Rationale: The heat-related risk of hospitalization for respiratory diseases among the elderly has not been quantified in the United States on a national scale. With climate change predictions of more frequent and more intense heat waves, it is of paramount importance to quantify the health risks related to heat, especially for the most vulnerable. Objectives: To estimate the risk of hospitalization for respiratory diseases associated with outdoor heat in the U.S. elderly. Methods: An observational study of approximately 12.5 million Medicare beneficiaries in 213 United States counties, January 1, 1999 to December 31, 2008. We estimate a national average relative risk of hospitalization for each 10 8 F (5.6 8 C) increase in daily outdoor temperature using Bayesian hierarchical models. Measurements and Main Results: We obtained daily county-level rates of Medicare emergency respiratory hospitalizations (International Classification of Diseases, Ninth Revision,(464)(465)(466)(480)(481)(482)(483)(484)(485)(486)(487)(490)(491)(492) in 213 U.S. counties from 1999 through 2008. Overall, each 10 8 F increase in daily temperature was associated with a 4.3% increase in same-day emergency hospitalizations for respiratory diseases (95% posterior interval, 3.8, 4.8%). Counties' relative risks were significantly higher in counties with cooler average summer temperatures. Conclusions: We found strong evidence of an association between outdoor heat and respiratory hospitalizations in the largest population of elderly studied to date. Given projections of increasing temperatures from climate change and the increasing global prevalence of chronic pulmonary disease, the relationship between heat and respiratory morbidity is a growing concern.Keywords: chronic obstructive pulmonary disease; hospitalization; hot temperature; respiratory tract infections; weatherOutdoor heat can cause spikes in respiratory deaths (1, 2), but considerably less is known about heat's impacts on respiratory morbidity. Given that: (1) climate change will increase exposure to extreme heat (3), (2) the prevalence of chronic respiratory diseases is increasing (4), and (3) the elderly will likely be most affected by heat-related problems (5), there is a pressing need to improve our understanding of respiratory heat effects among the elderly for both fatal and nonfatal outcomes.There are two major limitations to current research on the relationship between heat and respiratory hospitalizations. First, this relationship has not been adequately studied worldwide to confidently identify a consistent link between respiratory hospitalizations and heat. The few studies that have investigated heat and respiratory hospitalizations have found somewhat conflicting results (6). For example, studies of Brisbane, Australia (7,8) and Athens, Greece (9) found hospitalization rates decreased slightly during hot weather, whereas studies of California (10, 11), New York (12, 13), and 12 European cities (14) found respiratory hospitalizations increased with heat. Although a me...