Methods: Three hundred and fifty-four home care nurses at a non-profit home care agency in the U.S. were randomly assigned to usual care or one of two intervention groups. The basic intervention was a one-time e-mail reminder highlighting six heart failure-specific clinical recommendations. The augmented intervention consisted of the initial e-mail reminder as well as provider prompts, patient education material, and follow-up outreach by a clinical nurse specialist. An e-mail reminder was sent to each nurse when they began treating new heart failure patients. Baseline measures of patient health and functional status were derived from the nurse's routine assessment at the initial visit. Face-to-face follow-up patient interviews 45 days post home care admission were conducted to elicit information on: (1) patient disease self-management, knowledge and behaviour; (2) patient clinical and functional status (measured using the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the EuroQoL quality of life scale); and (3) patient health care utilization (e.g., home care, hospital and emergency services, and physician visits) during the 45 day follow-up period. Statistical analyses were used to compare outcomes from the usual care and intervention groups.

Finding: Of the 1,242 patients eligible for the study, death or institutionalization meant complete interview data were available for 628 (57.9%) patients. The mean age of the patients was 72 years. Approximately 40% were black, and almost one-third were of Hispanic descent. The majority had less than a high school education and were female. The severity of heart failure was similar across groups. Patients in both intervention groups performed significantly better than the usual care group with respect to medication knowledge, diet, and weight management. Clinical outcomes and functional status of patients in both intervention groups were also significantly improved (15.3% and 12.9%, respectively) relative to the control group. There were no significant differences between intervention and usual care groups in depression. Home care visits were more frequent and health care utilization greater for both intervention groups. The home care related cost of the basic and augmented interventions were approximately 19.8% and 21.7% higher than usual care. The cost-effectiveness of the interventions with respect to the KCCQ score and the EuroQoL quality of life scale was evaluated. For both outcomes, the basic intervention was found to be more favorable than the augmented intervention. The basic intervention produced equivalent patient outcomes at a lower cost than the augmented intervention.

Conclusions: The intervention capitalized on existing intranet infrastructure, thereby minimizing the cost and the need for organizational systems changes. This study illustrates that the use of e-mail reminders is an inexpensive and convenient mechanism for home care organizations and other decentralized health care practices to enhance service provision and improve patient self-management and health outcomes.

Reference: Feldman P, Murtaugh CM, Pezzin LE, McDonald MV, Peng TR. "Just-in-time evidencebased e-mail 'reminders' in home health care: impact on patient outcomes". Health Services Research, 2005; 4

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