In a rural Maine county, sustained, community-wide programs targeting cardiovascular risk factors and behavior changes were associated with reductions in hospitalization and death rates over a 40-year period (1970-2010) compared with the rest of the state. Substantial improvements were seen in control of hypertension and cholesterol, and smoking cessation, according to a study in the January 13 issue of JAMA.
"We think we have shown that communities can improve their own health if they can sustain effective, evidence-based interventions over decades and measure the result. They can do it more easily now that many resources and outcomes can be easily downloaded from websites, unavailable when our project started," said Daniel K. Onion, MD, MPH, Professor of Community and Family Medicine at the Geisel School of Medicine at Dartmouth and second author of the paper.
Reducing the burden of cardiovascular disease (CVD) has been a public health priority for more than 50 years and will continue to be in the foreseeable future. Few comprehensive cardiovascular risk reduction programs, particularly those in rural, low-income communities, have sustained community-wide interventions for more than 10 years and demonstrated improvements in known risk factors and reductions in illness and death, according to background information in the article.
N. Burgess Record, MD, of Franklin Memorial Hospital, Farmington, Maine, and colleagues studied health outcomes associated with a comprehensive cardiovascular risk reduction program in Franklin County, Maine, a low-income rural community. In the late 1960s, local community groups in Franklin County identified CVD prevention as a priority. A new Community Action Agency (CAA), a new nonprofit medical group practice (Rural Health Associates [RHA]), and later the community's hospital initiated and coordinated their efforts. With hospital medical staff sponsorship, RHA established the community-wide Franklin Cardiovascular Health Program (FCHP) in 1974.
"This study was different. It's a massive study over four decades of what happens when coordinated interventions are performed in a community-wise way," explained Christopher Amos, PhD, who worked directly with the data analysis. Dr. Amos is chair of the Department of Biomedical Data Science and Associate Director of Population Sciences at Dartmouth-Hitchcock's Norris Cotton Cancer Center.
The programs targeted hypertension, cholesterol, and smoking, as well as diet and physical activity. The current analysis included residents of Franklin County (population of 22,444 in 1970), and used the preceding decade as a baseline and compared Franklin County with other Maine counties and state averages.
In its first four years, FCHP screened about 50 percent of county adults. Individuals with hypertension showed significant movement from detection to treatment and blood pressure control; the proportion in control increased from 18.3 percent to 43 percent from 1975 to 1978, an absolute increase of 24.7 percent. After introducing cholesterol screening in 1986, FCHP reached 40 percent of county adults within five years, half of whom had elevated cholesterols. Over subsequent decades, cholesterol control had an absolute increase of 28.5 percent, from 0.4 percent to 28.9 percent, from 1986 to 2010. Similarly, after initiation of multiple community smoking cessation projects, community-wide smoking quit rates improved significantly, from 48.5 percent to 69.5 percent, and became significantly higher than that for the rest of Maine; these differences later disappeared when Maine's overall quit rate increased.
Franklin County hospitalizations per capita were less than expected for the period 1994-2006. The lower overall hospitalization rates were associated with $5,450,362 reductions in total in- and out-of-area hospital charges for Franklin County residents per year.
After being at or above overall Maine mortality rates in the 1960s, Franklin County rates decreased below Maine rates for almost the entire period 1970-2010. Cardiovascular-specific mortality rates decreased similarly. The greatest differences coincided with periods of peak efforts to improve health care access, detect and control hypertension and hypercholesterolemia, and reduce smoking.
"The experience in Franklin County suggests that community health improvement programs may be both feasible and effective. This may be especially true in socio-economically disadvantaged communities where the needs are the greatest, as the increasing association of lower household income with higher mortality in Maine suggests. Further studies are needed to assess the generalizability of such programs to other U.S. county populations, especially rural ones, and to other parts of the world," the authors wrote.
This study also represents the culmination of decades of collaboration between Dartmouth and physician scientists in Maine. Several of the authors and researchers including Daniel Onion, MD and Roderick Prior, MD worked closely with Jack Wennberg, MD when he did his early, Maine-based work, and used population-based and area-variation techniques in their analysis. Roderick Prior is a graduate of Dartmouth College and Dartmouth Medical School (now the Geisel School of Medicine). He learned computer programming from John Kemeny, PhD, did computerized physiology model development at Dartmouth under the tutelage of George R Stibitz, PhD.