008 and 2016. Using a case-crossover design and fitting Bayesian conditional logistic regression models, we characterized the association between heat-related hospitalization and temperature and PM$_{2.5}$ exposures. We estimated the relative excess risk due to interaction (RERI) to quantify the additive-scale interaction of simultaneous exposure to heat and PM$_{2.5}$. Results: We observed 112,969 heat-related hospitalizations. Fixing PM$_{2.5}$ at the case day median, increasing temperature from its case day median to the 95th percentile was associated with an odds ratio of 1.045 (95% CI: 1.026, 1.063). Fixing temperature at the case day median and increasing PM$_{2.5}$ from its median to the 95th percentile was associated with an odds ratio of 1.014 (95% CI: 0.993, 1.037). We estimated the RERI associated with simultaneous median-to-95th percentile increases in temperature and PM$_{2.5}$ to be 0.032 (0.007, 0.057). Conclusion: Using nationwide Medicare claims and a self-matched study design, we found evidence supporting synergism between temperature and PM$_{2.5}$ exposures on the risk of heat-related hospitalization.