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

Interventions听 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听 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听 More than 150鈥�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鈥夆垝鈥塭xpected [O鈥夆垝鈥塃], 11.3%; 95% CI, 5.5%-17.7%; P鈥�<鈥�.001), 1996-2000; these differences later disappeared when Maine鈥檚 overall quit rate increased. Franklin County hospitalizations per capita were less than expected for the measured period, 1994-2006 (O鈥夆垝鈥塃, 鈭�17 discharges/1000 residents; 95% CI 鈭�20.1 to 鈭�13.9; P鈥�&濒迟;鈥�.001). Franklin was the only Maine county with consistently lower adjusted mortality than predicted over the time periods 1970-1989 and 1990-2010 (O鈥夆垝鈥塃, 鈭�60.4 deaths/100鈥�000; 95% CI, 鈭�97.9 to 鈭�22.8; P鈥�<鈥�.001, and 鈭�41.6/100鈥�000; 95% CI, 鈭�77.3 to 鈭�5.8; P鈥�=鈥�.005, respectively).

Conclusions and Relevance听 Sustained, community-wide programs targeting cardiovascular risk factors and behavior changes to improve a Maine county鈥檚 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.

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.¹ Preventive interventions have been attempted in many different settings, including communities, schools, faith groups, worksites, and health care facilities.² Most efforts have focused on single risk behaviors (diet, tobacco use, physical inactivity), single clinical risk factors (hypercholesterolemia, hypertension), earlier recognition, and treatment of overt disease. A few relatively brief, comprehensive, community-wide risk-reduction studies with nonintervention comparison populations in urban settings^3-7 reported inconsistent results⁸ and often lacked sustained interventions or consistent engagement with local health care systems. Few studies have sustained interventions, documented preventive services, monitored changes in risk factors and behaviors, and measured associated reductions in morbidity and mortality. Very few involved rural, socially disadvantaged communities,^9,10 which typically lag behind metropolitan areas in cardiovascular mortality improvements.^11,12

We describe a set of interventions to improve population health and their associated outcomes over 40 years in Franklin County, a low-income, rural county in west central Maine. In the late 1960s, local community groups 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鈥檚 hospital initiated and coordinated their efforts.^13,14 We report what this community collaboration, using modest start-up grants and many volunteers, did over decades to improve health care access and integrate clinical care with population-wide prevention programs. Specifically, we report rates of smoking cessation and control of hypertension and elevated cholesterol. We also extend prior mortality observations¹⁵ by 16 years, as well as report hospitalization and mortality rates by household income for Franklin County compared with other Maine counties over a 50-year observation period.

Beginning in the 1970s, several Franklin County initiatives to improve local health were begun (Table 1 and eFigure 1 and eMethods in the Supplement). The local CAA and physician and other community leaders convened to evaluate and improve local health, recruit primary care clinicians, and found a nonprofit, multispecialty medical and dental group practice (RHA), with 1 central and 3 remote clinics. Federal grants funded planning and implementation of a comprehensive capitated health insurance plan for 3000 indigent residents, the Franklin Area Health Plan, which eventually expanded to a commercial capitated health plan. With hospital medical staff sponsorship, RHA established in 1974 the community-wide Franklin Cardiovascular Health Program (FCHP).^15,16 Over time, many other local public and nonprofit organizations collaborated on various components of these community efforts. Participants included the hospital, local businesses, schools, and the local University of Maine campus, which developed a health education degree program and trained local CAA outreach workers.

The FCHP adapted a community-based clinic model, sending nurses and trained community volunteers into town halls, church basements, schools, and worksites. Early encounters emphasized screening, but FCHP staff also encouraged return for monitoring, counseling, and periodic rescreening. People with uncontrolled health conditions were referred to physicians for treatment. Ongoing results of patient monitoring were sent to the person鈥檚 physician, who often reciprocally referred to FCHP for interval monitoring between doctor visits. In its first decade, FCHP emphasized detection and control of hypertension.^17,18 Subsequently, it added programs to detect and control hyperlipidemia (1986), minimize tobacco use (1988), and co-manage diabetes in medical practices (2000), and from the beginning, it promoted physical activity and healthy eating. The FCHP adapted elements of contemporary, innovative national^3,5-7 and international^4,9 programs. Quiz Ref IDStrategies included using (1) evidence-based targets, interventions, and standard operating procedures; (2) measurable and monitored objectives; (3) lay and professional leadership; (4) primary care clinician and community participation in program design, implementation, and evaluation; (5) coordination with and supplementation of medical practices; (6) risk factor screening, referral, and follow-up, with education and individual health coaching¹⁹ predominantly by a large cadre of volunteer local nurses in multiple community, school, worksite, and health care settings; (7) patient, physician, and health coach collaboration, including practice-based nurse care management²⁰; and (8) monitoring and tracking systems that FCHP created (Table 1 and eMethods and eFigure 1 in the Supplement).

The outcomes monitored over the decades were adult participation measured by total and individual person encounters with program staff; intermediate risk factor outcomes (hypertension, hyperlipidemia, and smoking); morbidity, measured by income- and age-adjusted hospitalization rates compared with other Maine counties; and mortality, measured by overall and cardiovascular-specific age- and income-adjusted mortalities compared with other Maine counties.

For hypertension, hypercholesterolemia, and smoking cessation, program efficacy was monitored based on local guidelines and, once available, national guidelines.^21-24 Beginning in 1985, county-of-residence hospitalization and mortality rates from Maine public sources were available from data sources described next.

The FCHP paper and computerized medical record systems provided aggregated data from 1974-2009 on screening and follow-up encounters, demographics, behavioral risk factors, and hypertension and cholesterol control. A reanalysis of previously reported data^17,18 was done on the first 4 years of FCHP. United States Census reports provided demographic data, including county population, age, education level, and median household income for 1970-2010.²⁵ The Maine Center for Disease Control鈥檚 Office of Data, Research, and Vital Statistics (ODRVS) provided mortality rate data for 1960-1967 and indirectly for 1968-2010 from the US Centers for Disease Control and Prevention鈥檚 (CDC) Wonder website,²⁶ using International Classification of Diseases codes for coronary heart disease and stroke to reflect CVD. The ODRVS provided smoking data from the US CDC鈥檚 Behavioral Risk Factor Surveillance System (BRFSS) for 1994-2011.²⁷ Franklin Memorial Hospital and the Maine Health Data Organization²⁸ provided 1994-2006 hospitalization data based on county of residence. The beginning and ending dates of reported outcome data sets vary because of availability. The University of Southern Maine institutional review board stated that this study was exempt from review on March 7, 2014.

Data were aggregated at a Maine county level, and the other 15 Maine counties were used for comparison with Franklin. The period 1960-1970 was used as a baseline for comparison with the described community interventions period, which began in the early 1970s. Maine county鈥搇evel age-adjusted mortality rates for the 1960s were available only in ODRVS final report form, already age-adjusted to the US 1940 standard population. Without those raw data to age-adjust to a more contemporaneous population, we age-adjusted subsequent decade data to 1940 to maintain comparability of mortality rates over the entire 50-year period 1960-2010. Cardiovascular and total mortality data were summed to rolling 3-year averages to improve statistical power. Hospitalization rate analyses omitted Maine鈥檚 southernmost county, because a substantial proportion of its population鈥檚 hospitalizations occur in adjacent states and hence are unavailable for analysis. Obstetric and neonatal hospitalizations were omitted from the overall hospitalization rate analysis to conform to usually reported hospitalization rates.

Smoking quit rates were calculated from BRFSS questions on 鈥渆ver smoking鈥� and 鈥減resently smoking鈥� as the number of people who reported quitting, divided by quitters plus present smokers. Changes in rates of hypertension and cholesterol control and smoking cessation were analyzed using 蠂² statistics, t tests, or both. Maine vs Franklin County comparisons were analyzed for significance using t tests. Maine county hospitalization and mortality rates were adjusted for income and the goodness-of-fit of the relationship tested using linear regression methods developed by the Institute for Healthcare Improvement²⁹ using data from the County Health Rankings.³⁰ Outlier analysis was performed by calculating the regression models, excluding Franklin County from the Maine county data, calculating the expected Franklin County income-adjusted rate based on the regression model, and comparing the difference between Franklin County鈥檚 actual (observed) vs expected value, based on all other Maine counties using t test scores. Statistical analyses were performed using SYSTAT version 13.00.05. Significance threshold was set at 2-sided P鈥�&濒迟;鈥�.05.

Franklin County is a sparsely populated (22鈥�444 in 1970, 30鈥�768 in 2010), predominantly white, rural county in west central Maine (Table 2). Over the past 40 years, its residents became poorer and older, but its ratio of population to primary care physician improved.

One-on-one interactions between a county resident and a nurse or other health coach in any one of several programs were recorded by FCHP tracking systems (Figure 1). Encounters averaged 5000 per year from 1974-1994 and 3000 per year subsequently. By 2010, more than 150鈥�000 encounters, an average of greater than 5 encounters per Franklin County resident, had been documented.

In its first 4 years, FCHP screened about 50% of county adults. Individuals with hypertension showed significant movement from detection to treatment and control (蠂²₄鈥�=鈥�210, P鈥�<鈥�.001); the proportion in control increased from 18.3% to 43.0%, an absolute increase of 24.7% (95% CI, 21.6%-27.7%; P鈥�<鈥�.001) (Figure 2A). After introducing cholesterol screening in 1986, FCHP reached 40% of county adults within 5 years, half of whom had elevated cholesterols. Over subsequent decades, cholesterol control had an absolute increase of 28.5% (95% CI, 25.3%-31.6%), from 0.4% to 28.9% (蠂²₄₈鈥�=鈥�5499, P鈥�<鈥�.001) (Figure 2B), from 1986 to 2010; individuals with more visits manifested better control (蠂²₁₀鈥�=鈥�598, P鈥�<鈥�.001) (eFigure 2 in the Supplement). Quiz Ref IDSimilarly, after initiation of multiple community smoking cessation projects (eFigure 3 in the Supplement), community-wide smoking quit rates improved significantly, from 48.5% to 69.5%, and became significantly higher than that for the rest of Maine, which improved from 58% to 61% in 1996-2000 (observed鈥夆垝鈥塭xpected [O鈥夆垝鈥塃], 11.3%; 95% CI, 5.5%-17.7%; P鈥�&濒迟;鈥�.001). Both the Franklin and rest-of-Maine quit rates remained significantly above US median rates since that time (Franklin County vs US quit rates for 1996-2000: O鈥夆垝鈥塃, 17.7%; 95% CI, 12.4%-23.0%; for 2001-2005: O鈥夆垝鈥塃, 7.7%; 95% CI, 1.6%-13.9%; and for 2006-2010: O鈥夆垝鈥塃, 10.2%; 95% CI, 6.6%-13.7%) (Figure 2C).

Maine hospitalization rates were strongly associated with household income (R²鈥�=鈥�0.72; 95% CI, 0.33 to 0.90; P鈥�&濒迟;鈥�.001; Figure 3). For the period for which data were available, 1994-2006, Franklin County鈥檚 observed hospitalization rate was significantly lower than predicted by household income (O鈥夆�撯�塃, 鈭�17 discharges/1000 population; 95% CI, 鈭�20.1 to 鈭�13.9; P鈥�&濒迟;鈥�.001).

After being at or above overall Maine mortality rates in the 1960s, Franklin County rates (age-adjusted deaths/100鈥�000/y) decreased below Maine rates for almost the entire period 1970-2010 (Figure 4), with differences that reached statistical significance during 2 time periods, 1970-1985 and 2001-2006. Cardiovascular-specific mortality rates decreased similarly (eFigure 4 in the Supplement). The greatest divergences coincided with periods of peak efforts to improve health care access, detect and control hypertension and hypercholesterolemia, and reduce smoking (Figure 1).

Franklin County mortality rate divergences from Maine averages were greater when adjusted for income (Figure 5). During the 1960s, Franklin County age- and income-adjusted mortality rates were not significantly different from the rest of Maine (O鈥夆垝鈥塃, +7.9 deaths/100鈥�000 people; 95% CI, 鈭�22.0 to +37.9; P鈥�=鈥�.36) (Figure 5A). During 1970-1989, despite static relative income, Franklin mortality rates were the lowest in Maine (O鈥夆垝鈥塃, 鈭�60.4 deaths/100鈥�000; 95% CI, 鈭�97.9 to 鈭�22.8; P鈥�<鈥�.001) (Figure 5B). During 1990-2010, Franklin鈥檚 household income decreased relative to other Maine counties, but Franklin continued to show significantly lower mortality than predicted by income (O鈥夆垝鈥塃, 鈭�41.6 deaths/100鈥�000; 95% CI, 鈭�77.3 to 鈭�5.8; P鈥�=鈥�.005) (Figure 5C) with rates comparable with those of more affluent counties. At the same time, the proportion of mortality variance among Maine counties explained by household income increased from 14% in 1960-1969 (95% CI, 0% to 55%, P鈥�=鈥�.17), to 38% in 1970-1989 (95% CI, 2% to 74%, P鈥�=鈥�.01), and to 81% (95% CI, 51% to 93%, P鈥�<鈥�.001) in 1990-2010. With the exception of Franklin County, Maine county death rates were increasingly related to income levels from 1960 to 2010.

In a rural Maine county, we observed consistent temporal associations between sustained community-wide preventive interventions and several health outcomes, including health behaviors, risk factor control, hospitalization rates, and mortality. Quiz Ref IDSubstantial improvements were observed for hypertension control, cholesterol control, and smoking cessation within Franklin County. These were temporally associated with favorable rates of hospitalization and cardiovascular and all-cause mortality compared with the rest of Maine. The increasing association of total mortality variance with household income in Maine throughout this 50-year period appears to have affected Franklin less than other counties. The lower overall hospitalization rates were associated with $5鈥�450鈥�362 reductions in total in- and out-of-area hospital charges for Franklin County residents per year (eTable in the Supplement).

The strengths of this study include (1) community-wide support from local physicians, nurses, community leaders, volunteers, and the local hospital; (2) the unusually long, continuous interventions and observation period; (3) the stability of the population over the observation period; and (4) the acceptance of the program by the community.

Several limitations must be considered. As in most observational studies, proving a causal connection between the multifactorial interventions and health outcomes is challenging. The ecological study design leaves open the possibility that the intervention-outcome associations observed could be due to other factors. Nor does the design permit distinguishing any effects of improving health care access from those of community-wide efforts to reduce unhealthy behaviors or identifying which of the various interventions were more effective. Improved primary care access was associated with programmatic interventions. Demographic changes over time could have confounded the observed changes. Franklin County residents did become older and poorer. Available data on net migration were similar to Maine and adjoining counties.¹⁵ Very recent mortality trends, unadjusted for income, were back to state averages, perhaps associated with the observed further declines in local household income, waning effort intensity, or 鈥渃atch up鈥� by the rest of the state, as many counties developed programs modeled on those in Franklin. But the outcome associations over a long time period suggest that any confounder would have to have been active over the same period. However, despite these limitations, the most plausible explanation for the observed health benefits appears to be the sustained community-wide programs to improve health.

Cardiovascular and total mortality data from vital statistics sources have been used as reliable health outcomes.³¹ Two recent national analyses^29,30 identified Franklin County as having unusually favorable current health indicators compared with the rest of Maine; both also reveal substantial county-level variation in health with very few US counties demonstrating better health than would be predicted by their household incomes. Primary and secondary prevention interventions are likely responsible for rapid declines in CVD mortality nationally since 1990.³² Total and CVD age-adjusted mortality declines in Franklin County and Maine over these 40 years often preceded that national decline. Franklin鈥檚 insurance program for a large segment of its low-income population for the first 15 years of the program may also have jump-started improvements, as Medicaid expansion appears to have recently done in Massachusetts.³³

The intervention programs in Franklin County adopted and continually updated evidence-based health risk assessment and intervention strategies. They were unusual for their early adoption and persistence over decades. In 1970, few intervention programs were in place for Franklin to follow.^3,4 Other published rural cardiovascular intervention programs were not initiated until the 1980s.^9,10 Calls for comprehensive, multisector community interventions^34,35 were not forthcoming for another 20 years. Quiz Ref IDSubsequently, the role of social determinants, especially education and income, in heart disease, stroke, and other chronic diseases have been well documented in studies of both individuals and populations.^36-38 Rural counties, including Franklin, have been falling behind in these determinants, with stagnant household incomes, increasing poverty, and an increasingly elderly population. National data also document slower heart disease mortality declines in rural compared with urban populations.^11,12 Rural communities, with high poverty rates and below-average health care access, are often 鈥渓ate-adopter communities,鈥� resisting 鈥渄iffusion of innovation.鈥�³⁹

Several key factors may explain why Franklin County residents have had better outcomes than their peers elsewhere in Maine. Late-adopter communities frequently fail to engage innovation unless additional efforts are expended to organize the community, to ensure personal health services, and to enact policy and environmental changes.⁴⁰ Such efforts did occur in Franklin, likely explaining why it became an early adopter, only later matched by the rest of the state, as the smoking and mortality data demonstrate. Rural Health Associates and its physician group rapidly improved financial access as well as local access to dental, specialty, and primary care, subsequently maintained in large part by the single county hospital. The FCHP initiated multiple risk factor intervention programs and rallied community support for public policies and initiatives to discourage smoking and encourage better diet and physical activity for all citizens. Also likely important were program sponsorships by multiple community organizations, consistent with the role of 鈥渟ocial capital鈥� in health.⁴¹ Despite annual variations over time as program funding, enthusiasm, and the economy fluctuated, the total number of people engaged in the programs demonstrated that multisector, comprehensive, and locally administered programs have been active at many levels in Franklin County since the early 1970s, despite static household incomes.

Quiz Ref IDThree major CVD prevention projects in the 1980s (Stanford,^42,43 Minnesota,⁴⁴ and Pawtucket⁶) contributed substantially to subsequent models^45,46 but failed to show reduced CVD morbidity and mortality. In contrast, the prospective, controlled Finnish North Karelia⁴⁷ project documented sustained, population-wide risk factor improvement and decreased deaths from CVD and cancer.^48,49 It and Franklin shared distinguishing program characteristics: indigenous impetus, rural community ownership, multidecade longevity, flexible interventions, sustained risk factor and client tracking and follow-up, professional nursing prominence, and programmatic integration with primary medical care.^14,16 The last may well facilitate reconciliation of individual vs population health goals.⁵⁰

Is the Franklin County experience relevant to other US communities? The Affordable Care Act created new opportunities to implement changes such as these elsewhere and to measure their effects on noncommunicable diseases and health care costs.⁵¹ Among them are requirements that tax-exempt hospitals assess the health needs of their communities and develop implementation strategies to meet those needs.⁵² In 2009, US hospitals spent 7.5% of their operating expenses on community benefits, but largely on charity care.⁵³ Only 0.4% was spent on population health improvements like those described here. The experience in Franklin County suggests that community health improvement programs may be both feasible and effective. 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.

Sustained, community-wide programs targeting cardiovascular risk factors and behavior changes to improve a Maine county鈥檚 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.

Corresponding Author: Roderick E. Prior, MD, 243 High St, Farmington, ME 04938 (rprior04938@myfairpoint.net).

Author Contributions: Drs N. B. Record and Prior had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: N. B. Record, Onion, Dixon, S. S. Record, Fowler, Pearson.

Acquisition, analysis, or interpretation of data: N. B. Record, Onion, Prior, S. S. Record, Cayer, Amos, Pearson.

Drafting of the manuscript: N. B. Record, Onion, Prior, Dixon, S. S. Record, Fowler, Amos, Pearson.

Critical revision of the manuscript for important intellectual content: N. B. Record, Onion, Prior, Dixon, S. S. Record, Cayer, Amos, Pearson.

Statistical analysis: N. B. Record, Prior, Amos.

Administrative, technical, or material support: Prior, Dixon, S. S. Record, Fowler, Cayer, Pearson.

Study supervision: Onion, Pearson.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr N. B. Record and Ms S. S. Record reported that they and Franklin Memorial Hospital hold minority interests in Franklin ScoreKeeper, a company formed to develop and market the software developed by the FCHP. No other disclosures were reported.

Funding/Support: Logistical and financial support was provided by Franklin Memorial Hospital. Federal support beginning in 1972 until the mid-1980s came from the Office of Economic Opportunity and the Rural Health Care Service Outreach grant program; multiple small grants of $10鈥�000 to $80鈥�000 over the past 40 years, mostly during the initial 2 decades came from the Federal Health Underserved Rural Area grant program, the Bingham Program, the Regional Medical Program, Maine Bureau of Health, Maine Department of Human Services 314(d) grants, Western Maine Community Partnership, the Healthy Communities Coalition, Franklin Memorial Hospital, the United Way, and others, the details for which are no longer available.

Role of the Sponsors: There was no sponsor and no direct financial support for this report beyond the participation in the study group, from which this article eventually emerged, of some present (G.R.C,) and past (N.B.R., S.S.R., D.C.D., R.E.P.) Franklin Memorial Hospital employees. The hospital and ScoreHealth System provided some administrative support, such as meeting space and clerical services. Neither the hospital nor other partial funders over the decades listed here had any controlling role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Additional Contributions: We gratefully acknowledge the vital contributions of Clinton C. Conant, BS, MS, and Paul A. Judkins Jr, BA, both now deceased, for their original leadership in the community and the formation of Rural Health Associates. We also thank Richard Batt, BS, MBA, then president of the local hospital, for recognizing the potential of the Franklin Cardiovascular Health Program (FCHP) to advance area community health; John W. Whittington, MD (Institute for Healthcare Improvement [IHI]) for sharing his outcome vs income adjustment methodology, publishing the IHI internal study of outlier US counties online for public access, and general encouragement; David Harris, RN, PhD (University of Southern Maine), and Sheena Bunnell, PhD, MBA (University of Maine at Farmington), for their advice in study concept and design; Michael Rowland, MD, MPH, and Jay Naliboff, MD (Franklin Memorial Hospital), for study group participation and current Franklin Community Health Network information; Jane Arcari, LPN (FCHP), for more than 20 years of diligent FCHP information system development and support, and who, along with Dwight Payne, BS (ScoreHealth System), and Nicole Ditata, MCHES (Healthy Community Coalition of Greater Franklin County), provided data for this article; Kim E. Haggan (Maine Center for Disease Control鈥檚 Office of Data, Research, and Vital Statistics) for her provision of Maine vital statistics records; and W. Gregory Feero, MD (Maine-Dartmouth Family Medicine Residency), James L Glazer, MD (North Conway, New Hampshire, Memorial Hospital/Tufts University School of Medicine), Susan Thomas, MD (ScoreHealth System), and Daniel L. Meyer, PhD (DEWN Associates, Readfield, Maine), for their critical manuscript reviews. None of the authors or contributors received personal compensation for their assistance.

Correction: This article was corrected online April 28, 2015, for errors in the age data in Table 2.