Alana Hippensteele, Editor

According to 2 editorials in the journal 

, research in the nursing field has been critically influential to understanding evidence-based health care practice, care delivery, and policy during the coronavirus disease 2019 (COVID-19) pandemic. In order to investigate this influence further, researchers at the University of Pennsylvania School of Nursing assessed what the role of nursing research has been in supporting patients during the pandemic.

According to the authors of the guest editorial “Nursing Research Is Coronavirus Research

,” nursing practice has not only saved lives throughout the pandemic, but it has also played a critical role in understanding the nature of care for patients with COVID-19. The research conducted to understand this role further has helped to progress knowledge regarding the necessary elements of more supportive work environments that save patient lives and promote recovery in both hospitals and nursing homes.

Additionally, research in the field of nursing has helped to advance knowledge regarding how individuals sheltering at home with in-home nursing care are managing diets to support their health in light of chronic conditions, as well as how in-home nursing care has been able to stabilize chronic conditions during the pandemic.

The research in the field has also been able to bring to light lessons from the past around areas of concern for patients in order to positively impact policy around patient care during the pandemic.

"We know that nursing practice is saving lives in this pandemic. Nursing research also plays a critical role," write the authors of the guest editorial. “We support the move in universities to concentrate research on innovations directly related to the coronavirus crisis. But so much of nursing's research is coronavirus research. We applaud the search for reliable epidemiological data, effective treatments, and vaccines. We, though, must articulate nursing research's fundamental frame. We focus on the lived experiences of clinicians, patients, families, and communities.”

The author of the second editorial “How Effective Response to COVID-19 Relies on Nursing Research

,” Eileen T. Lake, PhD, the associate director of the Center for Health Outcomes and Policy Research and editor in chief of 

, explained further that throughout the pandemic, several clear challenges to an effective response to the public health crisis became evident. These challenges included the country’s restricted access to health care, the present surging demand for health care personnel, and the moral distress that many health care providers face during the pandemic.

Lake also noted that in order to better help institutions meet the demands that the COVID-19 pandemic posed to the health care system, nursing research was critical to effectively inform crucial elements of policy response and institutional preparedness.

"Nursing research provides answers during crises," writes Lake in the editorial. “In a time of profound upheaval, risk, and strain, it is reassuring to have evidence-based solutions to the challenges confronting our health care system and its clinicians.”

Nursing research informs response to COVID-19 pandemic. Philadelphia, PA: University of Pennsylvania School of Nursing; April 27, 2020. eurekalert.org/pub_releases/2020-04/uops-nri042720.php. November 30, 2020.

D’Antonio P, Naylor M, Aiken L. Nursing research is coronavirus research. 

Lake ET. How effective response to COVID‐19 relies on nursing research. 

2020;43(3):213-214. doi: 10.1002/nur.22025.

Articles

According to 2 editorials, research in the nursing field has been critically influential to understanding evidence-based health care practice, care delivery, and policy during the COVID-19 pandemic.

Nursing Research Has Been Critical to Improving the COVID-19 Pandemic Response

A diet rich in flavan-3-ols, more commonly referred to as flavanols, includes food and beverages such as tea, apples, and berries. According to the European Prospective Investigation into Cancer (EPIC) Norfolk study published in 

, this type of diet may lower blood pressure, indicating its ability to support the maintenance of cardiovascular (CVD) health on a population scale.

Flavanols are a group of bioactive compounds that have demonstrated an ability to help vascular function in prior intervention studies. For this reason, the researchers were interested in investigating flavanols as dietary support in the prevention of CVD diseases due to a lack of reliable data from observational studies on the subject. They noted that such a lack may be in part because of the high variability in the flavanol content of food, making estimates of actual intake difficult without nutritional biomarkers.

The researchers assessed the biomarker-estimated flavanol intake of 25,618 citizens of Norfolk in the United Kingdom in relation to their blood pressure and other CVD risk markers, as well as longitudinal associations with CVD risk. However, the researchers strayed from common practice in studies of this kind by not relying on the reported diets of participants, and instead measured flavanol intake through nutritional biomarkers, such as indicators of dietary intake, metabolism, or nutritional status present in the blood.

"Previous studies of large populations have always relied on self-reported data to draw conclusions, but this is the first epidemiological study of this scale to objectively investigate the association between a specific bioactive compound and health,” said lead author Gunter Kuhnle, PhD, a professor of nutrition at the University of Reading, in a press release.

The results demonstrated that participants with the lowest 10% of flavanol intake and participants with the highest 10% of intake had a difference in blood pressure between 2 and 4 mmHg. Such significant changes in blood pressure are comparable to those with a Mediterranean diet or moderate salt reduction.

"What this study gives us is an objective finding about the association between flavanols—found in tea and some fruits—and blood pressure. This research confirms the results from previous dietary intervention studies and shows that the same results can be achieved with a habitual diet rich in flavanols. In the British diet, the main sources are tea, cocoa, apples and berries,” Kuhnle said.

Kuhnle explained that the methodology of the study was also of importance in their research.

“This is one of the largest ever studies to use nutritional biomarkers to investigate bioactive compounds. Using nutritional biomarkers to estimate intake of bioactive food compounds has long been seen as the gold standard for research, as it allows intake to be measured objectively. The development, validation and application of the biomarker was only possible because of the long-term commitment of all collaborators. In contrast to self-reported dietary data, nutritional biomarkers can address the huge variability in food composition. We can therefore confidently attribute the associations we observed to flavanol intake," Kuhnle said.

Following this study, researchers from the University of Reading; Cambridge University; University of California, Davis; and Mars, Incorporated assessed the data of the participants from the EPIC Norfolk study and observed that the greatest change in blood pressure due to diet was observed in participants with the highest blood pressure.

The researchers noted this finding suggests that an increase in flavanol intake among the general public could result in an overall reduction in CVD disease incidence.

"This study adds key insights to a growing body of evidence supporting the benefits of dietary flavanols in health and nutrition,” said Hagen Schroeter, PhD, chief science officer at Mars Edge, in a press release. “But, perhaps even more exciting was the opportunity to apply objective biomarkers of flavanol intake at a large scale. This enabled the team to avoid the significant limitations that come with past approaches which rely on estimating intake based on self-reported food consumption data and the shortcomings of current food composition databases."

Ottaviani JI, Britten A, Lucarelli D, et al. Biomarker-estimated flavan-3-ol intake is associated with lower blood pressure in cross-sectional analysis in EPIC Norfolk. 

. 10,17964(2020). doi: 10.1038/s41598-020-74863-7.

High flavanol diet may lead to lower blood pressure. Reading, UK: University of Reading; October 21, 2020. eurekalert.org/pub_releases/2020-10/uor-hfd101620.php. Accessed October 28, 2020.

According to a recent study, a flavanol-rich diet may lower blood pressure, indicating its ability to support the maintenance of cardiovascular (CVD) health on a population scale.

Flavanol-rich Diet May Lower Blood Pressure

Data science can be effectively used to predict patient outcomes for areas such as medication utilization and readmission rates to hospitals, according to a session on applying data science at the DHX Virtual conference. These predictions can help the users of data science tools to support the delivery of optimal patient care.

Data science uses the scientific method, processes, algorithms, and systems to extract applicable knowledge from structural and unstructured data, explained speaker Dalton Fabian, PharmD, RPh, a data science analyst at UnityPoint Health, during the session.

The field is comprised of different disciplines in order to tap into their skillsets, including math and statistics, business knowledge, and computer science, according to Fabian. Each of these disciplines then fits in uniquely to the function of data science in pharmacy.

For the use of math and statistics, data science analysts apply these skills when using data from the past to predict the future, such as the likelihood of whether someone will be readmitted to the hospital within 30 days of discharge.

Business knowledge, on the other hand, is used by data science analysts to communicate with nurses regarding the tools that the analysts have made. This communication helps analysts confirm that the nurses have a full understanding of the tools they are using, according to Fabian.

“As pharmacists, we understand the intricacies of health care, like how to read lab descriptions and how to interpret lab values using those types of skills in our data work,” Fabian explained.

Additionally, Fabian noted that data scientists use computer science skills when writing sequel queries to obtain or analyze data implementing models and programming languages, such as R and Python, as well as visualizing data with platforms such as tableau.

David Berkowitz, PharmD, an Omnicell One field strategist and director of the Omnicell fellowships in data analytics and automation research, said during the session that obtaining data is always the first step to commencing work as a data science analyst.

“First, you need data,” Berkowitz said. “The standard nomenclature is ETL—extract, transform, and load. And that’s getting data from your source system, whether it would be an electronic health record, laboratory system, IOT device, blood pressure cuff, etc.”

The next step is to transform these data into a format that is usable, such as Epic, which is written using Massachusetts General Hospital Utility Multi-Programming System (MUMPS). MUMPS, a programming code that was developed in the late 1960s, is a language that is effective for fast operations, which allows users to click a lab result and find the necessary information quickly.

“That’s why when you build, say, a workbench report, it’ll sort of crap out after looking back 14 days, because that type of search is not meant for querying, doing research, and doing data analysis—it’s meant for operations,” Berkowitz said.

By moving the data and encoding it into a different format, which is usually structured query language (SQL) in health care, data science analysts are able to store the data. The databases available to for storage are generally SQL, No-SQL, and cloud storage; however, not all providers use these databases when storing data.

“There are still a lot of folks in health care, probably actually a majority, that store their data on premises, or you’ll hear ‘on prem,’ which can make it a little harder to do data science because you have to sort of, when doing a specific analysis, enrich data with different sources,” Berkowitz said. “It’s harder to do that on prem in real time because of connections. So, cloud first is my motto.”

At Omnicell, Berkowitz noted that his team uses almost exclusively SQL. However, other employees at Omnicell will code using Python, R, or Scala, although the language used is often dependent on the specific problem the analyst is trying to solve.

For data visualization, analysts commonly use Qlik, Power-BI, Tableau, or R-Studio in order to communicate data more effectively and support business intelligence and predictions, Berkowitz explained.

At UnityPoint Health, Fabian noted that they have used these different elements of ETL to create a tool called Population Health, which is primarily used by care managers to enroll patients in care management services. This tool can help to lower costs for high-risk patients by decreasing utilization and increasing the frequency of patients’ meetings with care managers. This helps to catch issues before they become critical and require a hospital visit.

“What we did, as a data science team, is develop a machine learning model that predicts the likelihood that a patient is going to go to the hospital or the ED in the next 12 months, and that’s how we determine high risk,” Fabian said.

Fabian noted that this tool helps to allow care managers to spend more time taking care of patients rather than needing to focus on administrative tasks that they were doing previously to figure out whom to enroll.

Another tool created by UnityPoint Health is the Readmission Heat Map, which is used to decrease 30-day admission rates. This tool allows for the prediction of whether patients will readmit to the hospital within 30 days of discharge, down to the day.

“In this tool, we’re taking all of the data we have access to in Epic, like disease states, medication, and the fact that people are in the hospital, and pairing that with a predictive model to help those nurses make better decisions about the care that a patient is going to need once they get out of the hospital,” Fabian said. “Anything over a 20% likelihood, and nurses will take heed and intervene on behalf of those patients.”

Berkowitz noted that by applying these same types of data science tools to medication utilization, analysts are able to help pharmacists visualize data from their pharmacy in a chart. For example, this could be applied to visualizing the effects of the pandemic on medication utilization at a pharmacy.

“I took a look at vaccination rates since January 2020 to see how COVID-19 has affected vaccination rates,” Berkowitz said. “Basically, it went down to nothing. This kind of tells me that either folks weren’t stepping on nails or they weren’t getting care and going to their pharmacies.”

Fabian D, Berkowitz D. Applying Data Science. Presented at: DHX Virtual 2020; October 2, 2020; virtual. cpha.com/event/dhx-virtual/. Accessed October 2, 2020.

Data science can help to predict patient outcomes for areas such as medication utilization and readmission rates to hospitals. 

Data Science Can Predict Patient Outcomes to Optimize Care

Two phase 3 studies showed an investigational 15-valent pneumococcal conjugate vaccine (V114, Merck) was well-tolerated among patients and met the primary immunogenicity objectives.

The phase 3 Pneu-age study assessed the vaccine’s efficacy in healthy adults aged 50 years or older. The results showed that the vaccine was not inferior to the currently available 13-valent pneumococcal conjugate vaccine (PCV13), according to the researchers.

In this study, the new 15-valent vaccine was found to be as successful in targeting the 13 serotypes that are currently targeted in the 13-valent version, with the V114 vaccine being superior in targeting serotypes 22F and 33F. This study also demonstrated the 15-valent vaccine was superior in targeting serotype 3, which is known to be a leading cause of invasive pneumococcal disease globally.

In the Pneu-true study, the researchers found V114 successfully demonstrated equivalent immune response across all 15 serotypes in healthy adults aged 50 years or older. In both studies, the researchers found that V114 was not only well-tolerated among patients, but the safety profile of the vaccine was comparable with the current PCV13 and consistent with the results of previous studies that assessed V114.

Merck plans to present these results and any additional phase 3 data from its clinical program to the public, allowing the data to form the basis of global regulatory licensure applications before the end of 2020.

“Diseases caused by serotypes not covered by the currently available pneumococcal conjugate vaccine are increasing worldwide and can vary by country or region. Additionally, we continue to see pneumococcal disease caused by serotypes included in the existing pneumococcal vaccines,” said Roy Baynes, MD, PhD, senior vice president and head of global clinical development, chief medical officer, Merck Research Laboratories, in a press release.

The pneumococcal serotypes that are not included in the current 13-valent pneumococcal conjugate vaccine, such as 22F and 33F, have been found to be associated with invasive pneumococcal disease throughout the country. These 2 serotypes, 22F and 33F, specifically cause 13% of the invasive pneumococcal disease observed in adults aged 65 years and older in the United States.

Additionally, serotype 3, which is targeted in V114, remains a leading cause of invasive pneumococcal disease in adults and children, despite the current 13-valent version in use also targeting this serotype. In total, 15% of invasive pneumococcal disease among adults aged 65 years and older is still caused by serotype 3 in the United States.

“These phase 3 data demonstrated that V114 generated a robust immune response to all 15 serotypes included in the vaccine and reinforce the potential for this investigational vaccine to help protect adults against pneumococcal disease,” Baynes said.

Baynes noted that additional research into pneumococcal disease prevention is necessary in order to target those serotypes that remain a risk factor for certain populations.

Merck Announces Positive Topline Results from Two Phase 3 Adult Studies Evaluating V114, Merck’s Investigational 15-valent Pneumococcal Conjugate Vaccine, Including Pivotal Trial. Kenilworth, NJ: Merck; September 9, 2020. merck.com/news/merck-announces-positive-topline-results-from-two-phase-3-adult-studies-evaluating-v114-mercks-investigational-15-valent-pneumococcal-conjugate-vaccine-including-pivotal-trial/. Accessed September 11, 2020.

Two phase 3 studies showed an investigational 15-valent pneumococcal conjugate vaccine (V114, Merck) was well-tolerated among patients and met the primary immunogenicity objectives. 

Articles

Nursing Research Has Been Critical to Improving the COVID-19 Pandemic Response

Flavanol-rich Diet May Lower Blood Pressure

Data Science Can Predict Patient Outcomes to Optimize Care

Positive Results Announced From Phase 3 Adult Studies Evaluating 15-valent Pneumococcal Conjugate Vaccine