Impact of extreme temperatures on emergency hospital admissions by age and socio-economic deprivation in England

Extreme Heat, Functional Disability, and Social Isolation: Risk Disparity Among Older Adults

This study examines how functional disability worsens among older adults exposed to extreme heat, particularly those socially isolated. Analyzing data from over 35,000 older adults aged 50 or older from the Health and Retirement Study from 1996-2018, this study found that more frequent exposure to extreme heat is associated with an increase in the number of instrumental activities of daily living (IADL) that older adults find difficulty in performing over time. This heat-related disability progression is greater among those living alone and not working. However, findings indicate that maintaining contact with children and receiving higher levels of support from friends can alleviate the risk of IADL disability progression amidst extreme heat days for older adults with limited social relationships at home and work. By examining various aspects of social isolation and their nuanced effects, this study underscores the need for social support and assistance for older adults during extreme heat.

Effects of extreme temperature on morbidity, mortality, and case severity in German emergency care

Climate change affects the frequency and intensity of extreme heat and cold events, which can have severe health repercussions. Therefore, we investigated the effects of extreme ambient temperature on emergency care-associated morbidity, mortality, and case severity in Germany. We analyzed all somatic emergency admissions (EA) to German hospitals from 2010 to 2019. Using weather station data from the German Meteorological Service, we estimated immediate and 28-day lagged effects of extreme heat (99th percentile of mean temperature) and extreme cold (1st percentile of mean temperature) in a two-stage time-series analysis using a distributed lag non-linear model. 78,486,368 EAs were included in the study. The cumulated immediate and lagged effect of temperature indicated that extreme cold decreased the EA risk but increased the fatal EA risk and case mortality. In turn, extreme heat increased the EA risk, the fatal EA risk, and the case mortality. The 1% (5%) coldest days prevented 3,400 (11,950) EAs but led to 450 (2150) additional in-hospital deaths following an EA. The 1% (5%) hottest days resulted in 4,900 (20,550) additional EAs and 300 (1,050) additional deaths. Generally, the effect of extreme cold unfolded over four weeks, while the effects of heat manifested more promptly and subsided virtually within the first week. Our findings highlight that extreme heat is associated with an increase in emergency care-associated morbidity, while both extreme heat and cold are associated with a higher emergency care-associated mortality and case severity in Germany, urging greater efforts to curb the health effects of extreme temperatures.

Sociodemographic and geographic inequalities in exposure to projected hot and extreme summer days in England: A nationwide socio-spatial analysis

INTRODUCTION

Climate change is a global health emergency, with extreme heat events increasing morbidity, mortality, and hospitalisations, and exacerbating health and social inequalities. Global temperatures have risen by over 1.1 °C since pre-industrial times and could reach 2.5 °C or even 4.0 °C based on current policies. This study examined how projected climate change will vary geographically and by population sub-group in England, to assess whether these changes will affect existing health inequalities.

METHODS

We used small-area baseline (2001 to 2020) and climate projection data from the UK's Met Office, linking it to area-level sociodemographic (2019) and health data (2016/17 to 2020/21), including age, socioeconomic status, ethnicity, hospital admissions, and mortality. Summated numbers of hot and extreme summer days were plotted by area-level health and sociodemographic quintiles. Models assessed the association between area-level quintiles and the projected number of hot (>30 °C) and extreme (>35 °C) summer days under 2.5 °C and 4.0 °C global heating scenarios.

RESULTS

There were clear geographical variations in experiencing hot and extreme summer days, with the South of England seeing the highest increases. The pattern of projected temperature increases does not align with typical health inequalities, as less deprived areas will experience more hot and extreme summer days, while areas with larger ethnic minority populations will face a greater number.

CONCLUSION

Climate adaptation strategies are needed to two levels: (1) locally to support vulnerable population groups in coping with global heating; and (2) national and global strategies to prevent global temperatures from exceeding 2.5 °C or reaching 4.0 °C, given the severe population-level health risks such increases would entail.

Extreme Temperatures, Hospital Utilization and Public Health Insurance Spending

Objectives

This study examines the impact of extreme temperatures on hospital utilization and public health insurance program spending in a country with no universal health coverage.

Methods

Using nationwide U.S. county-level panel data and a fixed effects model, we estimate the impact of annual variations in the number of hot and cold days on hospital utilization and medical reimbursements for low-income and elderly beneficiaries of public health insurance.

Results

Our results show that extreme heat and mild cold increase medical reimbursements to low-income beneficiaries, while extreme cold increases benefit transfer to the elderly. We find that extreme temperatures have particularly stronger positive effect on hospital admission and inpatient care utilization among old and poor patients. The fiscal impact of extreme temperatures is greater in areas with more generous income eligibility criteria for public health insurance.

Conclusion

The study advances our understanding of how extreme temperatures affect healthcare utilization of low-income and elderly populations and the roles public health insurance plays in supporting them from increasing weather risks. Our findings suggest that climate change can augment the financial burden on governments.

Heat-related impacts on all-cause emergency hospitalisation differ by area deprivation and urbanicity: a time-stratified case-crossover study in Japan

BACKGROUND

Climate-related health impacts have been a global public health concern. Identifying vulnerable populations is critical in implementing adaptation strategies. This study aimed to examine how heat-related impacts on all-cause emergency hospitalisations differ by area deprivation and urbanicity.

METHODS

All-cause emergency hospitalisations were identified in the Japanese nationwide administrative database during the warm season between 2011 and 2019. A time-stratified case-crossover study was conducted to examine short-term associations between daily mean temperature and hospitalisation. Days of heat exposure were defined as days when the daily mean temperature exceeded the minimum morbidity temperature (ie, temperature with the lowest relative risk between the 25th and the 75th percentiles of the daily mean temperature distribution). Analyses were stratified by area deprivation index and urbanicity. Heat-related excess hospitalisations were quantified using the population attributable fraction (PAF), derived as a fraction of heat-attributable emergency hospitalisations to the total number of emergency hospitalisations for all study subjects or within specific subgroups.

RESULTS

We identified 5 914 084 hospitalisations. Among all study subjects, PAF for heat-related excess hospitalisations was 1.69% (95% CI 1.54% to 1.87%). PAF for heat-related excess hospitalisations was more pronounced in people living in the most deprived areas (1.87%, 95% CI 1.68% to 2.06%) than those in the least deprived (1.19%, 95% CI 0.98% to 1.41%) and in urban populations (2.03%, 95% CI 1.78% to 2.30%) than rural ones (1.42% (95%CI 1.24% to 1.60%)). When further stratified by deprivation and urbanicity simultaneously, PAF for heat-related excess hospitalisations was most significant among urban populations living in the most deprived areas (2.62%, 95% CI 2.26% to 3.03%).

CONCLUSION

These findings revealed that individuals living in the most deprived areas in urban settings were particularly vulnerable to heat exposure. Adaptation strategies tailored to socioeconomic and geographical inequalities can potentially reduce future heat-related health impacts.

A molecular toxicological study to explore potential health risks associated with ultrafine particle exposure in cold and humid indoor environments

Environmental pollutants including ultrafine particulate matter (UFPs) and adverse meteorological conditions pose significant public health impacts, particularly affecting respiratory health. This study aims to elucidate the synergistic effects of cold-humid conditions and UFPs exposure on respiratory health, utilizing Carbon Black Nanoparticles (CB-NPs) as surrogates for UFPs. Through comprehensive lung function tests, histopathological examinations, and biomarker analyses, this research focuses on the modulation of oxidative stress signaling pathways and NF-κB activation. Male Balb/c mice were exposed to specific concentrations of CB-NPs (30-50 nm in diameter, 0.184 mg/(kg·day)) in a controlled environmental chamber mimicking cold (10°C/14°C) and humid (90 % RH) conditions over three weeks. The results indicate that exposure to CB-NPs alone increased lung function, oxidative stress (ROS, GSH, MDA), inflammation (IL-6, TNF-α, IL-1β), apoptosis (Caspase 3, Caspase 8, Caspase 9), and histopathological alterations in lung tissue. Furthermore, these effects were notably more severe under combined exposure with cold-humid conditions. These results suggest that the adverse effects of pollutants are not solely concentration-dependent but are exacerbated by specific environmental contexts. It is evident that Vitamin E (100 mg/kg/day) can attenuate these adverse effects, underscoring its potential as a protective agent against environmental stressor-induced air pollutants and cold humid conditions. Our findings suggest that the synergistic effects of environmental factors and pollutant exposure significantly impact respiratory health, providing valuable insights for the design of healthier indoor environments and the development of strategies to mitigate these risks.

Health perceptions of adverse weather in older adults in England: analysis of 2019/20 survey data

Risks to older adults (OA) (aged 65+ years) associated with hot and cold weather in the UK are well-documented. The study aim is to explore OA perception of health risks from high and low temperatures, health-protective measures undertaken, and implications for public health messaging. In 2019/20, Ipsos MORI conducted face-to-face surveys with OA in England (n = 461 cold weather survey, n = 452 hot weather survey). Participants reported temperature-related symptoms, risk perceptions for different groups, and behaviours during hot and cold weather. Analysis involved binomial logistic regression models to assess potential factors (demographics, vulnerability, behaviours) associated with older adults' health risk perception in hot and cold weather. Less than half of OA in both surveys agreed that hot or cold weather posed a risk to their health. OA with higher education, annual income >£25 000 or home ownership were less likely to perceive their health at risk during cold weather and regional differences in hot weather were identified. OA who recognized those the same age or living alone as at an increased risk were more likely to perceive their own health as at risk. OA were more likely to self-identify health risks when reporting those aged 65 yrs+ to be at an increased risk in cold weather. Various temperature-related protective behaviours were associated with older adults' risk perception in hot and cold weather. These findings provide evidence for public health agencies to target high risk individuals, and modify temperature-related public health messaging to protect OA.

Impact of Climate Change on Cardiovascular Health

PURPOSE OF REVIEW

Climate change is profoundly impacting cardiovascular disease through rising temperatures, more extreme weather events, and worsening air pollution. This review analyzes how these factors affect cardiovascular health.

RECENT FINDINGS

Extreme heat and cold cause physiological changes, including increasing the risk of blood clots, faster heart rates, and inflammation. Air pollution and wildfire smoke lead to oxidative stress and systemic inflammation, leading to heightened cardiovascular risk. Extreme weather disrupts healthcare access, complicating chronic condition management and negatively impacts people from lower socioeconomic communities. Climate-related stressors also affect mental health, which in turn impacts cardiovascular health. Long-term changes, such as food insecurity and migration, further strain heart health due to poor diets and psychological stress. Cardiologists must understand these risks to better support and treat patients in our changing climate.

Daily temperature variability and mental health-related hospital visits in New York State

BACKGROUND

Despite plausible behavioral and physiological pathways, limited evidence exists on how daily temperature variability is associated with acute mental health-related episodes.

OBJECTIVES

We aimed to explore associations between daily temperature range (DTR) and mental health-related hospital visits using data of all hospital records in New York State during 1995-2014. We further examined factors that may modify these associations, including age, sex, hospital visit type and season.

METHODS

Using a case-crossover design with distributed lag non-linear DTR terms (0-6 days), we estimated associations between ZIP Code-level DTR and hospital visits for mood (4.6 million hospital visits), anxiety (2.4 million), adjustment (∼368,000), and schizophrenia disorders (∼211,000), controlling for daily mean temperature, via conditional logistic regression models. We assessed potential heterogeneity by age, sex, hospital visit type (in-patient vs. out-patient), and season (summer, winter, and transition seasons).

RESULTS

For all included outcomes, we observed positive associations from period minimum DTR (0.1 °C) until 25th percentile (5.2 °C) and between mean DTR (7.7 °C) and 90th percentile (12.2 °C), beyond which we observed negative associations. For mood disorders, an increase in DTR from 0.1 °C to 12.2 °C was associated with a cumulative 16.0% increase (95% confidence interval [CI]: 12.8, 19.2%) in hospital visit rates. This increase was highest during transition seasons (32.5%; 95%CI: 26.4, 39.0%) compared with summer (10.7%; 95%CI: 4.8, 16.8%) and winter (-1.6%; 95%CI: -7.6, 4.7%). For adjustment and schizophrenia disorders, the strongest associations were seen among the youngest group (0-24 years) with almost no association in the oldest group (65+ years). We observed no evidence for modification by sex and hospital visit type.

DISCUSSION

Daily temperature variability was positively associated with mental health-related hospital visits within specific DTR ranges in New York State, after controlling for daily mean temperature. Given uncertainty on how climate change modifies temperature variability, additional research is crucial to comprehend the implications of these findings, particularly under different scenarios of future temperature variability.

Prevalence of occupational heat stress across the seasons and its management amongst healthcare professionals in the UK

Occupational heat stress (OHS) is an issue in healthcare facilities (HCFs) in the United Kingdom (UK). The aims of this study were to evaluate perceived levels of OHS during two seasons and its perceived consequences on healthcare professionals (HCPs) and to assess the efficacy of heat stress management (HSM) policies. An anonymous online survey was distributed to HCPs working in HCFs in the UK. The survey returned 1014 responses (87% women). Descriptive statistics and content analysis of survey data identified that OHS in HCFs is frequently experienced throughout the year and concerned most HCPs. Over 90% perceived OHS impairs their performance and 20% reported heat-related absenteeism. Awareness of HSM policies was poor and 73% deemed them not adequate. To help reduce the financial loss and impact on staff performance, health and well-being and patient safety, it is recommended that revisions and widespread dissemination of HSM policies are made.

Multimorbidity and emergency hospitalisations during hot weather

BACKGROUND

People with chronic diseases are a commonly listed heat-vulnerable group in heat-health action plans. While prior research identifies multiple health conditions that may increase vulnerability to ambient heat, there is minimal evidence regarding the implications of multimorbidity (two or more chronic diseases).

METHODS

From the statewide hospital registry of Queensland, Australia, we identified people aged ≥15 years who had emergency hospitalisation(s) between March 2004 and April 2016 and previously had 0, 1, 2, or ≥3 of five chronic diseases: cardiovascular disease, diabetes, mental disorders, asthma/COPD, and chronic kidney disease. We conducted time-stratified case-crossover analyses to estimate the odds ratio of hospitalisations associated with ambient heat exposure in people with different numbers, types, and combinations of chronic diseases. Ambient heat exposure was defined as a 5 °C increase in daily mean temperature above the median.

FINDINGS

There were 2,263,427 emergency hospitalisations recorded (48.7% in males and 51.3% in females). When the mean temperature increased, hospitalisation odds increased with chronic disease number, particularly in older persons (≥65 years), males, and non-indigenous people. For instance, in older persons with 0, 1, 2, or ≥3 chronic diseases, the odds ratios associated with ambient heat exposure were 1.00 (95% confidence interval: 0.96, 1.04), 1.06 (1.02, 1.09), 1.08 (1.02, 1.14), and 1.13 (1.07, 1.19), respectively. Among the chronic diseases, chronic kidney disease, and asthma/COPD, either existing alone, together, or in combination with other diseases, were associated with the highest odds of hospitalisations under ambient heat exposure.

INTERPRETATION

While individuals with multimorbidity are considered in heat-health action plans, this study suggests the need to consider specifically examining them as a distinct and vulnerable subgroup.

FUNDING

Wellcome.

Spatiotemporal distribution and lag effect of extreme temperature exposure on mortality of residents in Jiangsu, China

Background

With the ever-increasing occurrence of extreme weather events as a result of global climate change, the impact of extreme temperatures on human health has become a critical area of concern. Specifically, it is imperative to investigate the impact of extreme weather conditions on the health of residents.

Methods

In this study, we analyze the daily death data from 13 prefecture-level cities in Jiangsu Province from January 2014 to September 2022, using the distributed lag nonlinear model (DLNM) to comprehensively account for factors such as relative humidity, atmospheric pressure, air pollutants, and other factors to evaluate the lag and cumulative effects of extreme low temperature and high temperature on the death of residents across different age groups. Additionally, we utilize the Geographical Detector to analyze the effects of various meteorological and environmental factors on the distribution of resident death in Jiangsu Province. This provides valuable insights that can guide health authorities in decision-making and in the protection of residents.

Results

The experimental results indicate that both extreme low and high temperatures increase the mortality of residents. We observe that the impact of extreme low temperatures has a delayed effect, peaking after 3-5 days and lasting up to 11-21 days. In contrast, the impact of extreme high temperature is greatest on the first day, and lasts only 2-4 days.

Conclusion

Both extreme high and low temperatures increase the mortality of residents, with the former being more transient and stronger and the latter being more persistent and slower. Furthermore, residents over 75 years of age are more vulnerable to the effects of extreme temperatures. Finally, we note that the spatial distribution of resident deaths is most closely associated consistent with the spatial distribution of daily mean temperature, and there is significant spatial heterogeneity in deaths among residents in Jiangsu Province.

The impacts of extreme temperature on mortality and emergency hospital admissions within East Sussex in comparison with pre-existing national trends

BACKGROUND

The impacts of heatwaves are a rapidly growing area of study; however, much of the existing research focusses on national data analysis. This article aims to add a local perspective using data from only one county, East Sussex, and comparing these with the pre-existing national data.

METHODS

Population data were obtained from publicly available sources such as the Office of National Statistics, in addition to anonymized data from patients. Statistical analysis calculated excess mortality and emergency hospital admissions associated with both winter and heatwaves. Further analyses into factors associated with worse health outcomes in pre-existing data, such as the extremes of age (under 1 s and over 75 s), dementia and respiratory conditions, were conducted and their effect on excess mortality and emergency admissions was compared with national data.

RESULTS

Excess winter mortality within East Sussex averaged 22.5%. Excess heatwave mortality averaged 17%, measuring higher than national data. The relative significance of these data is expected to increase over the next 30 years in line with the UK Health Security Agency projection of heat-related mortality tripling by 2050 in the context of global warming and increasing temperatures.

CONCLUSIONS

Although the number of residents dying or requiring emergency admission due to cold weather is larger than that of heatwaves, trends show a worsening impact of heatwaves. The results of this report are significant findings which show more action is required to mitigate the effects of extreme heat.

The impact of the COVID-19 pandemic on mortality in Sweden-Did it differ across socioeconomic groups?

The characterization of the socioeconomic profile of COVID-19 mortality is limited. Likewise, the mapping of potential indirect adverse outcomes of the pandemic, such as suicide and alcohol abuse, along socioeconomic lines is still meagre. The main aim of this paper is to (i) depict SES-differences in COVID-19 mortality, and (ii) to assess the impact of the COVID-19 pandemic on suicide and alcohol mortality across socioeconomic groups. We used Swedish monthly data spanning the period January 2016-December 2021. We chose education as indicator of socioeconomic status (SES). The following causes of deaths were included in the analysis: COVID-19, all-cause mortality excluding COVID-19, suicide and a composite index of alcohol-specific deaths. SARIMA-modelling was used to assess the impact of the pandemic on suicide and alcohol-specific mortality. Two alternative measures of the pandemic were used: (1) a dummy that was coded 1 during the pandemic (March 2020 and onwards), and 0 otherwise, and (2) the Oxford COVID-19 Government Response Tracker's Stringency Index. There was a marked SES-gradient in COVID-19 mortality in the working-age population (25-64) which was larger than for other causes of death. A SES-gradient was also found in the old-age population, but this gradient did not differ from the gradient for other causes of death. The outcome from the SARIMA time-series analyses suggested that the pandemic did not have any impact on suicide or alcohol-specific mortality in any of the educational and gender groups.

The Impact of Heat Waves on Health Care Services in Low- or Middle-Income Countries: Protocol for a Systematic Review

BACKGROUND

Heat waves significantly impact ecosystems and human health, especially that of vulnerable populations, and are associated with increased morbidity and mortality. Besides being directly related to climate-sensitive health outcomes, heat waves have indirectly increased the burden on our health care systems. Although the existing literature examines the impact of heat waves and morbidity, past research has mostly been conducted in high-income countries (HICs), and studies on the impact of heat waves on morbidity in low- or middle-income countries (LMICs) are still scarce.

OBJECTIVE

This paper presents the protocol for a systematic review that aims to provide evidence of the impact of heat waves on health care services in LMICs.

METHODS

We will identify peer-reviewed studies from 3 online databases, including the Web of Science, PubMed, and SCOPUS, published from January 2002 to April 2023, using the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Quality assessment will be conducted using the Navigation Guide checklist. Key search terms include heatwaves, extreme heat, hospitalization, outpatient visit, burden, health services, and morbidity.

RESULTS

This systematic review will provide insight into the impact of heat waves on health care services in LMICs, especially on emergency department visits, ambulance call-outs, hospital admissions, outpatient department visits, in-hospital mortality, and health care operational costs.

CONCLUSIONS

The results of this review are anticipated to help policymakers and key stakeholders obtain a better understanding of the impact of heat waves on health care services and prioritize investments to mitigate the effects of heat waves in LMICs. This entails creating a comprehensive heat wave plan and ensuring that adequate infrastructure, capacity, and human resources are allocated in the health care sector. These measures will undoubtedly contribute to the development of resilience in health care systems and hence protect the health and well-being of individuals and communities.

TRIAL REGISTRATION

PROSPERO CRD42022365471; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=365471.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44702.

Ambient Temperature and Emergency Hospital Admissions in People Experiencing Homelessness: London, United Kingdom, 2011-2019

Objectives. To assess the impacts of ambient temperature on hospitalizations of people experiencing homelessness. Methods. We used daily time-series regression analysis employing distributed lag nonlinear models of 148 177 emergency inpatient admissions with "no fixed abode" and 20 804 admissions with a diagnosis of homelessness in London, United Kingdom, in 2011 through 2019. Results. There was a significantly increased risk of hospitalization associated with high temperature; at 25°C versus the minimum morbidity temperature (MMT), relative risks were 1.359 (95% confidence interval [CI] = 1.216, 1.580) and 1.351 (95% CI = 1.039, 1.757) for admissions with "no fixed abode" and admissions with a homelessness diagnosis, respectively. Between 14.5% and 18.9% of admissions were attributable to temperatures above the MMT. No significant associations were observed with cold. Conclusions. There is an elevated risk of hospitalization associated with even moderately high temperatures in individuals experiencing homelessness. Risks are larger than those reported in the general population. Public Health Implications. Greater emphasis should be placed on addressing homeless vulnerabilities during hot weather rather than cold. Activation thresholds for interventions such as the Severe Weather Emergency Protocol (SWEP) could be better aligned with health risks. Given elevated risks at even moderate temperatures, our findings support prioritization of prevention-oriented measures, rather than crisis response, to address homelessness. (Am J Public Health. 2023;113(9):981-984. https://doi.org/10.2105/AJPH.2023.307351).

The challenge of population aging for mitigating deaths from PM2.5 air pollution in China

Estimating the health burden of air pollution against the background of population aging is of great significance for achieving the Sustainable Development Goal 3.9 which aims to substantially reduce the deaths and illnesses from air pollution. Here, we estimated spatiotemporal changes in deaths attributable to PM2.5 air pollution in China from 2000 to 2035 and examined the drivers. The results show that from 2019 to 2035, deaths were projected to decease 15.4% (6.6%-20.7%, 95% CI) and 8.4% (0.6%-13.5%) under the SSP1-2.6 and SSP5-8.5 scenario, respectively, but increase 10.4% (5.1%-20.5%) and 18.1% (13.0%-28.3%) under SSP2-4.5 and SSP3-7.0 scenarios. Population aging will be the leading contributor to increased deaths attributable to PM2.5 air pollution, which will counter the positive gains achieved by improvements in air pollution and healthcare. Region-specific measures are required to mitigate the health burden of air pollution and this requires long-term efforts and mutual cooperation among regions in China.

Hospital admission tendencies caused by day-to-day temperature changes during summer: a case study for the city of Novi Sad (Serbia)

Increased temperature risk in cities threatens the health and well-being of urban population and is fueled by climate change and intensive urbanization. Consequently, further steps must be taken for assessing temperature conditions in cities and their association with public health, in order to improve public health prevention at local or regional level. This study contributes to solving the problems by analyzing the connection between extreme temperatures and the tendencies of all-cause hospital admissions. The analyses used (a) 1-h air temperature data, and (b) daily data of all-cause hospital admissions. The datasets include the summer period (June, July, August) for the years 2016 and 2017. We tested the effects of two temperature indices, day-to-day change in maximum temperature - T_max,c and daily temperature range - T_r, with all-cause hospital admission subgroups, such as all-cause cases - H_a, hospital admissions in the population below 65 - H_a<65, and hospital admissions in the population aged 65 and over - H_a≥65. The results show the highest values of H_a when T_max,c is between 6 and 10 °C. Therefore, more intensive hospital admissions can be expected when T_max increases from day-to-day (positive values of T_max,c), and it is more visible for H_a and H_a<65 (1 °C = 1% increase in hospital admissions). Also, T_r values between 10 °C and 14 °C cause an increase in the number of hospital admissions, and it is more noticeable for H_a≥65.