Modifiers of the temperature and mortality association in seven US cities

This paper examines effect modification of heat- and cold-related mortality in seven US cities in 1986-1993. City-specific Poisson regression analyses of daily noninjury mortality were fit with predictors of mean daily apparent temperature (a construct reflecting physiologic effects of temperature and humidity), time, barometric pressure, day of the week, and particulate matter less than 10 mum in aerodynamic diameter. Percentage change in mortality was calculated at 29degreesC apparent temperature (lag 0) and at -5degreesC (mean of lags 1, 2, and 3) relative to 15degreesC. Separate models were fit to death counts stratified by age, race, gender, education, and place of death. Effect estimates were combined across cities, treating city as a random effect. Deaths among Blacks compared with Whites, deaths among the less educated, and deaths outside a hospital were more strongly associated with hot and cold temperatures, but gender made no difference. Stronger cold associations were found for those less than age 65 years, but heat effects did not vary by age. The strongest effect modifier was place of death for heat, with out-of-hospital effects more than five times greater than in-hospital deaths, supporting the biologic plausibility of the associations. Place of death, race, and educational attainment indicate vulnerability to temperature-related mortality, reflecting inequities in health impacts related to climate change.