Research articles
Mortality impact of an integrated community cardiovascular health program

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Abstract

Background: Preventing cardiovascular disease through community interventions makes theoretical sense but has been difficult to demonstrate. We set out to determine whether a community cardiovascular health program had an impact on mortality.

Design: Program evaluation plus ecologic observational analysis of program encounters and mortality rates with external comparisons.

Setting: Franklin County and two comparison counties in rural Maine.

Participants: Program encountered >50% of regional adults, broadly distributed by site, gender, and age.

Interventions: From 1974 to 1994, a community program, integrated with primary medical care and staffed by professional nurses, provided education, screening, counseling, referral, tracking, and follow-up for cardiovascular risk factors.

Main Outcome Measures: Age-adjusted mortality rates (total, heart, coronary, cerebrovascular, cancer) for three counties and Maine, plus annual program encounters.

Results: Relative to Maine, the Franklin heart disease death rate was 0.97 at baseline (1960–1969; 95% confidence interval, 0.91 to 1.03), 0.91 during the program (0.85 to 0.97), 0.83 during the 11 years of program growth (0.78 to 0.88), but 1.0 during the 10 years of decreasing encounters. Franklin’s total death rate was 1.01 at baseline, 0.95 during the program (0.92 to 0.98), and 0.90 during program growth (0.86 to 0.94). Results were similar for coronary disease, stroke, and cancer. Relative death rates did not fall in either comparison county. Nurse–client encounters totaled 120,280 over 21 years. Relative to Maine, heart disease death rates correlated inversely with program encounters (r = −0.53) but not with unemployment or physician supply.

Conclusions: Integrated with primary medical care, a comprehensive, nurse-mediated community cardiovascular health program in rural Maine has been associated with significant time-dependent and dose-dependent reductions in cardiovascular and total mortality.

Introduction

Preventing cardiovascular disease through community interventions makes theoretical sense.1 Several small-scale community interventions2, 3, 4, 5, 6, 7, 8, 9 and nurse-mediated initiatives10, 11, 12 have improved risk factors. In North Karelia, Finland, community programs reduced risk factors and probably reduced cardiovascular deaths.13, 14, 15 In the United States, however, three major community demonstration projects (Stanford,16 Minnesota,17 and Pawtucket18) showed only modest effects on citizen attitudes, behaviors, and risk factors, and no significant effect on health outcomes.19, 20, 21

The Franklin Cardiovascular Health Program has served Franklin County in rural Maine since 1974. Here we describe the program and assess its impact on cardiovascular disease by comparing cardiovascular and total mortality in Franklin County with two adjoining, demographically similar, rural counties and with the state of Maine.

Section snippets

Region and population

The program has served 23 predominantly rural communities in Franklin County, Maine. Table 1 presents comparative sociodemographic, health care resource, and cardiovascular risk-factor characteristics for Maine and three counties: Franklin, Oxford, and Somerset.22

Regional health care

Starting in 1970, Rural Health Associates (RHA), a community-based, nonprofit health care corporation, attracted recently trained physicians to a new primary care network. With federal funding, RHA established Maine’s first health

Intervention intensity

The Program reached clients at 27 community sites in 14 towns, over 50 worksites, and many civic groups. Participation was broadly distributed by site (community, 36%; workplace, 64%); gender (male, 42%); and age (18–40 years, 35%; 41–60 years, 32%; 61–80 years, 25%; >80 year, 7%). The program encountered >50% of regional adults in each phase. Franklin residents accounted for 76% of program encounters, compared with Oxford, 6%, and Somerset, 1.4%. Overall, there were 120,280 encounters,

Discussion

In this observational analysis of the Franklin Cardiovascular Health Program in rural Maine, we demonstrate significant associations consistent with the hypothesis that a nurse-mediated community cardiovascular health program, integrated with primary medical care, can help reduce cardiovascular and total mortality. During the program, Franklin County rates were significantly below those of Maine for both heart disease deaths (by 9%) and total deaths (by 5%) (Figure 3). Relative to Maine,

Conclusion

For more than 2 decades, a comprehensive community cardiovascular health program in rural Maine has helped integrate medical practice and public health. Featuring community-based, nurse-mediated risk-factor assessment, counseling, referral, and follow-up, the Franklin program has been associated with significant time- and dose-dependent reductions in cardiovascular and total mortality. Periods of intense community program activity produced large numbers of clients, dynamic interaction between

Acknowledgements

The authors express appreciation for encouragement and critical insight to Henry Feldman, Stephen Fortmann, Thomas Kottke, Thomas Pearson, and Lars Weinehall; for editorial advice, to Mary Louise Hinckley; and for their participation in the Franklin program, to the nurses, physicians, and citizens of west central Maine.

For their willingness to review critically and provide written confirmation of the accuracy of our characterization of their respective programs in Table 2, the authors thank

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