Particulate matter and daily mortality: a case-crossover analysis of individual effect modifiers.

BACKGROUND: Several time-series studies have established the relationship between particulate matter (PM10) and mortality. We adopted a case-crossover design to evaluate whether individual socio-demographic characteristics and chronic or acute medical conditions modify the PM10-mortality association.
METHODS: We selected all natural deaths (321,024 subjects) occurring among adult (aged 35+ years) residents of 9 Italian cities between 1997 and 2004. We had access to individual information on socio-demographic variables, location of death, and chronic conditions (hospital admissions in the preceding 2-year period). For in-hospital deaths, we collected information on treatment wards at time of death and acute medical conditions. In a case-crossover analysis we adjusted for time, population changes, and meteorological conditions.
RESULTS: PM10 was associated with mortality among subjects age 65 years and older (0.75% increase per 10 microg/m3 [95% confidence interval = 0.42% to 1.09%]), with a more pronounced effect among people age 85 and older. A weaker effect was found among the most affluent people. The effect was present for both out-of-hospital and in-hospital deaths, especially among those treated in general medicine and other less specialized wards. PM10 effects were stronger among people with diabetes (1.03% [0.28% to 1.79%]) and chronic obstructive pulmonary disease (0.84% [0.17% to 1.52%]). The acute conditions with the largest effect estimates were acute impairment of pulmonary circulation (4.56% [0.75% to 8.51%]) and heart failure (1.67% [0.30% to 3.04%]).
CONCLUSIONS: Several factors, including advanced age, type of hospital ward, and chronic and acute health conditions, modify the PM10-related risk of death. Altered pulmonary circulation and heart failure are important effect modifiers, suggesting that cardiac decompensation is a possible mechanism of the fatal PM10 effect.