BackgroundBased on positive findings from a randomized controlled trial, Kaiser Permanente's national executive leadership group set an expectation that all Kaiser Permanente and partner hospitals would implement a consultative model of interdisciplinary, inpatient-based palliative care (IPC). Within one year, the number of IPC consultations program-wide increased almost tenfold from baseline, and the number of teams nearly doubled. We report here results from a qualitative evaluation of the IPC initiative after a year of implementation; our purpose was to understand factors supporting or impeding the rapid and consistent spread of a complex program.MethodsQuality improvement study using a case study design and qualitative analysis of in-depth semi-structured interviews with 36 national, regional, and local leaders.ResultsCompelling evidence of impacts on patient satisfaction and quality of care generated 'pull' among adopters, expressed as a remarkably high degree of conviction about the value of the model. Broad leadership agreement gave rise to sponsorship and support that permeated the organization. A robust social network promoted knowledge exchange and built on an existing network with a strong interest in palliative care. Resource constraints, pre-existing programs of a different model, and ambiguous accountability for implementation impeded spread.ConclusionsA complex, hospital-based, interdisciplinary intervention in a large health care organization spread rapidly due to a synergy between organizational 'push' strategies and grassroots-level pull. The combination of push and pull may be especially important when the organizational context or the practice to be spread is complex.

Background: The goal of this study was to identify target areas for psychosocial intervention for depressed patients with earlyinflammatory arthritis. Methods:One hundred and sixty-five patients with early inflammatory arthritis (≧1 joint with synovitis for ≧6 weeks and <1 year with a diagnosis of either rheumatoid or undifferentiated inflammatory arthritis) were referred to the McGill Early Arthritis Registry (McEAR) by their rheumatologist. McEAR patients agree to periodic physical exams and to completing questionnaires. Demographic, disease and psychosocial factors were compared between patients screening positive and negative for depression using independent samples t tests and Pearson’s χ² test and then were entered into a logistic regression model examining the likelihood of screening positive for depression. Results: Thirty-eight (23%) patients screened positive for depressive symptoms. Patients with symptoms of depression had significantly worse disease severity, disability, and pain, engaged in more emotional preoccupation coping, had less self-efficacy for pain and other arthritis-related symptoms, smaller social networks and were less satisfied with social support than the nondepressed group. In logistic regression analyses, pain and emotional preoccupation coping were positively related to the likelihood of screening positive for depression, while satisfaction with social support was negatively related to the likelihood of screening positive for depression Conclusion: Higher pain levels, emotional preoccupation coping and dissatisfaction with social support were related to depressive symptoms in this study. This suggests that the optimal care of depressed patients with inflammatory arthritis would include a psychosocial approach that addresses these specific target areas.

The goals of this study were to (1) provide preliminary reliability and validity of the Barriers to Treatment Adherence Questionnaire, developed for patients with fibromyalgia, and (2) examine barriers to adherence and general adherence to multimodal treatment during a 3-mo. period. A secondary goal was to explore in a focus discussion group format patients' perceptions of the adherence process and ways of managing the treatment program. 39 fibromyalgia patients were followed while participating in a combined outpatient program of physiotherapy, occupational therapy, nursing, and cognitive behavioral therapy. The Barriers to Treatment Adherence Questionnaire demonstrated good reliability. Construct validity of the Barriers to Treatment Adherence Questionnaire was supported through significant positive correlations with the General Adherence Scale at Months 1 and 3. In addition, a significant change was observed in scores on the Barriers to Treatment Adherence Questionnaire for the physiotherapy component of treatment, with scores decreasing between Months 2 and 3. Addressing barriers to improve adherence may maximize the benefit of treatment programs.

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