40-Year CVD Prevention Program Improves Health Outcomes in Rural, Low-Income US County

January 15, 2015

FARMINGTON, ME – A communitywide cardiovascular disease prevention program in a rural US county led to significant improvements in risk factors and behavioral changes, as well as a reduction in hospitalization and mortality rates, over a 40-year period, a new study shows[1].

As part of the Franklin Cardiovascular Health Program (FCHP), which was initiated in 1974, there were significant improvements in blood pressure, cholesterol levels, and smoking-cessation rates over time among residents of Franklin County, ME. From 1994 to 2006, the years in which data were available, the observed hospitalization rates were significantly lower than would have been predicted by household incomes, while mortality rates in Franklin County decreased below the state average for almost the entire period between 1970 and 2010.

"The experience in Franklin County suggests that community health-improvement programs may be both feasible and effective," according to Dr Burgess Record (Franklin Memorial Hospital, Farmington, ME) and colleagues. "This may be especially true in socioeconomically disadvantaged communities where the needs are the greatest, as the increasing association of lower household income with higher mortality in Maine suggests."

The study is published in the January 13, 2015 issue of the Journal of the American Medical Association.

Church Basements, Schools, and Workplaces

Franklin County is a rural, low-income community that included 22 444 individuals in 1970. The FCHP was established when a community-action agency, a nonprofit medical practice, and the community hospital coordinated their efforts to improve population health. Primary-care physicians were recruited, as were local businesses, schools, and the University of Maine.

The grassroots effort saw nurses and trained volunteers screen patients in church basements, schools, and work sites. At first, the FCHP concentrated solely on reducing blood pressure but was later expanded to screen for cholesterol (1986) and diabetes (2000), as well as health behaviors such as tobacco use (1988), diet (1990), and physical-activity levels (1990).

Between 1974 and 1978, there was a significant improvement in hypertension control, from 18.3% of individuals having their blood pressure treated and controlled in 1974 to 43.0% under control in 1978. Just 0.4% had total-cholesterol levels controlled in 1986 compared with 28.9% in 2010, a statistically significant improvement. Smoking-cessation rates increased from 48.5% in 1996 to 69.5% in 2000, also a statistically significant improvement. Smoking-cessation rates in Franklin County were significantly higher than the rest of Maine.

Regarding hospitalizations, which were strongly associated with household income, the Franklin County hospitalization rate was significantly lower than predicted by household income, with 17 fewer discharges than predicted per 1000 individuals. The mortality rate in Franklin County fell below the Maine mortality rate for almost the entire 1970–2010 period, despite being at or above the Maine rate in the 1960s. Overall, the mortality rate was significantly lower than the Maine rate in 1970–1985 and 2001–2006.

In an editorial[2], Drs Darwin Labarthe and Jeremiah Stamler (Northwestern University Feinberg School of Medicine, Chicago, IL) say the findings "reinforce the importance of cardiovascular health promotion and disease-prevention policies and practices at the community level." The FCHP, they state, shows that with an "integrated concerted effort based on good evidence, the cardiovascular health of a community can be improved."

Labarthe and Stamler question how broadly the experiences of the FCHP would translate to other communities, although they point out Franklin Country is typical of rural northern US communities in many ways, such as their population growth from 1970 to 2010, predominance of white individuals, shifts in age distribution, and increasing levels of poverty.

For the editorialists, the FCHP study shows that despite geographic isolation, limited financial resources, limited health-service infrastructure, and low household income, barriers to cardiovascular health can be overcome. The improvements made in Franklin County over the past 40 years would suggest the improvements can be replicated elsewhere, including urban areas, they say.

Record and Franklin Memorial Hospital hold a minority interest in Franklin ScoreKeeper, a company formed to make and market software developed by the Franklin Cardiovascular Health Program. Disclosures for the coauthors are listed in the paper. The editorialists report they have no relevant financial relationships.


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