Effect of a community cholesterol screening program on serum total cholesterol level

BRIEF REPORTS

Effect of a Community Cholesterol Screening Program on Serum Total Cholesterol Level Thomas C. Hilton, MD, and Harold L. Kennedy, MD. MPH

he National Cholesterol Education Program advocatesthe importance of “knowing your cholesterol.“’ However, the value of cholesterolawareness has not been tested. This report compares serum total cholesterol levels at baselineand 6 months later of apparently healthy volunteers participating in a cholesterol screening program with levels in control subjects who did not participate in the program. In November 1987, the Upson County Hospital in Thomaston, Georgia (population 10,000) sponsored a Community Health Fair. As part of the health fair, a voluntary total serum cholesterol test was offered for $3.00. Four hundred nine participating volunteers were advised to havefollow-up cholesterol testingfree of charge after 6 months. At the same time, 51 control subjects (mostly hospital employees and private patients of one of the authors (TCH)) agreed to have their serum cholesterol tested and to remain unaware of the test result until a 6-month follow-up cholesterol test had been performed. Persons were excluded from the control group if they had knowledge of their serum cholesterol level in the 6 months before baseline test, or if they attended the Community Health Fair. Pamphlets containing information about hypercholesterolemia were made available to volunteers at the health fair. Study volunteers were told their baseline test results by telephone. Additionally, their test results were forwarded to their personal physicians with a letter describing the baseline test results. Physicians were encouraged in the letter to discuss the test results with the study volunteers. The study coordinators made no specific recommendations to either the volunteers or their physicians regarding the risks of hypercholesteremia or therapeutic options. Study volunteers and controls were requested to return for a free follow-up test at 6 months. The control group was contacted by telephone and told the baseline and follow-up test results only when the follow-up testing had been completed. Control subjects were eliminated from the study if they had their cho-

T

From the Division of Cardiology, Department of Internal Medicine, St. Louis University Medical Center, 3635 Vista at Grand Boulevard, St. Louis, Missouri 63110-0250, and the Department of Medicine, Upson County Hospital, Thomaston, Georgia. This research was sponsored in part by a grant from the Parke-Davis Company, Morris Plains, New Jersey. Manuscript received November 19, 1990; revised manuscript received March 11, 199 1, and accepted March 17.

lesterol tested between the baseline and follow-up testing. A follow-up questionnaire was sent to study volunteers who completedfollow-up testing asking: (I) Did their doctor discuss their test results with them? (2) Did their doctor make specific recommendations (diet or medications)? (3) Did they begin taking a cholesterol-lowering drug? (4) Did they alter their diet, and (5) if so, for what reason? All specimens (mostly nonfasting) were analyzed enzymatically on a DuPont Aca(R) discreet clinical analyzer.2 Comparison of continuous variables between groups was performed with the independent t test. Comparison of continuous variables in the same groups vrom baseline to follow-up) was performed with dependent t test. Discreet variables were compared using chi-square analysis. Differences were considered significant at p (0.05. Percent changes represent the mean of percent changes in persons. Continuous variables are reported as mean f standard deviation. Eight hundred people attended the Health Fair, of whom 409 volunteered to have cholesterol testing: 303 volunteers (37% men, mean age 60 years) completed the (i-month follow-up test and comprised the study group. Mean cholesterol level was 258 mg% (Table I). Thirty-seven people (58% men, mean age 52 years) were recruited as control subjects completed followup testing. Mean serum cholesterol was 224 mg% (Table I). Participants who did not complete followup testing had baseline characteristics similar to the participants who did. From baseline to 6-month follow-up (Table I) statistically significant improvement in cholesterol levels was observedin the older age subgroups of volunteers, and the greatest improvement was observed in volunteers aged >60 years (266 to 235 mg%, -10.2%, p KO.001) (Figure I). There was no significant change in serum cholesterol from baseline to follow-up testing in any age subgroup of control subjects. From baseline to follow-up there was a shift in individual volunteers from the group with abnormally high cholesterol to the groups with normal and moderately elevated cholesterol (Figure 2). This improvement was not observed in control subjects. One hundred eighty-eight volunteers (62%) responded to the questionnaire. Volunteers who disBRIEF REPORTS 247

cussed their test results with their doctor had a signif- doctor’s specific recommendations achieved a significantly greater percent improvement at follow-up cant reduction (-12.7%, p <0.002) at follow-up. Volthan those who did not (-11.1 us -8.4%, p = 0.05). unteers who altered their diet specifically to lower Participants who altered their diet had a greater rela- their cholesterol had signijcantly greater improvetive decrease in serum cholesterol at follow-up than ment in cholesterol levels (272 to 241 mg%, -10.5%, those who did not (-10.7 us -IA%, p 60 years) volunteers with high serum cholesterol

Age < 40 years Number Baseline’ Follow-up+ Mean % change per individual p Value* Age 40-60 years Number Baseline Follow-up Mean % change per individual p Value Age > 60 years Number Baseline Follow-up Mean % change per individual p Value

Volunteers (n = 3031

Control Subjects (n = 37)

p Value*

26 232 228 -0.6%

8 212 243 +19.9%

NS NS 0.03

NS

NS

107 251 233 -5.3%

18 219 228 +6.4%


Improvement In Volunteers by Age Subgroq Pc.all f-l P<.om

NS NS 0.002

NS 11 240 256 -+7.7%

170 266 235 -10.2%
NS NS
<40yrs. 626)

NS

ilntergroupcomparisons. ‘Cholesterol values expressedin mg%. ‘Intragroup comparisons. NS = not significant.

760

yts.

(n-170)

FtGURE 1. Significant reductions in mm chotesterol from baseline to follow-up were observed in the older age subgroups of volunteers. NS = not significant.

:

CONTROLS (n=37)

80

80

P<.Oi Baseline

70

-yrS. (-107)

I-?

izi

70

6 Month Follow - up

60

P=NS P=NS P=NS I

P=NS

i-5

P<.Ol

r240 nlg%

.c?oo nlgx

Serum Cholesterol FIGURE 2. Compared with control subjects, the votudeer population ted group from baseline to follow-up. NS = not signittcant.

248

THE AMERICAN

JOURNAL

OF CARDIOLOGY

VOLUME

68

200 -240 mg%

2240 rng%

Level

demonstrated

JULY 15, 1991

a significant

shift toward

the nomlalcboles-

(>240 mg%), who discussedtheir test results with their doctor and who altered their diet or started drug therapy for the specific purpose of decreasingcholesterol.Other studies have reported the results of community-based cholesterol awarenessprograms3-5but have not compared the results of volunteers to control subjects unaware of results. The present study sought to assessa “cholesterol awarenesseffect” in a controlled manner, and to provide data about the individual responseto the cholesterol testing. The significant improvement in the study group compared with control subjectsis partially the result of regressionto the mean and differencesbetween the 2 groups. However, the very significant improvement in cholesterol levels, especially in patients in the older subgroups who discussedthe test results with their physician, validates our conclusion that cholesterol screening resulted in cholesterol reduction. Wynder et al3 tested cholesterol levelsof 12,432volunteersin New York City. Forty percent of volunteersin that study respondedto the testing with a changein diet compared with 77% in the present study. This may be due to the higher prevalenceof hypercholesterolemiain the present volunteer group. Also, in the present study, 41% of volunteers discussedtheir test results with their physician, and this was associatedwith reduction of serum cholesterol levels. The Stanford Three Community Study4 evaluated the effect of cholesterol awarenessand diet modification by performing a health education campaign in 2 communities and comparing the effects on diet and serum cho-

lesterol levels to a control community with no health education campaign. There was a significant decreasein dietary fat consumption in the study cohort compared with the control group at 1 and 2 years. However, the predicted decline in serum cholesterollevelswas not observed.The greater improvement in volunteer cholesterol levels in the present study compared to the Stanford study may be attributable to (1) the shorter duration of our study (6 months vs 2 years), (2) the involvement of the local physician, or (3) increased acceptance and availability of low-cholesterol foods in the 1980’s compared with the 1970’s when the Stanford Study was completed. Acknowledgment: We gratefully acknowledge Sue Marler for her expert assistancein the preparation of this manuscript. We alsogratefully acknowledgethe laboratory assistanceof Mike Pascoeand the editorial assistance of Morton J. Kern, MD.

1. The Expert Panel. Report of the National Cholesterol Education Program Expert Panelon Detection,Evaluation, and Treatment of High Blood Cholesterol in Adults. Arch Intern Med 1988;148:36-69. 2. DuPont aca cholesterolmethod.Wilmington, DE: DuPont Company,Clinical SystemsDivision, 1982. 3. Wynder EL, Field F, Haley NJ. Populationscreeningfor cholesteroldetermination. JAMA 1986;256:2839-2842. 4. Stern MP, Farquhar JW, Maccoby N, Russell SH. Results of a two-year health educationcampaignon dietary behavior.The Stanford Three Community Study. Circulation 1976;54:826-833. 5. Sutterer JR, Carey MP, Silver DK, Nash DT. Risk factor knowledge,status, and changein a communityscreeningproject.J Community Health 1989;14:137.

Effect of a Two-Year Public Education Campaign on Reducing Response Time of Patients with Symptoms of Acute Myocardial Infarction H. Weston Moses, MD, Nina Engelking, RN, George J. Taylor, MD, C. Prabhakar, Jerry A. Colliver, PhD, Herschl Silberman, MD, a;d Joel A. Schneider, MD arlier application of thrombolytic therapy for acute myocardial infarction (AMI) improves efficacy.1-5 For maximal benefit, patients must recognizecardiac symptomsand seekcare promptly. To determine whether a public education program would improve the public’s ability to recognize symptoms of AM1 and seekprompt medical attention, thereby reducing delay between onset of symptoms and hospital presentation, we evaluated emergency department records before and after a public education campaign.

E

From St. John’s Hospital, P.O. Box 19420, Springfield, Illinois 627949420. This study was supported by St. John’s Hospital. Manuscript received January 14, 1991; revised manuscript received March 18, 1991, and accepted March 19.

MD,

M. Vallala,

MD,

Jacksonville is a town in rural central Illinois with 1 hospital serving a population of 26,000 in town and a total population of 55,000. Baseline data were gatheredfor I year: 9 months from retrospective review of emergencydepartment charts, and 3 months prospectively. We selected 80 complaints commonly suggestive of AMI (Table I). The study population consisted only of persons reporting to the emergency department with I or more of these 80 complaints. Records of persons who did not report any of the 80 target symptoms are not included in this study. A 1-year public education program, targeted at the entire population, was instituted at a cost of $10,000, which was felt to be a reasonable cost expenditure for a mediumsize hospital. The program consisted of patient eduBRIEF REPORTS 249