Current findings also can be applied to systems of health care in programmatic ways to improve the quality of care without necessarily increasing the cost. Existing programs of patient education and evaluation can be refocused without major expansion to include family needs. Program protocols can provide information about disease management that includes relational coping and encourages better family problem solving and disease-related planning, emotional expressiveness, and conflict resolution within the home. Anderson and coworkers25 showed that a brief office-based intervention that helped adolescents with type 1 diabetes and their parents negotiate glucose monitoring and insulin injections improved parent-adolescent relationships, reduced conflict between members of both generations, and prevented parental withdrawal, which was linked to poor glucose control. These programs, sometimes brief and surprisingly simple, can be very effective. They do not require a massive reorganization of care but emphasize a refocusing of care that adopts a family-based perspective.
Although many studies have begun to demonstrate the power of family-based interventions, new studies are needed to refine and enhance the design of family-based intervention protocols, the technology of intervention evaluation, and the documentation of cost savings. The need is especially evident for chronic diseases of adulthood, such as type 2 diabetes, cardiovascular disease, and COPD/asthma.
Conclusions
The growing cost of disease management and the requirement that patients and families provide increasing amounts of care outside the health care system require a re-evaluation of the interventions currently in use. We suggest that a broader social and ecologic perspective to the management of chronic disease has several advantages compared with other approaches. It includes expanded clinical flexibility of more aspects of the management process; it incorporates more of the important players who participate in disease management; it harnesses the power and resources of the family to optimize care and brings them into the system as active participants; and it addresses a broad array of protective and risk factors that can affect outcomes over time. In this sense, a family-focused perspective integrates patient, family, and community perspectives by linking them directly to the setting where most disease management takes place. By so doing, it provides an expanded set of options for care that addresses the growing problems and costs that patients, families, and health care providers face when managing chronic disease.
Acknowledgments
Supported by the Office of Behavioral and Social Sciences Research, National Institutes of Health, and Pfizer Pharmaceuticals, Inc.
In addition to the authors, the members of the National Working Group on Family Based Interventions in Chronic Disease are: Barbara Anderson, PhD; Macaran A. Baird, MD; Janice Bell, RN, DNSc; Thomas Campbell, MD; Catherine A. Chesla, RN, DNSc; Frank deGruy, MD; Perry Dickenson, MD; Ann Garwick, PhD; Catherine L. Gilliss, RN, DNSc; Darryl Goetz, PhD; Ronald Goldschmidt, MD; George Howe, PhD; Nadine Kaslow, PhD; Ann Kazak, PhD; Morton A. Lieberman, PhD; Mary Mittelman, PhD; Susan McDaniel, PhD; Joan Patterson, PhD; Donald Ransom, PhD; John Rolland, MD; David Reiss, MD; Cleveland Shields, PhD; Peter Steinglass, MD; Frank Wamboldt, MD; Marianne Wamboldt, MD; Beatrice Wood, PhD; and Lyman Wynne, MD.