Skip to main page content
Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
, 376 (26), 2513-2522

Air Pollution and Mortality in the Medicare Population


Air Pollution and Mortality in the Medicare Population

Qian Di et al. N Engl J Med.


Background: Studies have shown that long-term exposure to air pollution increases mortality. However, evidence is limited for air-pollution levels below the most recent National Ambient Air Quality Standards. Previous studies involved predominantly urban populations and did not have the statistical power to estimate the health effects in underrepresented groups.

Methods: We constructed an open cohort of all Medicare beneficiaries (60,925,443 persons) in the continental United States from the years 2000 through 2012, with 460,310,521 person-years of follow-up. Annual averages of fine particulate matter (particles with a mass median aerodynamic diameter of less than 2.5 μm [PM2.5]) and ozone were estimated according to the ZIP Code of residence for each enrollee with the use of previously validated prediction models. We estimated the risk of death associated with exposure to increases of 10 μg per cubic meter for PM2.5 and 10 parts per billion (ppb) for ozone using a two-pollutant Cox proportional-hazards model that controlled for demographic characteristics, Medicaid eligibility, and area-level covariates.

Results: Increases of 10 μg per cubic meter in PM2.5 and of 10 ppb in ozone were associated with increases in all-cause mortality of 7.3% (95% confidence interval [CI], 7.1 to 7.5) and 1.1% (95% CI, 1.0 to 1.2), respectively. When the analysis was restricted to person-years with exposure to PM2.5 of less than 12 μg per cubic meter and ozone of less than 50 ppb, the same increases in PM2.5 and ozone were associated with increases in the risk of death of 13.6% (95% CI, 13.1 to 14.1) and 1.0% (95% CI, 0.9 to 1.1), respectively. For PM2.5, the risk of death among men, blacks, and people with Medicaid eligibility was higher than that in the rest of the population.

Conclusions: In the entire Medicare population, there was significant evidence of adverse effects related to exposure to PM2.5 and ozone at concentrations below current national standards. This effect was most pronounced among self-identified racial minorities and people with low income. (Supported by the Health Effects Institute and others.).

Conflict of interest statement

No potential conflict of interest relevant to this article was reported.


Figure 1
Figure 1. Average PM2.5 and Ozone Concentrations in the Continental United States, 2000 through 2012
Panel A shows the average concentrations of fine particulate matter (particles with a mass median aerodynamic diameter of less than 2.5 μm [PM2.5]) in micrograms per cubic meter, as estimated on the basis of all daily predictions during the study period. Panel B shows the concentration of ozone levels in parts per billion as averaged from April 1 through September 30 throughout the study period.
Figure 2
Figure 2. Risk of Death Associated with an Increase of 10 μg per Cubic Meter in PM2.5 Concentrations and an Increase of 10 ppb in Ozone Exposure, According to Study Subgroups
Hazard ratios and 95% confidence intervals are shown for an increase of 10 μg per cubic meter in PM2.5 and an increase of 10 parts per billion (ppb) in ozone. Subgroup analyses were conducted by first restricting the population (e.g., considering only male enrollees). The same two-pollutant analysis (the main analysis) was then applied to each subgroup. Numeric results are presented in Tables S3 and S4 in the Supplementary Appendix. Dashed lines indicate the estimated hazard ratio for the overall population.
Figure 3
Figure 3. Concentration–Response Function of the Joint Effects of Exposure to PM2.5 and Ozone on All-Cause Mortality
A log-linear model with a thin-plate spline was fit for both PM2.5 and ozone, and the shape of the concentration-response surface was estimated (Fig. S8 in the Supplementary Appendix). The concentration–response curve in Panel A was plotted for an ozone concentration equal to 45 ppb. The concentration–response curve in Panel B was plotted for a PM2.5 concentration equal to 10 μg per cubic meter. These estimated curves were plotted at the 5th and 95th percentiles of the concentrations of PM2.5 and ozone, respectively. The complete concentration–response three-dimensional surface is plotted in Fig. S8 in the Supplementary Appendix.

Comment in

Similar articles

See all similar articles

Cited by 111 PubMed Central articles

See all "Cited by" articles

MeSH terms