Community-wide cardiovascular disease prevention programs and health outcomes in a rural county, 1970-2010

Abstract

Importance: 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 the effect of risk factor improvements on reductions in morbidity and mortality.

Objective: To document health outcomes associated with an integrated, comprehensive cardiovascular risk reduction program in Franklin County, Maine, a low-income rural community.

Design, setting, and participants: Forty-year observational study involving residents of Franklin County, Maine, a rural, low-income population of 22,444 in 1970, that used the preceding decade as a baseline and compared Franklin County with other Maine counties and state averages.

Interventions: Community-wide programs targeting hypertension, cholesterol, and smoking, as well as diet and physical activity, sponsored by multiple community organizations, including the local hospital and clinicians.

Main outcomes and measures: Resident participation; hypertension and hyperlipidemia detection, treatment, and control; smoking quit rates; hospitalization rates from 1994 through 2006, adjusted for median household income; and mortality rates from 1970 through 2010, adjusted for household income and age.

Results: More than 150,000 individual county resident contacts occurred over 40 years. Over time, as cardiovascular risk factor programs were added, relevant health indicators improved. Hypertension control had an absolute increase of 24.7% (95% CI, 21.6%-27.7%) from 18.3% to 43.0%, from 1975 to 1978; later, elevated cholesterol control had an absolute increase of 28.5% (95% CI, 25.3%-31.6%) from 0.4% to 28.9%, from 1986 to 2010. Smoking quit rates improved from 48.5% to 69.5%, better than state averages (observed - expected [O - E], 11.3%; 95% CI, 5.5%-17.7%; P < .001), 1996-2000; these differences later disappeared when Maine's overall quit rate increased. Franklin County hospitalizations per capita were less than expected for the measured period, 1994-2006 (O - E, -17 discharges/1000 residents; 95% CI -20.1 to -13.9; P < .001). Franklin was the only Maine county with consistently lower adjusted mortality than predicted over the time periods 1970-1989 and 1990-2010 (O - E, -60.4 deaths/100,000; 95% CI, -97.9 to -22.8; P < .001, and -41.6/100,000; 95% CI, -77.3 to -5.8; P = .005, respectively).

Conclusions and relevance: Sustained, community-wide programs targeting cardiovascular risk factors and behavior changes to improve a Maine county's population health were associated with reductions in hospitalization and mortality rates over 40 years, compared with the rest of the state. Further studies are needed to assess the generalizability of such programs to other US county populations, especially rural ones, and to other parts of the world.

Figure 1. Franklin Cardiovascular Health Program Annual Encounters, Risk Factor Focus, and Locations: 1974–2010

Encounters were in-person contacts between program staff and individuals in the community. The beginning of each bar under the graph indicates the year in which the component was introduced.

Figure 2. Cardiovascular Risk Factor Reduction

A, Status of the screened population who were found to have hypertension as of the last encounter of the year. Data for 1975 and 1976 taken from Miller and Record. Data for 1978 taken from Record and reanalyzed to allow comparability with 1975–1976 data. χ² calculated on change of hypertension treatment and control over time. B, Study population each year is the group of patients with a high cholesterol level at initial screening who had at least 1 encounter at which cholesterol control was measured; control was stated as of the last encounter of the year; and control definitions of cholesterol were based on “at-goal” criteria of contemporaneous Adult Treatment Panel (ATP): ATP I, 1988–1992; ATP II, 1993–2001; and ATP III, 2002, updated 2004–2013. C, Data are from the Behavioral Risk Factor Surveillance System for 1994–2011, questions “SmokeNow” and “SmokeDay.” Error bars indicate 95% 2-tailed confidence intervals.

Figure 3. Maine County Hospitalization Rates vs Income, 1994–2006

County-level hospital inpatient discharge rates from the Maine Health Data Organization Inpatient Hospital Discharge Data Set, 1994–2006, assigning cases to the county of residence and excluding obstetric and newborn cases. York County is excluded from this analysis. Error bars indicate non–income-adjusted 95% confidence intervals. Regression estimate performed on Maine county-level data excluding Franklin County. Franklin County observed vs income-adjusted expected discharge rate: −17/1000 residents (95%CI, −20.1 to −13.9; P < .001).

Figure 4. Mortality Rates for Franklin County and Maine, 1960–2010

Age-adjusted total mortality rates. Data was summed to 3-year rolling averages. Age adjustment performed using 1940 standard US population. Error bars indicate 95% confidence intervals.

Figure 5. Age-Adjusted Total Mortality Rates vs Household Income for 3 Time Periods: 1960–1969, 1970–1989, and 1990–2010

Maine county age-adjusted mortality rates vs income over 3 time periods. Error bars indicate non–income-adjusted 95% confidence intervals. County death data were not available for 1960–1969 to calculate confidence intervals. Regression was performed on Maine county-level data excluding Franklin County. Franklin County external t test values: 1960–1969: 0.27 (P = .36); 1970–1989: 3.15 (P < .001); 1990–2010:2.28 (P = .005). The observed − expected mortality in Franklin County for each period: 1960–1969: 7.9 deaths/100 000 (95% CI, −22.0 to 37.9); 1970–1989: −60.4 deaths/100 000 (95% CI, −97.9 to −22.8); 1990–2010: −41.6 deaths/100 000 (95% CI, −77.3 to −5.8).