Medication or lifestyle changes are generally used for patients with chronic diseases –- such as diabetes, asthma or hypertension –- to control their conditions and avoid adverse consequences. This fact is both a blessing and a curse. While patients with well-managed illness may remain healthy for decades, doing so typically requires significant behavior changes, which take understanding and motivation. Finding new ways to make this process easier and more effective has long been a goal for the Research Institute's Department of Health Services Research.

Led by Sandra Wilson, Ph.D., the department studies what makes people likely to behave in unhealthy ways and whether changing aspects of health care delivery – such as how physicians and other clinical caregivers interact with patients –- can improve chronic disease outcomes. Research by Dr. Wilson and colleagues, for example, suggests altering how treatment is selected and prescribed increases the chance that patients will take medication to prevent asthma attacks.

The National Institutes of Health-funded Better Outcomes of Asthma Treatment (BOAT) study examines "shared decision-making," in which asthma care managers (such as nurses or pharmacists) and patients discuss treatment goals and lifestyle preferences. "Does the patient want to run marathons or just sleep without symptoms? How many times a day are they willing to take medications? The care manager asks all sorts of questions," Dr. Wilson said. Caregiver and patient then negotiate a plan to meet the patient's goals. Under a traditional care-management model, patients receive medication prescriptions based on medical guidelines, without specifically determining what the patient wants from the treatment and is willing to do regarding medications.

Study results to date indicate that, for patients with poorly controlled asthma, care management using a shared decision-making approach is more effective than traditional care management in increasing use of asthma control medications, and both are more effective than usual medical care by a physician with no care manager involvement. If disease outcomes are improved as well, the findings could have "major implications for managing not just asthma, but other chronic diseases," Dr. Wilson said. A paper presenting the findings to date was given special recognition at the American Thoracic Society's 2006 International Conference.

Chronic illness management is of increasing interest across PAMF, thanks in part to technologies, such as the electronic health record (EHR), that make it easier to deliver and monitor patient care. Dr. Wilson and her colleagues frequently collaborate with PAMF clinicians to test new care models.

For instance, with Pharmacy Coordinator Khue Nguyen, Pharm.D., they are currently designing studies to reduce alcohol-related risk among PAMF's senior patients, who often take multiple medications that can make some patterns of alcohol consumption risky.

Research to improve chronic disease care and medication therapy will likely expand in the coming years, Dr. Wilson said, especially as new researchers join the Health Services Research Department. The topic is of local and national interest as baby boomers age, since older patients are at particularly high risk for chronic illness.

PAMF already plays a key role in this national discussion. In partnership with Acumen LLC, a research group headed by a Stanford economist, the Research Institute is now part of DEcIDE, a network of 13 top research centers selected by the federal Agency for Health Care Research and Quality to conduct studies on health care delivery, costs and quality in the Medicare population. PAMF's recent inclusion in DEcIDE, said Dr. Wilson, "recognizes our potential to make important contributions in answering key questions about how to care for this age group."

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