Alana Hippensteele, Editor

During the coronavirus disease 2019 (COVID-19) pandemic, many patients in the United States reduced the number of in-person preventive and elective health care visits and increased the number of telemedicine appointments. However, an analysis of the data from March and April 2020, which were the first 2 months of the COVID-19 pandemic lockdown, found that the switch to telemedicine was not sufficient enough to offset the overall reduction in visits.

The analysis of the data was pulled from the medical records of approximately 5 million Americans with private health insurance and demonstrated that the number of mammograms and colonoscopies decreased by approximately 65%, as these types of elective medical care were not easily transferable to a telemedicine format. Overall, use of preventive and elective health care by patients declined by 23% in March and by 52% in April.

However, in lower-income or predominately non-white zip codes, there was a lower reduction in in-person care in addition to lower rates of telemedicine use. The authors who published these findings in 

 noted that this is another example of how the COVID-19 pandemic intensified existing disparities related to health care.

"This adds detailed evidence to the anecdotal reports that Americans quit going to see the doctor when the pandemic shutdown started," said lead author Christopher Whaley, PhD, a policy researcher at the nonprofit research organization RAND Corporation, in a press release. "If important visits are only delayed for a few months, there will likely be no harm. But if patients do not get important screenings, there could be long-term negative health consequences."

Although other studies have analyzed data from this same period, most have assessed data from a single health system or geographic market in order to observe the impact of COVID-19 on the utilization of medical services. In this study conducted by Whaley and his colleagues, the researchers used insurance claims data from 2018 to 2020 from approximately 200 employers across the country.

The results of the study demonstrated that when compared to the rates in March and April 2019, colonoscopies decreased by approximately 70% during March and April 2020. When conducting the same comparison for mammograms, the researchers observed a 67% decrease among women aged 46 to 64 years.

Additionally, utilization of blood sugar tests decreased by approximately 50%, vaccinations among children under age 2 decreased by 22%, and angioplasty procedures decreased by approximately 17%. Surgeries such as musculoskeletal surgery and cataract surgery, as well as MRIs, all decreased by 45% or more. However, only a small decreased was observed in utilization of chemotherapy treatments.

In April 2020, use of telemedicine appointments increased by over 4000% when compared to April 2019. Yet, this significant increase in telemedicine visits replaced only approximately 40% of the decline in in-person visits during this period.

Notably, the authors observed that patients living in lower-income or predominately non-white zip codes had approximately a third lower increase in telehealth visits than those who lived in the wealthiest neighborhoods.

"The extent to which access barriers to telemedicine contribute to lower rates of in-person care deferral, and thus increases in potential exposure to COVID-19, should be examined in future work," Whaley said in the press release.

Health care use drops during pandemic; switch to telemedicine creates disparities. Rand Corporation; November 5, 2020. 

https://www.eurekalert.org/pub_releases/2020-11/rc-hcu110320.php

Articles

During the first 2 months of the COVID-19 pandemic, many Americans reduced their in-person preventive and elective health care visits and increased telemedicine appointments. 

Telemedicine Use During the First 2 Months of the Pandemic Did Not Offset the Drop in In-Person Visits

In a recent study conducted in Sweden, researchers found that women who were diagnosed with invasive cervical cancer had an increased risk of iatrogenic injuries, which are injuries that occur as a result of medical intervention, and noniatrogenic injuries, which occur due to accidents and self-harm.

The correlation was observed through the analysis of data from approximately 3 million women who had participated in cervical cancer screenings during the period of 2001 to 2012. By cross referencing multiple Swedish registries, the researchers were able to identify women within this cohort who received a diagnosis of invasive cervical cancer or cervical cancer precursor lesions, as well as women who had a normal smear during follow-up examination.

"Cervical cancer screening is one of the most successful cancer prevention programs, [and] has greatly reduced cervical cancer incidence and mortality," said Qing Shen, PhD, researcher in the Department of Medical Epidemiology and Biostatistics at the Karolinska Institutet in Stockholm, in a prepared statement. "Despite these substantial benefits, our research indicates that women with invasive cervical cancer experienced medical complications and psychological stress during their diagnostic workup, although at a very low level."

In prior research, Shen and her colleagues had found the potential for increased risk of injuries to be demonstrated during the time period before and after a diagnosis of any cancer.

"These injuries were likely a result of invasive procedures and the severe psychological distress experienced during the clinical evaluation of a potential cancer," Shen said in the press release. She additionally noted that what remains unknown is whether there would be a similar increase in risk among patients screened for cervical cancer if an organized cancer screening program was largely accessible.

After analysis of the initial 3 million women who had participated in cervical cancer screenings, the final cohort of women included in the study were approximately 1.85 million women with a normal smear, approximately 22,000 women with cervical intraepithelial neoplasia (CIN) grade 1, approximately 21,000 women with CIN grade 2 (CIN2), approximately 37,000 with CIN grade 3 (CIN3)/adenocarcinoma in situ (AIS), and approximately 5000 women with invasive cervical cancer.

The researchers then investigated the incidence rates of both iatrogenic injuries and noniatrogenic injuries that had occurred during the diagnostic workup. They found that the Iatrogenic injuries were frequently related to receipt of a punch biopsy, while noniatrogenic injuries were most frequently the result of unintentional falls.

For those injuries that occurred during the diagnostic workup, incidence rate ratios were found through comparing women with a diagnosis of cervical cancer or its precursor lesions to women who had a normal smear, with adjustments made for age, calendar period, screening adherence, education, income, and marital status.

The results of the research showed that women with a diagnosis of invasive cervical cancer, when compared with women with a normal smear, had 8 times the likelihood of iatrogenic injuries, while women with CIN3/AIS had a 3 times increased likelihood of iatrogenic injuries. However, women with CIN1-2 did not have a significantly increased rate of iatrogenic injuries when compared with women with a normal smear.

"Women with invasive cancer can have greater vascularity due to tumor growth, which can lead to hemorrhage and hematoma following a biopsy," Shen said.

Additionally, the results showed that women with a diagnosis of invasive cervical cancer had about twice the likelihood of noniatrogenic injuries than women with a normal smear. However, women with CIN1-2, CIN3, or AIS did not have a significantly increased rate of noniatrogenic injuries when compared with women with a normal smear.

"This study, for the first time, systematically examined the risks of injuries during the cervical diagnostic workup,” Shen said. “Although the chance of having such injuries was rare, we found an increased risk of inpatient care for iatrogenic and noniatrogenic injuries for women with invasive cervical cancer. It is important to emphasize, however, that cervical cancer screening is greatly beneficial for the early detection of cancer and is largely safe."

Women with cervical cancer may have increased risk of injury during diagnostic workup. Philadelphia, PA: American Association for Cancer Research; October 21, 2020. eurekalert.org/pub_releases/2020-10/aafc-wwc101920.php. Accessed January 8, 2020.

Researchers found that women who were diagnosed with invasive cervical cancer had an increased risk of injuries during diagnostic workups.

Women With Cervical Cancer May Have Increased Risk of Injury During Diagnostic Workup

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.

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.

Alana Hippensteele, Editor

Articles

Telemedicine Use During the First 2 Months of the Pandemic Did Not Offset the Drop in In-Person Visits

Women With Cervical Cancer May Have Increased Risk of Injury During Diagnostic Workup

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

Flavanol-rich Diet May Lower Blood Pressure