{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"institution":[{"name":"medRxiv"}],"indexed":{"date-parts":[[2026,3,26]],"date-time":"2026-03-26T19:15:34Z","timestamp":1774552534926,"version":"3.50.1"},"posted":{"date-parts":[[2026,3,24]]},"group-title":"Epidemiology","reference-count":51,"publisher":"openRxiv","license":[{"start":{"date-parts":[[2026,3,24]],"date-time":"2026-03-24T00:00:00Z","timestamp":1774310400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/www.medrxiv.org\/about\/FAQ#license"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"accepted":{"date-parts":[[2026,3,24]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                <jats:p>Exposure to high ambient temperature is responsible for more than 11,000 deaths and over 230,000 disability-adjusted life-years in the United States each year. However, which individuals and populations are most at risk, and why, is still not well understood. In 2015, a subset of \u201cZ\u201d diagnosis codes (or \u201cZ-codes\u201d) were introduced as a standardized option for healthcare providers to document the social needs and conditions of their patients. To assess heat-related risk across social determinants of health (SDoH), we leverage these codes using a dataset of patient-level emergency department (ED) visits from seven US states. Using a bi-directional, time-stratified, case-crossover design and conditional logistic regression, we compared hospital encounters for seven different health outcomes with SDoH Z-codes at discharge to a reference group matched on age, sex, race, ethnicity, year and hospital. We investigated the following Z-code domains: inadequate housing (Z59.0, Z59.1), poverty-related (Z56.0, Z59.5-Z59.7), living alone (Z60.2), institutional living (Z65.1, Z59.3), and other problems with the social environment (other Z60 sub-codes). We calculated cumulative odds ratios (ORs) for a 3-day lag change in temperature from the 95th to 50th percentile, using ZIP code-specific temperature percentiles. Among 60,557,958 ED visits with available demographic and meteorological data, 461,468 (0.8%) included a SDoH Z-code. Across temperature metrics and outcomes, patients with SDoH Z-codes consistently showed higher associations with heat than the matched reference group without SDoH Z-codes. The largest difference was for acute kidney injury, with a ratio of ORs of 1.21 (1.10,1.33) for daily mean temperature. Notable subgroup findings included elevated kidney-related risks in patients with inadequate housing or poverty-related SDoH, increased mental health risks among those living alone, and elevated cardiovascular risks in people with other problems related to the social environment.<\/jats:p>","DOI":"10.64898\/2026.03.20.26348922","type":"posted-content","created":{"date-parts":[[2026,3,24]],"date-time":"2026-03-24T22:10:19Z","timestamp":1774390219000},"source":"Crossref","is-referenced-by-count":0,"title":["Modification of temperature-morbidity associations by social determinants of health"],"prefix":"10.64898","author":[{"given":"Noah","family":"Scovronick","sequence":"first","affiliation":[{"name":"Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Danlu","family":"Zhang","sequence":"additional","affiliation":[{"name":"Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Zachary H.","family":"McCann","sequence":"additional","affiliation":[{"name":"Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rohan","family":"D\u2019Souza","sequence":"additional","affiliation":[{"name":"Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Morgan","family":"Lane","sequence":"additional","affiliation":[{"name":"Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rebecca","family":"Zhang","sequence":"additional","affiliation":[{"name":"Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rebecca","family":"Philipsborn","sequence":"additional","affiliation":[{"name":"Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA"},{"name":"Department of Pediatrics, Emory University School of Medicine, Emory University, Atlanta, GA, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Stefanie","family":"Ebelt","sequence":"additional","affiliation":[{"name":"Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Howard H.","family":"Chang","sequence":"additional","affiliation":[{"name":"Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"54368","reference":[{"key":"2026032611400818000_2026.03.20.26348922v1.1","unstructured":"Intstitute of Health Metrics and Evaluation (2023) GBD Compare."},{"key":"2026032611400818000_2026.03.20.26348922v1.2","doi-asserted-by":"publisher","DOI":"10.59327\/IPCC\/AR59326-9789291691647"},{"key":"2026032611400818000_2026.03.20.26348922v1.3","doi-asserted-by":"crossref","first-page":"492","DOI":"10.1038\/s41558-021-01058-x","article-title":"The burden of heat-related mortality attributable to recent human-induced climate change","volume":"11","year":"2021","journal-title":"Nature climate change"},{"key":"2026032611400818000_2026.03.20.26348922v1.4","unstructured":"US Environmental Protection Agency (2024) Climate Change Indicators: U.S. and Global Temperature."},{"key":"2026032611400818000_2026.03.20.26348922v1.5","doi-asserted-by":"crossref","unstructured":"R. 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