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Community CVD prevention programs improved outcomes during 40-year period
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Sustained community-wide CVD prevention programs introduced in a rural county in Maine were associated with improved hospitalization and mortality rates during a 40-year period, according to new findings.
Compared with the rest of the state, residents of Franklin County, Maine, had lower-than-expected per capita hospitalization and mortality rates, the researchers found.
From 1970 to 2010, researchers conducted an observational study of residents of Franklin County, a low-income, rural area with a population of 22,444 in 1970. Beginning in 1970, community organizations in the county initiated a number of programs focused on hypertension, cholesterol, smoking, diet and physical activity.
Monitored outcomes included adult participation, as indicated by encounters with the program staff; intermediate risk factor outcomes including hypertension, hyperlipidemia and smoking; morbidity, as measured by age- and income-adjusted hospitalization rates in Franklin County compared with other counties in Maine from 1994 through 2006; and mortality, as measured by overall and CV-specific age- and income-adjusted mortalities in Franklin vs. other counties in Maine from 1970 to 2010.
During the 40 years of the study, more than 150,000 contacts occurred between individual county residents and program staff, N. Burgess Record, MD, from Franklin Memorial Hospital, Farmington, Maine, and colleagues reported.
Health indicators improved
In time, health indicators improved with the addition of CV risk factor programs, Record and colleagues wrote. They observed an absolute increase of 24.7% (95% CI, 21.6-27.7) in hypertension control (18.3% in 1975 vs. 43% in 1978) and an absolute increase of 28.5% (95% CI, 25.3-31.6) in elevated cholesterol control (0.4% in 1986 vs. 28.9% in 2010).
Smoking quit rates among county residents improved from 48.5% in 1996 to 69.5% in 2000, which were better than state average (observed – expected = 11.3%; 95% CI, 5.5-17.7). However, in subsequent years, the difference between the county and the state disappeared as the state’s overall quit rate improved, according to the researchers.
Per capita hospitalizations in Franklin County were less than expected between 1994 and 2006 (observed – expected = –17 discharges per 1,000 residents; 95% CI, –20.1 to –13.9), Record and colleagues wrote.
In addition, Franklin was the only county in Maine with consistently lower adjusted mortality than predicted (1970-1989, observed – expected = –60.4 deaths per 100,000 people; 95% CI, –97.9 to –22.8; 1990-2010, observed – expected = –41.6 deaths per 100,000 people; 95% CI, –77.3 to –5.8), according to the researchers.
“The experience in Franklin County suggests that community health improvement programs may be both feasible and effective,” Record and colleagues wrote. “This may be especially true in socioeconomically disadvantaged communities where the needs are the greatest.”
Multiplicity of interventions
In a related editorial, Darwin R. Labarthe, MD, MPH, PhD, and Jeremiah Stamler, MD, wrote that determining the role of each intervention component and intermediate outcome is not the point of the study. “Rather, the multiplicity of interventions merits emphasis and illustrates an approach to population health, an increasingly important concept in health care,” they wrote.
Labarthe and Stamler, both from the department of preventive medicine at Northwestern University Feinberg School of Medicine, wrote that the results ought to be generalizable because “putatively adverse general features of the county are typical of rural areas — eg, geographic isolation, scant financial resources, limited health services infrastructure and low levels of household income. The Franklin County experiences indicate that these barriers can be overcome and suggest that demonstrated improvements in community health can be replicated elsewhere, including in urban areas.”
For more information:
Labarthe DR. JAMA. 2015;doi:10.1001/jama.2014.16963.
Record NB. JAMA. 2015;doi:10.1001/jama.2014.16969.
Disclosure: Two researchers report holding equity in Franklin ScoreKeeper. The other researchers and Labarthe and Stamler report no relevant financial disclosures.