Date of Award

January 2026

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Jodi D. Sherman

Abstract

BackgroundClimate change is increasing health risks for communities across the United States. Rising temperatures and worsening air quality contribute to higher rates of heat-related illness, including heat exhaustion, heat stroke, and acute kidney injury, as well as increased incidence of cardiopulmonary and cerebrovascular acute events, and vector-borne infections. Extreme weather events—such as hurricanes, wildfires, and heatwaves—disrupt healthcare delivery, displace patients, and strain care operations. Hospitals stand at the front-line response to these climate health hazards. Healthcare systems must recognize climate change as a community health threat that requires systematic assessment and planning to improve resilience of continuous care delivery and quality outcomes. U.S. nonprofit hospitals are federally mandated to complete a Community Health Needs Assessment (CHNA) every three years. The CHNA defines the community served, identifies urgent health needs, informs community-benefit strategy and priority-setting and may shape planning and investments related to identified community needs. It is the primary mechanism through which the federal government ensures that tax-exempt hospitals address local health priorities. Despite well-known U.S. population vulnerabilities, current CHNA regulations do not require hospitals to assess climate-related health risks, raising a question about whether the CHNA process is keeping pace with emerging climate threats.

Aims and HypothesisThis study evaluated climate-related health content in recent CHNAs. It sought to (1) quantify the presence and depth of climate-related health content; (2) characterize variation; and (3) assess whether hospitals serving communities with higher climate vulnerability were more or less likely to identify climate-related health risks. We hypothesized that climate-related risks would be insufficiently addressed in CHNAs nationwide, reflecting the need for clearer regulatory requirements and guidance.

MethodsThe study population included U.S. nonprofit hospitals. Eligible facility types included short-term acute care, critical access, children’s, long-term acute care, and rural emergency hospitals; specialty facilities were excluded. Hospitals were geocoded and linked to county-level climate vulnerability using the Climate Vulnerability Index (CVI) from the Environmental Defense Fund (EDF) and hazard-specific measures from the Federal Emergency Management Agency (FEMA) National Risk Index (NRI). CHNAs were collected using a custom scripted web-scraping process. A 20% random subsample was selected for detailed analysis. Climate-related content was identified using a systematic keyword screening approach, followed by manual verification. CHNAs were scored for climate-content using an 18-point rubric, where higher scores indicate greater depth. Associations among climate-content score, hospital characteristics, and climate vulnerability were examined using descriptive statistics and multivariable regression.

ResultsCHNAs were obtained for 3,468 of 5,543 eligible U.S. non-profit hospitals. A 20% random subsample was reviewed and verified, yielding 566 CHNAs for analysis. Hospitals represented all U.S. Census regions and major facility types, predominantly short-term acute care (66%) and critical access hospitals (29%). Overall, climate-related CHNA content was very limited. On an 18-point scale, the mean climate-content score was 2.51 (SD 2.84), and 28.6% (n=162) of CHNAs contained no climate-related material at all. Hospitals serving more climate-vulnerable communities, especially those with greater socioeconomic disadvantage, were less likely to document climate-related health risks in their CHNAs. Hospitals located in the Northeast and West included more climate-related content than those in the South and Midwest, although absolute levels remained very low nationwide. Hospitals in areas with higher hurricane risk were more likely to mention climate, though not in greater depth.

ConclusionsThese findings demonstrate that current CHNAs inadequately assess climate-health risks, suggesting that health system planning and investments may be insufficient. Recommendations include modernization of CHNA regulations and guidance to better support climate-informed, equity-focused community health planning. As climate hazards intensify, hospitals must be positioned to evaluate and respond to these risks to maintain continuous care and protect patient health.

Comments

This thesis is restricted to Yale network users only. It will be made publicly available on 07/14/2028

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