Academic journal article Environmental Health Perspectives

Fine and Coarse Particulate Matter Exposures and Associations with Acute Cardiac Events among Participants in a Telemedicine Service: A Case-Crossover Study

Academic journal article Environmental Health Perspectives

Fine and Coarse Particulate Matter Exposures and Associations with Acute Cardiac Events among Participants in a Telemedicine Service: A Case-Crossover Study

Article excerpt


Short-term exposure to ambient particulate matter (PM) has been linked to increased cardiovascular morbidity and mortality (Brook et al. 2010; Du et al. 2016; Munzel et al. 2017; Newby et al. 2015; Zanobetti and Schwartz 2009) with large public health burdens (WHO 2016, 2018). Experimental studies indicate that subclinical cardiovascular changes may occur within minutes to hours after exposure (Ghelfi et al. 2008; Mills et al. 2007). Yet, although the U.S. Environmental Protection Agency (EPA) continues to look for additional evidence of effects associated with sub-daily exposure that may serve as a basis for establishing shorter than 24-h PM standards (U.S. EPA 2009, 2011), information about hourly associations of PM and clinical events is limited, as indicated in a review of studies examining cardiovascular outcomes and sub-daily PM25 exposures (Burgan et al. 2010). Most studies have investigated associations on a daily time scale (Ito et al. 2011; Stafoggia et al. 2013; Stieb et al. 2009; Wolf et al. 2015; Zanobetti and Schwartz 2005) because of a lack of detailed information on onset time in administrative data. In addition, the use of administrative data without additional adjudication can limit the ability of researchers to accurately identify events and classify the type of events. Error in either the onset time or outcome definition may result in an underestimation of the true magnitude of the health effects associated with air pollution (Lokken et al. 2009).

The few studies that have investigated associations between hourly exposures of PM and clinical cardiac events used patient interview (Berglind et al. 2010; Peters et al. 2001), disease register (Bhaskaran et al. 2011; Sullivan et al. 2005), or implantable cardioverter defibrillator (ICD) data (Link et al. 2013; Ljungman et al. 2008; Rich et al. 2005) to assess onset time. However, these sources are either subjective, focus on specific outcomes, or pertain to limited populations. Like emergency respondent data, telemedicine offers a novel resource for conducting environmental health research on clinical events (Leshem-Rubinow et al. 2011b). With telemedicine services, subscribers can phone a medical call center upon experiencing symptoms for a remote clinical evaluation and follow-up action, if required. Through earlier engagement with the patient, telemedicine is able to detect the onset time of confirmed clinical symptoms earlier than would be possible from a phone call for emergency respondents or hospital admissions (Audebert et al. 2005). Telemedicine also collects clinical data remotely at the time of the event, providing additional information with which to adjudicate an event with greater certainty. Although telemedicine offers a novel and clinically confirmed data source (Birati and Roth 2011; Chaudhry et al. 2010; Schwaab et al. 2003; Wennberg et al. 2010), it has been rarely used to test associations between health effects and environmental stressors (Crabbe et al. 2004).

Our study utilized unique telemedicine data to more accurately estimate associations between sub-daily PM exposure and acute clinical cardiac events among residents in two large metropolitan areas in Israel between 2002 and 2013. In secondary analyses, we further examined the impacts on our association of using more accurate information on symptom onset time and greater certainty of diagnosis from adjudicated data.


Study Subjects

SHL Telemedicine (pronounced "Shahal" an acronym for Sherut Holey Lev, a service for heart disease patients; provides medical assistance to over 300,000 subscribers worldwide (about 100,000 in Israel) (Birati et al. 2008; Roth et al. 2009; Shacham et al. 2012). Telemedicine is a popular service among the older population of Israel, with approximately 10-20% of people over 65 y of age enrolled in one of two major providers. In Shahal, 48% of the service is used by patients 60-80 y of age, and 31% by those over 80 y of age. …

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