Background: Increasingly, health care providers are seeking ways to promote evidence-based practices and reduce unwarranted variations in clinical care. Reminder systems offer promising approaches to achieving this goal of translating research into practice. However, little research has examined the effectiveness of such strategies among non-physician providers.

Purpose: To test the effectiveness and cost-effectiveness of two email-based interventions targeted to home care nurses, designed to promote their adoption of clinically proven practices and to improve patient outcomes.

Study Design: This was a randomized trial whereby nurses were assigned to usual care or one of two interventions. The basic intervention was a one-time email reminder highlighting six clinical recommendations for two conditions: heart failure and cancer pain. The augmented intervention consisted of the initial email reminder supplemented by other condition-specific provider education materials, patient education materials, and follow-up by a clinical nurse specialist.

Data on nurses’ adoption of recommended care practices—such as monitoring patient weight and providing patients with instructions on the signs and symptoms of worsening heart failure—was collected from clinical records. Patient outcomes data was collected through patient interviews approximately 45 days after home care admission. All patients received care from the Visiting Nurse Service of New York.

Findings: Heart Failure: Over 350 nurses caring for 628 patients with heart failure were assigned to either the usual care group, the basic intervention group, or the augmented intervention group. Both the basic and the augmented intervention groups demonstrated a significant increase of documented evidence-based care comapred to the control group. Patients treated by nurses in both intervention groups had better heart failure specific quality of life scores. In addition, the interventions had a positive impact on self-management practices including medication knowledge, diet, and weight monitoring. The basic intervention was found to be more cost-effective than the agumented intervention in improving clinical outcomes.

Cancer Pain: Over 300 nurses were randomized and outcomes of 673 of their patients were reveiwed. the intervention as limited in its effectiveness on nurse documented care practices but some positive findings were found in patient outcomes. Pain intesity at its worst was improved signivicantly more in the augmented group then the control group, and pain on average was better for those in the basic group then the control group. There was a trend of improvement in other outcomes measures as well.

Conclusions: The study supports the effectiveness of evidence-based e-mail reminders to influence home care practice and improve patient knowledge, self-care behavior and outcomes. However, the interventions were more consistently positive and significant for HF than cancer pain. The cost-effectiveness anlysis for both conditions showed the basic intervention to be more cost-effective than the augmented, but net patient care costs increased for HF, while they were not significantly impacted for pain. The study demonstrated that it is possible to successfully translate research findings into home health practice but that clinical context and intervention intensity matter.

Publications:

Feldman, P.H., Murtaugh, C.M., Pezzin, L.E., McDonald, M.V., & Peng, T.R. 2005.
Just-in-time evidence-based e-mail "reminders" in home health care: Impact on patient outcomes.
Health Services Research. 40(3): 859-879.

McDonald, M.V., Pezzin, L.E., Feldman, P.H., Murtaugh, C.M., & Peng, T.R. 2005.
Can just-in-time evidence-based "reminders" improve pain management among home heatlh care nurses and their patients?
Journal of Pain and Symptom Management. 29(5): 474-488.

Murtaugh, C.M., Pezzin, L.E., McDonald, M.V., Feldman, P.H., & Peng, T.R. 2005.
Just-in-time evidence-based e-mail "reminders" in home health care: Impact on nurse practices.
Health Services Research. 40(3): 843-858.

Feldman, P.H.& McDonald, M.V. 2004.
Conducting translation research in the home care setting: Lessons from a just-in-time reminder study.
World Views on Evidence Based Nursing, 1(1): 49-59.*
* This is an electronic version of an article published in Worldviews on Evidence-Based Nursing. Complete citation information for the final version of the paper, as published in the print edition of Worldviews on Evidence-Based Nursing, is available on the Blackwell Synergy online delivery service, accessible via the journal's website at www.blackwellpublishing.com/wvn or www.blackwell-synergy.com

Sponsor: Agency for Healthcare Research and Quality (AHRQ)