Does choice of outdoor heat metric affect heat-related epidemiologic analyses in the US Medicare population?

Outdoor air temperature is associated with increased morbidity and mortality. Other thermal indices theoretically confer greater physiological relevance by incorporating additional meteorological variables. However, the optimal metric for predicting excess deaths or hospitalizations owing to extreme heat among US Medicare beneficiaries remains unknown.

Methods: We calculated daily maximum, minimum, and mean outdoor air temperature (T), heat index (HI), wet-bulb globe temperature (WBGT), and Universal Thermal Climate Index (UTCI) for populous US counties and linked estimates with daily all-cause mortality and heat-related hospitalizations among Medicare beneficiaries (2006-2016). We fit distributed-lag nonlinear models for each metric and compared relative risks (RRs) at the 99th percentile.

Results: Across all heat metrics, extreme heat was statistically significantly associated with elevated risks of morbidity and mortality. Associations were more pronounced for maximum daily values versus the corresponding minimum for the same metric. The starkest example was between HI_max (RR = 1.14; 95% confidence interval [CI] = 1.12, 1.15) and HI_min (RR = 1.10; 95% CI = 1.09, 1.11) for hospitalizations. When comparing RRs across heat metrics, we found no statistically significant differences within the minimum and maximum heat values (i.e., no significant differences between T_max/HI_max/WBGT_max/UTCI_max or between T_min/HI_min/WBGT_min/UTCI_min). We found similar relationships across the National Climate Assessment regions.

Conclusion: Among Medicare beneficiaries in populous US counties, daily maximum and mean values of outdoor heat are associated with greater RRs of heat-related morbidity and all-cause mortality versus minimum values of the same metric. The choice of heat metric (e.g., temperature versus HI) does not appear to substantively affect risk calculations in this population.