Introduction

A well-known company New City Home Care is looking to grow its services in a nearby community due to the aging populations and retirees, granting the population of 55, 000, which is less than the current home health company. “Although”, the elderly population is growing there are no other home health companies in this Midwestern city.  New City Home Care is trying to be the first leader in entering this new market, “however”, for this to be successful, research on the present market is needed. The opening of a satellite agency involves employee staffing for customer service and scheduling of health care specialist.  The demand for services will be based on how the agency is run, office space required and how the company will market its services in this new Midwestern location.  A marketing plan will take into account the current business as well as the new market.

Historical Resident

According to an article by Santilli, J. & Vogenberg, R.F. (2015, Para 1-49) Market changes began to arise after the passage of the Affordable Care Act in 2010, because of the tracking and tracing of the developing trends in the ACA marketplace 2014 led to the identification of many strategic trends that will be important.

There are several trends that will impact participants over the courses of the years into 2018 include

1. Keeping the client informed in their healthcare
2. Quality controlled measures
3. Joining Revenue
4. Advancement in Information technology for communication

The old model of healthcare focused on treating the serious illnesses and the new model focus on the client, preventing diseases and the current management of the continuing disease, with the new healthcare market it allows the client to be involved in their care. The use of data allows open communication with the client, their physician, and home health team about their illness and treatment options. A cost estimator can help clients to understand the cost and quality of healthcare. There are many market exchanges that allows clients to choose from a selection of insurance plans and choices. Consumers enrolled in Consumer Directed Healthcare Plan tend to be more cost-conscious about medication prescription and cost, services and treatment.

The growth of quality measures rises and become more structured in a report from several sources stating that more is spent on the United States healthcare system and is no better than any other developing country in the world because the US healthcare system is mainly a fee for service, where the doctor collects compensation for each service that is performed and is given an incentive to deliver more services. The National Quality Strategy was effective as of March 2011 by the federal government to improve the quality of healthcare and to reduced cost. There are several agencies such as Center for Medicare & Medicaid Services, Agency for Healthcare Research and Quality, Joint Commission, and the National Committee for Quality Assurance that use different method for assessing and reporting on the performance of the doctor.  Private sector organizations function at the local, regional and national levels to give information on the doctors or health care insurance performance to the benefactors and clients.

The increase in cost of healthcare is causing sponsors to consolidate due to the shift in healthcare to the elderly population and the growing occurrence of chronic conditions. People, institutions, and resources are all part of the healthcare system that is responsible for the delivery of healthcare. To meet the demands of the developing market and healthcare delivery, risk are managed through primary care, medical home models and pay for value reimbursement. “When”, the healthcare system merge the demand for fee increases causing clients to be limited in choices when choosing their physician or hospital will keep premiums low but can cause many problems for clients under ACA.

Information technology is changing the way data is recorded and delivered amongst the client and doctor with such devices as smartphones, mobile applications, and an increase of approved medical devices for the clients’ homes and smartphone makes diagnosing and treating the client more appropriate in improving the need for a robust information security system. The use of activity trackers are becoming more popular and are used to track heart rate, sleep patterns, counting calories. Many companies are offering applications for smartphones to manage diseases such as asthma or diabetes and incorporating wellness in the management of illness or disorders are focused areas of growth in the coming years.

HIPAA/HITEC concerns of privacy will lose ground because of accessibility in 2015, with the use of digital tools and services that gather and evaluate healthcare data. There is a risk involved in sharing universal positioning system location and personal data can cause a security breach and protocols will need to be in place to reduce the risk of sharing of information. The applications use for data collection can improve healthcare productivity, although technology offer some return on healthcare more focus is geared toward the implementation of electronic medical records, and the client insurance companies having access to client information in real time. Advancement to the future technology will allow patients and doctors to improve their practice to manage and coordinate healthcare, this will require patient education and transparency.

Demographic data

Healthcare continues to be the major topic of United States due to the uncertainty surrounding the Affordable Care Act, New City Home Care findings include:

1. The older population over 65 years, which has the highest spending demographic per person and will double by 2055.
2. Containing cost continues to drive hospitals to merge and expansion of outpatient services
3. Medical office space is much greater than the supply and has led to an 8% vacancy rate in the first quarter of 2017.
4. Healthcare has seen a surge in transaction volume, spending nearly $10 billion for the year ending in the first quarter of 2017

Our overall mission of New City Home Care is to deliver quality service to the aging population in a well-organized, ethical and cost-effective manner and as healthcare continue to change. National Healthcare Midwest. (2018. Para 1-7)

Quality standards

According to the Standard of Home Health Nursing Practice. (U.N. P 31 Para1-4). New City Home Care is obligated to deliver and improve quality of care provided to our clients. Our standards characterize, measure and provide guidance in achieving excellence in home health care. We are accountable for our clients, respecting their rights and being an advocate for them. Acknowledgement of patients’ rights include:

1. Right to autonomy
2. Right to make informed decisions
3. Right to one’s domain, body, life, property and privacy

Marketplace Analysis, Including Competition

Alder, J. (2015, Para 1-41) suggested that new home health care should look for ways to offer home health type services to clients who need additional help by expanding its service to the community and hoping to reach the elderly who may potentially become residents. The aging population is living longer and more fragile than previous generations and would like to get help where they live oppose to moving. “Due”, to the continuous changes in healthcare in- home nursing is becoming a recognized practice with the goal to lower cost by keeping the senior population out of the hospital or nursing facilities.

On October 2014 Kindred Healthcare Inc publicized plans to purchase Gentiva Health Services Inc and is projected to close in the first quarter of 2015 and serving greater than 1 million clients a year thru out 47 states and following that announcement HealthSouth Corp a home health company that operates 107 rehabilitation hospital purchase a privately held Encompass Home Health and Hospice for roughly $750 million, After Brookdale Senior Living gain Emeritus Corp it is the world’s largest seniors housing operating with 1,147 communities on November 2014 calling to increase its ancillary and home health services which is currently underway for a senior citizen who do not live in the Brookdale building.

According to a large Los Angeles research based firm IBIS reported that on September 2014 the home healthcare business which includes medical and caregiver-type services, represents a $75 billion healthcare market with an annual growth rate of about 3.6 percent due to the elderly population, and the push to provide cost-efficient treatment outside of the hospital or nursing home setting. The healthcare business remains split while looking for ways to expand face regulations that vary state to state, also on November the Center for Medicare and Medicaid Services said that it will cut payments to home healthcare providers by 0.3 percent in 2015 to lower home health cost in a four- year period.

Home health care faces many challenges in expanding the business. There is a difference in running a building and operating a home healthcare agency because they have different enterprises, they require distinctive styles, and emphasize from an experienced healthcare professional. In 2014 the majority of the largest non-profit Continuing Care Retirement Community provided services to senior citizen outside the community and don’t have enough inner volume to produce a lot of income, “However”, CCRCs are committed to offering services to the greater community are likely huge operations with in-depth experience.

Operating a home health care business is a difficult business in which quality of service is difficult to control, but with the National Quality forum identifying a need on October 2014 that would improve basis to measure the quality of ancillary services.  Big companies must be equipped to manage outside service because senior citizens have the option to choose in house agency or seek services for extra help.  It is suggested that communities be licensed, provide the seniors with a contract and have policies in place to protect the senior citizens and limit the possibility of being liable. One of the greatest advantage of offering Medicare-certified healthcare services is the ability to decrease hospitalizations. The national hospital readmission rate has decrease from 16 percent to 11 percent over 60- day.

Models and Best Practices for Reaching the Target Audience

More than 70 million of Baby Boomers living in the United States were born between 1946 and 1964 and as senior citizens began to retire they will need more healthcare than any other age group before them and by 2030 hospital admission will double. 8.6 million Senior citizens who suffers from a chronic condition will grow to 37 million. A few ideas to help New City Home Healthcare for seniors to be successful include:

Seniors are becoming acquainted with technology such as smartphones and tablets, so we must make sure the website is quick to respond or easily adjusted to ensure they can without difficulty browse and locate information.  Use search engine to ensure that the website ranks highly for words and phrases most related to your hospital or facility. Older adults look up information online in regard to their illnesses, cures, products, and symptoms.  Applying context marketing can give your website added keywords for search engines to improve your companies ranking and making sure your healthcare company ranks when someone searches topic or treatment facility that focus on that topic.

“Although”, marketing to senior citizens can be difficulty we can focus on ways to handle this my spreading the word about your company organization through a short TV commercial, newspaper, or magazines articles. We can also look beyond marketing to create a long-term relationship though context marketing, we must also be truthful about our products, benefits, and the services we provide and lastly remain benefit focused. Web Fx. (U.N. Para. 21-30)

Recommendations to Ensure Alignment

In an article by Flanigan, D. (2017, Para 1-16). Healthcare organizations should be quick and easy, it just one piece of the pie that relates to healthcare industry and the lives of our clients and the senior population that New City Home Healthcare services. There is no assured success in an organization without alignment. If New city home healthcare want to work with other establishments, we should move pass a business agreement that affects all the parties involved into something that aligns continuous over time with change that’s beneficial to all parties involved.  In the long run strategic alignment is about building a path toward a professional organization, were the same values was shared between everyone involved.

In order for New City Home Healthcare to establish a successful partnership, we need to focus on these five principles of alignment. The first principle suggest that we should agree on the state of the health business and share the same vision. “Secondly”, the next alignment focus on the role that Health Information Technology will perform, which should be to manage the flow of information and to understand the digital record moving forward. We also need to understand that HIT does not only back organizations strategies but it is a primary strategy relating of itself. The third principle of alignment is assuring that together the business have the capability and intent to do what they said they will do, and the four principle is if the healthcare organization is going to work with each other they need to like each other.

The last principle, which is called mutually assured destruction failure must be mount up equally between the parties for success is balanced with a must not fail. We tend to equate partnerships around good thing that the business plans but need to be accountable for the bad. To build balance for success and failure in the relationship the key is making sure the scope are balanced for both parties.  “When”, both organizations stay together and form a great partnership they can accomplish great things.

Writing the Plan and Setting Expectations

A well-known company New City Home Healthcare is trying to open a new satellite company in a Midwestern community, LLC.is offering medical care services to elderly, disabled and people of all ages’ physical conditions and cognitive abilities who would like to remain living at home, yet need help with certain daily or weekly activities.  Working closely with a clients and their families we provide personalized assistance in a client’s home, the hospital, long-term assisted living facilities and other places of residence with things like, Physical Therapy.

We distinguish ourselves by finding and employing the very best caregivers who believe in and perform their work according to the high standards of excellence in quality care set forth by New City Home healthcare.

“As”, our senior citizen base grows we may consider adding additional services that would supplement the existing list of services.

Our Vision is for New City home healthcare to be the very best home care provider in the Midwest, providing the very best, superb care to senior in our geographical market by employing only proven, hard-working, professional, honest, compassionate and ethical home care providers in the market who are dedicated provide outstanding home care services and improving the quality of senior citizens lives.

Our Mission is to help every senior citizen with improving their quality of life, encouraging independence and allowing them to be comfortable with excellent care in their own homes by providing superb, professional care with respect, dignity, compassion, the highest ethical standards and honor.

New City Home healthcare is entering the Home Care Industry Market and distinguishing itself from competitors by hiring a staff consisting only of superb caregivers, who require special services and the use of technology in every aspect of the business as possible. In the competitive Home Care Industry, we looked at what other companies were doing, what senior citizens most common complaints were of other agencies, and how we plan to do better from the start. Starting with our caregivers, we employ only the very best caregivers.  We do this by:

Mandatory CNA certifications required by every caregiver is necessary to be considered for hire

Conducting several interviews, so we can see how serious the applicant are about taking care of our senior citizens to determine reliability

Perform extensive background checks, fingerprinting, licensing, to meet the state requirements and to maintain Human Resources Legal Compliance

Required training for staff over 10 hours, CNA certification, training including understanding, believing in and following through with our expectations for service to our senior citizen.

Implementation of technology to manage our seniors and staff, were we can get real time data on when staff arrive and leave a senior citizen home, service that was provided and alert to any issues. ABC Home Health Business Plan Template. (N.D. P 3-5)

Implementing the plan, proven best practices for implementing

According to an article by Kusserow, R. (2012. Para 1-15). Using best practice standards is important to effective healthcare compliances and allow us to enhance and improve efficiency to avoid government auditors. Best practices can be described as a practice or skill, through knowing how and testing can lead to a desired result for New City Home health company success.

Best practices can also can reduce potential for liability or being in violation set by the compliance program. New City Home Health Company will use best practices improving the program success.  Other benefits include:

• Gaining shared trust amongst the provider and oversight organizations.
• Sharing of a vision by which New City Home Health Company will use to conduct business.
• Creating objectives are in line with the company’s mission and vision.
• Supporting relations between compliance and New City Healthcare methods of operation.
• Recognizing the benefits of healthcare compliance in terms that are meaningful to employers and stakeholders

When following the best practices for health care providers we must consider the following:

1. Reduce cost by learning from other health care organization and applying that knowledge to your practice this can save money.
2. Knowledge of what other organization have done can keep New City Home Care from making costly mistakes
3. Adopting new idea
4. Following best practices from the outside will help raise the bar and set the standards of excellence for New city Home Care to drive forward.
5. Reduce risk and liability to avoid any potential lawsuits.

“When”, applying step for best practices New City Home Healthcare will form process improvement committees, create metric to measure improvements, gather data on the success and best practices of other organizations, and adapt best practices for particular culture, environment of New City Home Health Care and lastly implement the process and measure the outcomes

Tools for evaluating and adapting the plan

Tools are used in a variety of healthcare setting to avoid or compromise care and to make care safe. The United States Department of Health and Human Services Partnership for Patients and valued-based purchasing program says tools also address area of priority.

New City Home Healthcare will use Consumer Assessment of Healthcare Providers and Systems surveys that was established by AHRQ to measure patient’s healthcare experience, communication amongst patient, doctor, and nurses, staff awareness, and other pointers of safe high quality care. Based on the patient perspective is what will be measured.

We will also use Comprehensive Unit-Based safety Program tools for training that address patient safety issues by combining best practices, science of safety and safety culture, the training includes teaching tools and resources such as module, presentations slides, tools, and videos.

“Lastly”, the implementation of Team Strategies and Tools to Enhance Performance and Patient Safety tool are used to train the trainer, a program used to decrease risk to patient’s safety by trainer healthcare team to improve communication skills.  Agency of Healthcare Research and Quality. (2018, Para 1-5)

Conclusion

In my opinion I believe healthcare cost is rising because of the senior population having an improvement in the survival rate of chronic illness, injuries, and other diseases, also our veterans returning from combat with serious injuries, and the advancement of technology causing healthcare to move into the homes, servicing a diversity of people. Healthcare cost varies greatly in it safety measures, effectiveness, and efficiency and cost of quality of care. It is in my recommendations to improve the state of healthcare in the homes is the use of technology and medical devices in the home care environment, caregivers and our senior citizens, healthcare environment and the gap in information requiring additional research and development. Applying these recommendations can make home health care effective and reduce cost.

REFERENCES

• ABC Home Health Care LLC. (U.N.)
  
  ABC Home Care Business Plan Template
  
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  http://homecarehowto.com/mainsite/wp-content/uploads/2012/02/BusinessPlanTemplate.pdf
  
• Alder, J. (2015).
  
  Competition heats up in home healthcare and services
  
  Retrieved from
  
  http://seniorshousingbusiness.com/from-the-magazine/competition-heats-up-in-home-healthcare-and-services
  

         Flanigan, D. (2017).

5 Essential Principles of Alignment for Health Care Organizations

Retrieved from

https://www.cerner.com/blog/5-principles-of-alignment-for-health-care-organizations

• Kusserow, R. (2012). What Are Compliance Best Practice Standards Retrieved from
  
  https://compliance.com/articles/compliance-best-practice-standards/
  
• NATIONAL HEALTHCARE MIDWEST. (2018).
  
  The Innovation Expansion & Impact of Healthcare
  
  . Retrieved from
  
  https://www.bisnow.com/events/chicago/National-Healthcare-Midwest-1059
  
• Santilli, J & Vogenberg, R. F. (2015).
  
  Key Strategic Trends that Impact Healthcare Decision-Making and Stakeholder Roles in the New Marketplace
  
  Retrieved from
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  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4415172/
  
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  Standards of Home Health Nursing Practice
  
  . (U.N.) https://intranet.everydaychampions.org/policies/items/123/SN.04-Standards_of_Practice_&_Guidelines.pdf
• U.S. Department of Health and Human Services. (2018).
  
  AHRQ Patient Safety Tools and Resources
  
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  WebFX. (U. N).
  
  
  How to Reach Your Target Audience with Healthcare Marketing
  
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Abstract

According a report published by the World health organization about the most prevalent causes of mortality for the time periods of 2000 and 2011, it can be seen that Ischemic heart disease is the leading cause of mortality. There are many conditions that can lead to heart failure. Such conditions are raised blood pressure, myocardial infarction as well as atherosclerotic heart disease. Ischemia leads to necrosis of the myocardial cells due to lack of oxygen resulting in permanent loss of heart muscle. Stem cell therapy allows us to restore the motor function of the heart by delivering stem cells to the site of function loss. The aim of this review is to highlight key points about the different stem cell types that are being researched. Most importantly we will look at how and why recent advances are better suited for treatment of different conditions of the heart. This shall be argued by looking at the ways in which the stem cells used are obtained and transplanted as well as keeping in mind the natural behavior and purpose of the different classes of stem cells.

Different Stem cell Types Being Researched

The two classes of stem cells that have been researched the most are mulitpotent and pluirpotent stem cells. Pluripotent cells have a greater potency then multipotent stem cells meaning that only specific classes of multipotent stem cells can be used to restore cardiomyocytes.

Multipotent Stem cells

• 
  c-Kit+Cardiac Stem Cells
  

These cardiac stem cells exhibit c-Kit+ which is a surface receptor that has tyrosine kinase activity. There have been successful studies using these types of cells for myocyte regeneration. According to Sheng and co-workers (2012) use of these stem cells has led to regeneration of cardiomyocytes in the ventricles. SCIPIO, is a phase 1 study conducted by Bolli et al. This study looked at patients who suffered from an MI and then had cardiac stem cells introduced into their left ventricle. They published their results in 2011 showing that left ventricular function improved from the initial ejection fraction that was below 40%. Makkar et al. in 2012 published findings for the CADUCEUS study. This study again introduced CSCs into patients LV just after an MI. Results showed no harm being done to the patient as well as an increase in the ejection fraction of the LV.

Fuentes and Kearns-Jonker in 2013 released results were application of ephrin A1 can improve CSC treatment in rats. Ephrin A1 is a human protein important for moderating cell maturation that is introduced before transplantation of CSCs occurs. Most notably repopulation of the damaged area (infarct) was twice as much and as well as having improved systolic function as well as reduced number of complications such as arrhythmias.

• 
  Bone marrow derived stem cells (BMSC)
  

BMSCs are obtained from that patients bone marrow and then used to treat the same patient. BMSCs have been being used for a long time due to ease of acquirement as well as the fact that they don’t elicit an immune response when used. According to Sheng and co-workers (2012) BMSC therapy hasn’t lead to notable changes in patient quality of life with only temporary mild increase in ventricular systolic function. BMSCs release beneficial paracrine effects (Lee et al., 2005). Paracrines have a number of roles including cessation of apoptosis in sites of ischemic heart damage and stimulation of host vascular (angiogenesis) and cardiac tissue (cardiomyogenesis) growth. Inter-conversion of cells from 1 type to another as well as joining of 2 or more cells to become one cell results in formation of endothelial and ventricular muscle tissue from the precursor stem cell (Lee et al., 2005).

• 
  Pluripotent stem cells
  

Such cells are capable of forming all 3 primary layers.

Embryo Stem cells (ESCs)

ESCs are obtained from the mass of cells inside the blastocyst and are capable of self renewal. Compared to adult stem cells, embryonic stem cells have more inherent ability to replace damaged tissue in the heart. This is due to them being pluripotent they replace not only the muscle lost but also perform angiogenesis. Advancements in regulation of developmental pathways for ESCs have enabled improved results. BMP inhibitor improves the conversion of ESCs to cardiomyocytes but in so doing reduces conversion to other tissues of mesoderm origin (Hao et al., 2008). Hao and his co-workers (2008) also state that dorsomorphin can become a great tool for stem cell therapy in the future.

Wnt/β-catenin signaling control with the use of XAV939 improves ESC differentiation into cardiomyocytes.

Induced pluripotent stem cells (iPS)

Gene Transplantation

Direct gene delivery

For different forms of gene delivery the catheter has to both compatible to the site targeted as well as not having any property causing injury or eliciting an immune response. Naimark et al. compared the use of Nitinol stainless steel and Stiletto catheters for epicardial administration as well as endocardial showing that Stilletto catheters were twice as effective.

Intrapericardial injection

Advantage of this method of delivery is that there is no exposure of the heart and other organs. The use of intrapericardial infection in dogs has shown they endure the pain with not too much distress highlighting that the patient will undergo less distress compared to open surgery (March et al., 1999). This percutaneous method introduces the genes into the pericardial sac which then migrates into the myocardium. (Kawase et al., 2007) There are varying approaches to how to perform the injection. Fromes and coworkers used a transdiaphragmetic method. What was observed was that injection of the stem cells on their own lead to no gene expression difference in the myocardium. Stem cell expression results at the end of week one improved significantly with addition of proteinase in the injection fluid.

Endocardial injection

Microsphere retention varies according to volume used and site of injection. Endomyocardial injection had 28% greater retention then epicardial administration. Further retention can be obtained with the use of 10 μL rather then 100 μL. Greater spread of the adenovirus which encoded lac-Z was observed going to other organs in lower volumes too (Grossman et al., 2002). Use of fluoroscopy proved that this method is safe and that gene expression is present in 81% of the pigs used. Specimens used showed no symptoms and signs of cardiac arrhythmia or disturbance of blood flow. Patients suffering from chronic ischemia can develop complications such as perforation of the ventricle due to its thin nature as well as effusion of fluid in the pericardial sac decreasing cardiac output (Gwon et al., 2001).

Intramyocardial injection

This method has shown great success in many studies due to direct delivery of vector to site of damage. Injection of reporter gene into cardiac tissue and expression of the gene is feasible in canine myocardium. Response showed to be directly proportional to the volume of plasmid DNA used. Interestingly gene expression was uniform throughout the left ventricle independent of the level of injury. Stem cell expression gradually weakens over time showing greatest activity at the end of the first week (

von Harsdorf

et al., 1993). Use of plasmid DNA for cardiac muscle shows unique property of the tissue in being able to uptake DNA via the use of T tubules. Weakened expression after the first week is due to immune defensive mechanisms targeting transfected cells (Acsadi et al., 1991). Use of plasmid DNA vectors in early studies showed low efficiency in terms of transduction and time interval in which it is active; this lead to the use of adenovirus to transfer of β-galactosidase gene and plasmid. However results showed poor expression after day 7 as well as immune reaction generation (Guzman et al., 1993). Use of rAAV proved to be a more successful vector for the LacZ gene showing no immune response generation or inflammation at the site of injection. Expression was strongest after 1 week during weeks 4 to 8 showing very little results in the first 2 weeks. An increase in efficiency in terms of number of cells that undergo transduction due to perfusion was observed. Half of the cardiomyocytes showed LacZ gene expression (Svensson et al., 1999).

BetaARKct gene produces a peptide that improves betaAR (beta-adrenergic receptor) signaling which is seen to diminish after a myocardial infarct. BetaAR function is interfered upon by G protein-coupled receptor kinase 2. BetaARKct gene product will eliminate G protein-coupled receptor kinase 2 interference. rAAV6 was used as a vector. Introduction of the BetaARKct gene further increased the efficiency of the intramyocardial injection with improved transduction cell number and length of time interval expression is strongest – up to 12 weeks from start of experiment. Long term use of BetaARKct gene lead to raised cardiac contractility as well as a turn around in ventricular remodeling (Rengo et al., 2009). Transfer of vascular endothelial growth factor (VEGF) promoted angiogenesis in damaged myocardium and diminished anginal pain (Koransky et al., 2002).

Transvascular gene delivery

Some diseases such as pulmonary and essential hypertension, long QT syndrome and congestive heart failure require not just a percentage of their cells to undergo transduction but rather the entire myocardium. This can only be done by a method that ensures global delivery to the myocardium (Donahue et al., 1997). This is because it’s not just a group of cells that are contributing to the disease but rather every cell. E.g. Intramyocardial injection in these conditions would be useless as it only affects a small area.

Selective coronary catheterization with antegrade intracoronary delivery

A single pass method yields poor transduction values showing phenotype expression in only 5% of cardiac muscle at most (Ding et al., 2004). For optimal transduction to take place prolonged exposure time via occlusion of blood supply was necessary. The coronary arteries and coronary venous sinus were the tested targets with the latter producing almost 5 times increase in transduction (Logeart et al., 2001). Donahue and coworkers worked on rabbit myocardium observing key conditions for 96% of myocardial cells to undergo transduction. These parameters included increased virus concentrations, increased exposure, performing experiment at 37°C, increased coronary flow rate and use of crystalloid media with specific compositions.

Almost maximal transduction could be achieved with improved microvascular permeability in a decreased coronary perfusion time period of 2 minutes. Lowered Ca2+concentration coupled to bradykinin or serotonin pretreatment and raised virus concentration achieve this (Donahue et al., 1998). Use of catheters to occlude the aorta and venous return in the right atrium in rodents was coupled to cardiopulmonary arrest with the use of esmolol and acetylcholine for 2 and 5 minutes in order to increase viral incubation time proved to increase transduction response in 43% of cardiac muscle after 3 days. Minimally invasive surgical intervention is still required but the fore mentioned method shows a 400 time improvement in phenotype expression contrasted to the sham-operated group. S-Nitroso-N-acetyl-DL-penicillamine and histamine use failed to improve microvacular permeability (Ding et al., 2004).

Nonselective (indirect) intracoronary delivery

Using a number of injections to transfer genes with the use of surgery has been studied in research extensively (Guzman et al., 1993). Transduction of human beta 2- adrenergic receptor (betaAR) gene in patients diagnosed with chronic heart failure can restore the cardiac beta-adrenergic receptor system. betaAR function is also compromised in acute myocardial function upset. The betaAR signaling pathway is the main target of most drugs on the market today for heart failure treatment (Parsa et al., 2003). Use of catheter to deliver Adeno-beta 2 adrenergic receptor into the left ventricle in rabbits produced at most a ten fold increase in beta 2- adrenergic receptor expression. After 3 weeks improved myocardial function was observed. Left ventricular pressure was improved as a result of increased myocardial contractility and improved ventricle loading conditions. Isoproterenol receptivity was also observed to increase (Maurice et al., 1999). This indirect method of virus introduction will result in virus transport in the systemic circulation possibly resulting in β-AR overexpression in the lungs and liver. Larger doses of the virus result in systemic ischemia and decreased cardiac function (Parsa et al., 2003). According to Hajjar and coworkers gene transfer in vivo results in transduction occurring in more then one location.

In vivo

gene delivery involving adenovirus mediated transmission of betaAR kinase carboxyl terminus (betaARKct) or betaAR has shown that use of betaARKct prohibits smooth muscle hyperplasia in vascular intima after angioplasty. BetaARKct use improves ventrivular function via improved betaAR signaling via genetic inhibition of Gβγ-β-adrenergic receptor kinase. Over expression of betaAR improves cardiac function (Eckhart et al., 2000). Gene delivery in vivo improves ventricular contractility as well as adjustment of ECG intervals (Hajjar et al., 1998).

Global phenotypic changes can be improved via increased transduction with the use of an improved method of to deliver the viruses. Introduction of the catheter into the left ventricular cavity followed by movement superiorly to end in the aortic root is coupled with pulmonary artery and ascending aorta occlusion. As a result a transcoronary perfusion gradient is generated; which improves viral delivery. This method has a number of modifications such as prompting of asystole pharmacologically, hypothermia use to lengthen cross-clamp interval and occlusion of the distal aorta (Beeri et al., 2002), (del Monte et al., 2001) and (Hajjar et al., 2000).

Selective coronary sinus or coronary venous catheterization with retrograde delivery

Intracoronary delivery involves systemic spread of the vector due to the brief interval in which the vector can adhere to the coronary endothelium. This is the great disadvantage of the fore mentioned method as coronary flow and endothelial permeability have a large contribution (Logeart et al., 2001). Contrasted to intracoronary delivery, retrograde delivery results in improved expression of the delivered gene (Kaye et al., 2007). Adeno-associated viral vectors do not induce an immune response and cause no inflammation. AAV vectors facilitate long-term gene expression (Sakata et al., 2007). Retro-infusion has proven to transfer AAV vectors efficiently as a long term method of gene transfer. This is due to improved endothelial permeability and lengthening of adhesion time for the vector (von Degenfeld et al., 2003). Systemic spread of vector to liver and lungs was observed however with lack of gene expression due to use of an enhanced myosin light chain promoter sequence (Raake et al., 2008). Studies have proved that a single administration is enough in order for efficient regional myocyte transfection to occur. The advantages of only a single administration being necessary include minimal washout and controlled dwell times promoting longer exposure. The genes human developmentally regulated endothelial locus-1 and green fluorescent protein were used in this study (Hou et al., 2003).

Pulmonary and hepatic transgene expression can be avoided with the use of adjusted models of myocardial gene delivery. Kaye and coworkers established a high efficiency percutaneous closed-loop system. This closed loop system permits increased transduction in the cardiac muscle due to higher concentration of vector present. This method reduces peripheral systemic spread that results in decreased transgene expression outside the heart in the lungs and liver (Kaye et al., 2007). Bridges states that usage of the percutaneous closed-loop system just mentioned would result in loss of more then 99% of the vector to the systemic circulation and not to the myocardium. On close examination of results obtained 2,639 vector genomes/ mg DNA were found in the heart contrasted to 69,595 vector genomes/ mg DNA in the liver. It was suggested that lack of hemiazaygous vein control results in this systemic spread.

Ex vivotechnique

Many studies have been carried out on the use of transplantation model for gene transfer. In the study done by Griscelli and coworkers recombinant adenoviruses are injected into coronary vessels of the organ then the heart is transplanted. This study carried out on piglet hearts have emphasized prolonged exposure time for vector contact to the heart. The advantage of using such a transplantation model is that this takes place with no coronary flow. Expression of transferred gene was noted with little presence of the transferred genome in hepatic and pulmonary tissues (Griscelli et al., 2003). Wang and Knechtle experimented on and compared 2 different methods of vector delivery prior to transplantation; myocardial injection and perfusion. Injection produced a higher degree of transgene expression. Perfusion resulted in greater overall distribution of transgene expression. Use of these methods only provides as a short term method of gene transfer (Wang and Knechtle., 1996).

With reference to Keele (2011), critique and Evidence Based Practice (EBP) is relevant to healthcare because it aims to ensure that the delivery of care is supported with the best evidence available. In this assignment, two quantitative primary research articles are critically examined in the areas of wound management and comparison of negative pressure wound therapy utilizing vacuum assisted closure, to advanced moist wound therapy in the treatment of diabetic foot ulcers using the Holland & Rees framework widely used for quantitative analysis in the nursing field (Holland & Rees 2010; Keele, 2011; Zwarenstein et al., 2017).

Article 1:

A large cluster randomised trial of outcome – based pathways to improve home- based wound care.

Authors:

Zwarenstein, M., Shariff, S., Mittmann, N., Stern, A. and Dainty, K.

Year       : 2017

Aim: the aim of this study was to test a newly integrated model of wound care known as Integrated Client Care within the care home sector in Ontario, Canada to test for cost effectiveness of service and an improvement in health outcomes for patients.

Main body

Study design:

In article 1, In corresponding with the quantitative assessment report was created as a cluster randomized trial allocation of intervention randomized at the cluster level (CCAC) and analysis of outcomes based on a patient’s individual-level of recovery. Comparisons were made with clusters allocated to usual care. Again, the article described results gained using the RCT methodology that its results are valid and generalizable, and therefore relevant for creating real-world choices concerning events.

According to (Bonell et al., 2012), The approach randomized trials of complex public health interventions often fails to administer enough thought to however intervention parts act with one another and with native context. ‘Realists’ argue that trials construe the methodology, provide solely a ‘progressions’ approach to effort, that brackets out the quality of social effort, and fail to raise that interventions work, for whom and below what circumstance

Data collection:

Data collection was allied by, population-based databases involving registered personal database which contained demographic information. The Canadian Institute for Health Data discharge abstract information consists of standardized chart abstractions for all patient hospital episodes. The researcher also indicated that the National Ambulatory Care Coverage System involved in standardized coverage on all emergency call outs.

By collecting all different databases this was able to embody all of the knowledge regarding any interactions that the study participants had across the health care system.

(Thygesen and Ersbøll, 2014) argues that medical registers and records

medical records and registers square measure used extensively these days in medical specialty analysis. Despite the increasing use, no developed method literature on use and analysis of population-based registers is accessible, even if knowledge assortment in register-based studies differs from researcher-collected knowledge, all persons during a population square measure on the market and ancient applied mathematics analyses that specialize in sampling error because the main supply of uncertainty might not be relevant. we have a tendency to gift the most strengths and limitations of register-based studies, biases particularly necessary in register-based studies and strategies for evaluating completeness and validity of registers. the most strengths square measure that knowledge exist already and valuable time has passed, complete study populations minimizing choice bias and severally collected knowledge. Main limitations square measure that necessary data could also be unprocurable, knowledge assortment isn’t done by the man of science, confounder data is lacking, missing data on knowledge quality, truncation at begin of follow-up creating it troublesome to differentiate between prevailing and incident cases and also the risk of knowledge dredging. we have a tendency to conclude that medical specialty studies with inclusion of all persons during a population followed for many years on the market comparatively quick square measure necessary knowledge sources for contemporary medical specialty, however it’s necessary to acknowledge the information limitations.

Studies based on databases, medical records and registers are used extensively today in epidemiological research. Despite the increasing use, no developed methodological literature on use and evaluation of population-based registers is available, even though data collection in register-based studies differs from researcher-collected data, all persons in a population are available and traditional statistical analyses focusing on sampling error as the main source of uncertainty may not be relevant. We present the main strengths and limitations of register-based studies, biases especially important in register-based studies and methods for evaluating completeness and validity of registers. The main strengths are that data already exist and valuable time has passed, complete study populations minimizing selection bias and independently collected data. Main limitations are that necessary information may be unavailable, data collection is not done by the researcher, confounder information is lacking, missing information on data quality, truncation at start of follow-up making it difficult to differentiate between prevalent and incident cases and the risk of data dredging. We conclude that epidemiological studies with inclusion of all persons in a population followed for decades available relatively fast are important data sources for modern epidemiology, but it is important to acknowledge the data limitations.

Reference

• Bonell, C., Fletcher, A., Morton, M., Lorenc, T. and Moore, L. (2012). Realist randomised controlled trials: A new approach to evaluating complex public health interventions.
  
  Social Science & Medicine
  
  , 75(12), pp.2299-2306.

• Holland, K. and Rees, C. (2010).
  
  Nursing
  
  . Oxford: Oxford University Press.
• Keele, R. (2011).
  
  Nursing research and evidence-based practice
  
  . Sudbury, MA: Jones & Bartlett Learning.
• Zwarenstein, M., Shariff, S., Mittmann, N., Stern, A. and Dainty, K. (2017). A large cluster randomized trial of outcome-based pathways to improve home-based wound care.
  
  Trials
  
  , 18(1).