Making sense of health care delivery Where does the close to community health care worker fit in? – The case for congestive heart failure

Abstract

Close to community health care workers (CTC-HCW) is an increasingly used term to describe the emergence of a new partner in health services delivery. In strengthening arguments for this part of the health workforce the authorities, health staffers, supporters, sceptics and perhaps clients will look to the academicians and the evidence base to determine the fate of this group. There is no doubt, CTC-HCW are a vital resource, whose importance is tied to socio-demo-geographic variables. Regardless of what the common perceptions of its importance are, the evolving evidence base could suggest either way. In this short commentary we would like to highlight the importance of a balanced and common sense approach in these arguments. An important example is heart failure where the majority have an associated comorbidity and one in four would also suffer with cognitive or mood disturbances. It is unclear how the CTC-HCW would fare for this devastating syndrome. In moving forward it is important we understand there are: strengths and limitations in the evidence gathering processes; indecision as to the questions; uncertainty of the starting points to gather evidence; and sociodemogeographic biases, which have to be factored before determining the fate of this much needed health care resource.

1. Introduction

“Decades of categorical funding created a highly specialized and knowledgeable workforce that lacks many of the foundational skills now most in demand. The balance between core and specialty training should be reconsidered”

--Kaufman NJ et al. (1)

We can no longer think of health systems in silos. From the statement above, close to community health care workers (CTC-HCW), could face similar fates. Every arm of the health system is connected. The client and information about them are the common denominators. All health systems are faced with challenges in providing effective and equitable health services. These challenges are seen throughout the various health care delivery domains and the various dimensions within. There are significant permutations to negotiate for effective care within individual health clusters. As Kaufman et.al pointed out,^1,2 it is important that we look at CTC-HCW from a larger lens, or this group will serve a short term need and face an unclear future (Fig. 1). In this increasingly interconnected world demographic changes can be volatile and subject to change within a short period. Any resource spent in developing these strategies must factor this. Viewing health systems policy as a continuum rather than preventive bandaging of problem areas should be the new norm. In this case recruiting lay persons to address community health issues, which is not actually novel, can be the flavor of the month or could be a serious strategy. The case for short term medical needs are important, but not the scope of this commentary. Examples of CTC-HCW roles are listed.³

• •
  Medical Roles

  • ○
    Counseling;
  • ○
    Education, health promotion, immunization;
  • ○
    Data collection, community based drug distribution and basic treatment and care for some diseases.
  • ○
    Management of disease outbreaks, community mobilization;
  • ○
    Follow-up and referral;
  • ○
    Screening and point-of-care diagnostics;
• •
  Social Roles

  • ○
    Address a varied disease base many with cultural issues to consider e.g. prevalent in communities e.g. maternal and child health, including nutrition, to sexual and reproductive health, HIV, malaria and TB diagnosis.
  • ○
    Better understand social context to health services delivery
  • ○
    Flexible employment arrangements

Fig. 1.

Basic example of silos in health care systems. Health systems are often compartmentalized into silos. In this case the 3 most important arms the client, health care professionals and administrative are in seen in separate compartments. These groups have to encounter and/or address similar themes of access, cost, education, information (acquiring, sharing or interpreting) and respond to quality and satisfaction of services. The perspectives for these themes often come from the silo of that individual. The arrow highlights where we should be and the potential for identifying areas in common to break down the silos.

The issues faced in ambulatory chronic disease management programs (CDMP), in this case congestive heart failure (CHF) with comorbidities, and the role of CTC-HCW is the subject of this commentary. We explore the proven models of care, the evidence gathering process for important gaps, technology interface to close gaps and integrating the CTC-HCW in this process.

2. Defining the issues and health care team

You can't build an adaptable organization without adaptable people--and individuals change only when they have to, or when they want to.

--Gary Hamel

Chronic ambulatory health care conditions or diseases which are often without cure and thus require ongoing care involves large components of non-tertiary supports. In the case of CHF at least one in four would die within 2 years and suffer from a mental illness; while the majority will experience periods of decompensation, prescribed polypharmacy and have at least one comorbidity.^4,5 There remain many areas that will find it difficult to staff this. Thus the crux of the discussion for CTC-HCW in this context, is: firstly, not only do we have to embrace the role for CTC-HCW, we actually need to; secondly, having embraced the need, we have to decide, how and who best leads the management of these conditions outside the large hospitals, in areas with significant staff shortages. CTC-HCW is merely another, but new, term in the health vocabulary for what would be a case manager, usually a specialist nurse practitioner, who could address issues where there are resource shortages and cultural differences. While many may argue for evidence to be generated for the key word ‘CTC-HCW’, we will find that perhaps much of the evidence is already there, under different keywords. In fact the debate should revolve more around: practice (scope and breath); career pathways (ease of movement within the health system hierarchy, progression); remuneration (appropriate for level of training and weighting for geographical conditions), as examples.

Could CTC-HCW deliver CHF care? An accepted definition is a “…health worker who carries out promotional, preventive and/or curative health services and who is first point of contact at community level. They can be based in the community or in a basic primary facility. They have at least a minimum level of training in the context of the intervention that they carry out and not more than two to three years para-professional training.³” Some examples include CTC providers, community health workers, village midwives, traditional birth attendants, formal and informal private practitioners, community based drug distributors and lay counselors that deliver wide ranging services from different contexts.³ It is not inconceivable that these persons could similarly implement a structured HF program, or parts of it, as argued by Lewin et al.⁶ The learning curve would be greatest for those without any science background or life-experiences with chronic diseases.

Could CTC-HCW deliver comprehensive CHF care? Proven therapies for HF are associated with significant improvements in all prognostic and quality of life measures. The nurse lead CHF-CDMP program has a proven track record. Adequate prescription and compliance with physiological modulating CHF therapies, in selected cases invasive therapies and device therapies share similar positive track records. Prospective population level data now support such improvements outside the trial settings.^4,5,7 Should there even be small gaps outcomes could be affected, and similarly improved by addressing them. Importantly even the best centers find it difficult to facilitate delivery of best practice, for all care domains, in all cases.⁸ This perhaps explains the benefits of CDMP. Such programs address the holistic delivery of prescribed treatments with more structure. They address risk factors, nutrition, exercise and general wellbeing as well. Importantly evidence supports home based and telephone supported CDMP interventions. Clearly a minimum level of face-to-face contact is needed, however home and telephone support can replicate purely center based care.⁹ With adequate training it should be conceivable that CTC-HCW could fill or share the space with health practitioners based at tertiary centers and shoulder significant responsibilities.

Could the CTC-HCW deliver comorbidity and mental health support? The fundamentals of diagnosing and treatments are similar and are reflected in CDMP's. Certainly it would be a greater challenge to manage clients with mental health and comorbid conditions; however in the real world they will reflect the majority of CHF clients. It is perhaps important we detail the structure and hierarchy of health care team so that CTC-HCW are able to access support when needed. With distances such a structure will require is to embrace technologies and develop further tools to allow for real-time sharing, accessing and communicating information.

Where would the CTC-HCW fit into the CHF-CDMP? All medical staff partakes in six fundamental roles. Table 1 highlights these broad roles and the strengths for each HCW. Doctor's strength lies in their diagnostic and therapeutic skills, largely related to their improved understanding of physiology and pharmacotherapy. This effectively makes them prescribers of therapy. Nursing and allied health, function more as deliverers of therapy and have greater roles in prevention and promotion of health care. Many private practices now have allied health staff on site to further the other goals. In the Northern Territory of Australia, remote community health centers (CHC) are run by nurses with tele-health support from tertiary centers. It would not be inconceivable that CTC-HCW fill this space where trained HCW are unavailable. Let us explore how we can prove this and build a sustainable case for CHF.

Table 1.

Defining health care professionals role and relative strengths.

Health care practitioner	Diagnose	Prescribe	Deliver dispense	Maintain monitor	Prevention	Promotion	Notes
Medical	+++	+++	++	++	++	++	Ability to prescribe. Greater knowledge of curative and prevention in pharmacotherapy and interventions. PHC greater role in prevention and promotion. Specialist greater role in curative
Nursing	+	+	+++	+++	+++	+++	Ability to deliver therapies with selective prescribing. Greater knowledge in prevention and promotion.
Midwifery	+++	++	+++	+++	+++	+++	As for nursing but more focused on specific clientele. Greater role in specialized diagnostics and therapy.
Dentistry	+++	+++	+++	+++	+++	+++	As in medical but more specialized to one organ system. Takes on more responsibility in prevention and promotion than most medical staff.
Other allied health	++	++	+++	++	++	+++	As for midwifery.
Close to community	+	+	++	++	++	+++	No formal medical training. Standardization an issue. Efficacy largely determined by quality of individual personnel.

Table highlighting dimensions of for the various HCW. The medical doctor strength is in diagnosis and prescribing curative therapies. Allied health staff focuses more on delivering of therapies. This example of a silo may be more related to time constraints and abundance of staff to allow for specialization. The dentist, mid-wife and nurse practitioner are examples where the HCW can practice at high levels across all dimension of care. These later examples could help steer the capacity for CTC-HCW to assume greater responsibilities for all dimensions of care. A well-structured curriculum, adequate PHC and tertiary level support would provide greater checks and balances for CTC-HCW.

3. Trial design and validity

“…it is essential that those held accountable have the processes of care being assessed under their locus of control…”

--Harlan Krumholz (10)

It is essential that the generation and interpretation of the evidence involve the team from health care cluster where the services are to be delivered.¹⁰ In this, the sense of ownership or stake in the process could drive positive momentum in moving things forward. Once the local stakeholders have been factored details of the trial design must be factored. Trials are designed to test a hypothesis. Potential biases are controlled. An adequate sample size is determined to ensure the study is adequately powered to generalize the results. Finally the trial findings have to be factored by administrators, who will allocate the funding for the program.

What are appropriate hypotheses for CTC-HCW and CHF-CDMP? The first question is the hypotheses which essentially focuses the study on the area of ambiguity. In CHF management there are few ambiguities on therapeutics, devices and CDMP delivered by a health care team, preferably lead by the nurse practitioner with acceptable components of technology and delivery of services away from tertiary centers.^11,12 As replicating what is proven will likely deliver the results, there will no longer be a case to randomize one form of therapy against another for mortality benefits. In this case randomizing nurse lead care and CTC-HCW. The issues for CTC-HCW are:

• 1.
  Service delivery:

  • a.
    How we standardize the training to ensure there is accountability on the care being delivered?
  • b.
    What is the extent of the duties able to be administered and the gaps compared to nurse lead programs?
  • c.
    Is the ability to understand the cultural aspect at the micro level of significance?
• 2.
  Standards

  • a.
    What is the scope of the training program?
  • b.
    What is the breadth of the duties?
  • c.
    What are the KPI measures of adequacy?
  • d.
    What are guidelines for acceptance and rejection of applicants?
• 3.
  Plasticity

  • a.
    What are the career development prospects?
  • b.
    What are the opportunities for transition to other areas within health system?
  • c.
    What are remuneration models?

What is the appropriate trial design to answer the questions? The randomized controlled trial (RCT) is the gold standard to prove cause and effect. The internal validity which control for systematic errors and external validity which describes how well the study can be generalized highlight the strength and weaknesses of the method. What has been lacking in CHF have been post RCT implementation focused studies. In fact one such study, the OPTIMIZE-HF, we understand that it is essentially these simple measures that could make the difference, and there are in-fact many such opportunities. In the design of the NTHFI-CA, a prospective audit for the Northern Territory of Australia, we highlighted the six essential domains of care delivery each with numerous care dimensions.¹³ Thus it could be essential to determine if the CTC-HCW can address CHF-CDMP components at some of these levels. The likely trial design would thus be a prospective interventional cohort study. Should any area require greater focus this can be done within a nested case control or a quasi-experimental design. This will allow for a real world study, a broad look at all the potential gaps and introduce more than one intervention at a time.

Who are the stakeholders, what is the trial setting and who are the participants? It is imperative that administrators and local stakeholders play a leading role in the design whether the driving force is coming from within or outside the health cluster.¹³ It is also imperative that there is a Memorandum of Understanding (MOU) with the funding bodies of a commitment to implement some aspect of positive findings. The trial setting would be the various communities of the CTC-HCW. The participants should be all comers. Enrolling in a clinical study has outcome benefits. As resources are also scarce such trials should appear to be a continuation of clinical services. In addition such efforts would add a ‘Halo Effect’ where there is spill over knowledge through the health systems and communities.

What are suitable endpoints? There is probably enough evidence to inform the strategies that will produce the prognostic outcomes benefits. The issues currently are extending the external appeal for the Western Paradigm of CDMP, where a lot of the evidence already exist.³ No doubt there will be a subset of patients where there will be variations in response to therapeutics. There will also be groups with comorbidities that have to be factored. There are strategies that could address these both at the bedside and bench.⁵ While these processes are ongoing, it essential we continue the implementation of current findings in the various communities. On this point we feel that the primary endpoints should focus on QOL, cost efficacy (health economics), service utilization (e.g. readmissions) and less on cardiovascular and all cause outcomes. It would be ideal to steer away for composite endpoints as they would not give us the microscopic view of factors at play in individuals and communities.^14–16 Finally information will also be gathered on population demographics, data that can be used to fine tune therapeutics when more global data is available.

4. Technology

It is not the strongest or the most intelligent who will survive but those who can best manage change.

--Charles Darwin

There is a global demand for innovative and transformative care models to overcome the challenges of delivering health care in the 21st century. The rapid advances in digital health space are leading the transition of traditional health care systems to adopt personalized, preventative, predictive and participatory (P4) framework¹⁷ and digital health innovations are crucial to extend the P4 systems of care geographically disadvantaged and medically underserved communities. Let's explore how this could benefit CTC-HCW:

What diagnostic, management and communication tools should CTC-HCW become familiar with?

• 1.Apps – provide opportunities for more control over health now more than ever before, with hand held devices. There are several sensors and apps available to continuously monitor an increasing number of health parameters. Commercially popular electronic activity monitors provide tools for self monitoring, goal setting and feedback to encourage incidental behavior changes.¹⁸ They provide a medium to rollout clinical, rehab or public health interventions in geographically isolated populations at a low cost, as the techniques used by these apps are comparable to those used in clinical behavior interventions. The data from these devices can be used to track if the patients have adhered to the recommended habitual physical activity in the forms of structured exercise and spontaneous physical activity, for the management of CHF.
• 2.Telemedicine – High satisfaction rates with telemedicine and demonstrated clinical effectiveness in patients with CHF compared with usual care, makes it perfectly suited to expand specialist care to geographically isolated regions more efficiently.¹⁹ Studies in mental health care have shown that store and forward or asynchronous technology, that allows a primary care health professional to interview the patient and record it in a video for review at a later time by a specialist at a distant location, has been effective and been described as a feasible alternative to real-time telemedicine, as a consultation model for primary care.²⁰
• 3.Electronic Health Records and Shared information systems – There is a large amount of evidence suggesting that patients who access and manage their own health information are better engaged with care and also achieve desired outcomes.²¹ In recent years, health care organizations across the world have started initiatives, such as Blue Button in the US²² and Personally Controlled e-Health Records in Australia,²³ which facilitate patients' access to their health records online. Efficient and accurate sharing of information between patients, their carers and providers from multiple organizations will result in better coordinated care and reduce health care costs.²⁴ Timely access to right information is crucial especially when patients from geographically isolated regions are being assessed remotely by specialists. Personally Controlled Electronic health records such as Blue Button in US Veteran or the PCEHR in Australia allow patients access to their past and future appointments, problem lists, allergies, medications, laboratory results, procedures, vitals, and immunizations, etc. Patients can share these information with trusted others to receive timely and appropriate care.
• 4.Analytics and predictive tools – Linking disparate health care data sets and creating predictive application can help detect patient's deterioration early, offer opportunity to better target proven preventative therapies and find new effective ways of treating.²⁵ Text processing techniques on clinical notes can help in early diagnosis of heart failure.²⁶ Predictive applications can also assist in greater care personalization by allowing clinicians to determine who is likely to benefit from a particular type of treatment, so that they can better target therapies. The health data sets utility in clinical decision support for optimizing patient outcomes has already been demonstrated with a wide variety of targets including life expectancy and physiology status,^27,28 cancer,²⁹ heart failure,^30–33 kidney disease,³⁴ chronic obstructive pulmonary disease,³⁵ bipolar disorder,³⁶ and HIV.³⁷ Health data based applications designed for patients can help patients gain better insights, enhance engagement with clinical trials and adherence with recommended treatments.^25,38,39

What barriers should CTC-HCW and health systems become familiar with? Le Rouge identified several barriers for technology based care models^18,40:

• 1.Poor broadband infrastructure – Investments here are crucial for innovative care models using technology to emerge. Resistance to change by mainstream health professions coupled with medical licensure credentialing restrictions that restrict the practice jurisdictions can limit the ability of early adopters agents in increasing uptake of technology based care models services.
• 2.Legal barriers – Historically, the challenge of medical licensure or “credentialing” for multi-state service provision by medical providers has been burdensome and has therefore restricted growth across state lines. Even when licensing is in place, it is often difficult to work within multiple different health organizations because of privileging procedures within the organizations. Furthermore, the legalities surrounding virtual medical services can sometimes be inconsistent, vague, and increase liability concerns.
• 3.The Return on Investment (ROI) is not as readily apparent for many other services – The technology based care models are usually rolled as adjunct to existing care, making it difficult to demonstrate the ROI. Further efforts are required to gather metrics that can demonstrate that technology based services can be financially sustainable alternatives to traditional care models.
• 4.Business strategy – a telemedicine effort is often viewed by many health organizations as an adjunct project rather than as a sustainable service that can provide ongoing improvements in patient care and medical protocols. Demonstrating that telemedicine can be financially sustainable is perhaps the most difficult organizational issue resulting from challenging reimbursement situations and the challenges of gathering proper metrics. A growing aging population potentially open to telemedicine, coupled with a shortage of health care providers, and may become some of the leading drivers of telemedicine adoption. As these providers recognize that their patients are satisfied with telemedicine services, it may diminish providers' resistance to telemedicine
• 5.Human resources – CTC-HCW must also have the skills and willingness to operate the required medical telecommunication tools that facilitate the telemedicine process. There is a need to upskill existing health professionals technical skills to not just learn how to use technology but also to learn to form innovative care processes using these tools. In the absence of a formal training and upskilling the system relies on champions, which is not sustainable. Thus, another challenge is the inadequate pool of specialty providers available to meet the initial needs and growing stages of telemedicine. When specialty provider shortages exist, many of the responsibilities of providing telemedicine service fall upon a limited number of physician champions. These clinical champions of telemedicine services may find that they are subject to a high level of on-call availability and scheduling challenges, particularly in cases of rapid telemedicine adoption from spoke sites. Such a situation may detract from further provider participation (i.e., fewer champions emerging or existing champions not promoting expansion and future telemedicine efforts) and may lead to champion turnover. A telemedicine effort is often viewed by many health organizations as an adjunct project rather than as a sustainable service that can provide ongoing improvements in patient care and medical protocols.

Technology is here to stay. With time all communities will or will have to embrace some form of it. Being remote, collecting information at the point of first contact and sharing it is vital for many reasons. Thus advancing this should not be deferred, finding better solutions should be a priority.

5. Health clusters, universal health coverage and ownership of health services

“As Minister of Health, and as a frontline health care professional, there is nothing more important to me than the patient client experience.”

-- Hon. Eric Hoskins

What is the best health model for CTC-HCW to work in? In the present climate, discussing personnel should go hand-in-hand with discussions on health systems. As we have come to understand there will only be minor variations in the guidelines regardless of the demographics. The issues factored here would include easing pill dispensing strategies, simplifying therapeutic regimes, prescribing drugs with extra class benefits and reducing costs to consumers all aimed at improving compliance. Health systems delivery outside therapeutics and interventions must however factor demographics and rapport, as the Hon Eric Hoskins (Health Minister Ontario Canada) has spelled out it is the client health system interaction and satisfaction. It is perhaps this area that CTC-HCW could supersede most other HCW. The information gained from CTC-HCW should be factored into local HFCDMP strategies. In this point we thus emphasize on the regional health cluster concept. The push for universal health coverage may see funding sources centralized and these bodies determining funding streams. It is equally important however that flexibility or the locus of some control particularly in micromanagement of programs be allowed to occur within these health clusters. Administrative workforce is always the subject of political debate, thus it is vital that HCW in the future be aware of fundamental health economic issues. Allowing the prescribers and deliverers a greater say in the administration of health locally, should also occur in conjunction with greater accountability. Understanding the corporatisation of the management of public services must be part of the thinking of HCW, including the CTC-HCW.

Where could the CTC-HCW fit in? CTC-HCW could in fact lead in health services delivery for remote clients within those health clusters. We would encourage as part of the curriculum they understand their corporate responsibilities for the cluster they work for. They will also be best positioned to steer achieving the funding Key Performance Indicators (KPI), having that better understanding of the regional issues. In the design of the AUSI-CDS study, a prospective study aiming to deliver a CDSMP to Indigenous community we highlighted the need for a case manager to act as the clients advocate and negotiate the journey through the health systems.¹⁶ At the very least CTC-HCW should take the lead as this case manager. In this greater focus can be given to the strengths such as education and disease prevention. Targeting the healthy as well as the ill would be a measure ahead of the curve (Fig. 2).

Fig. 2.

Chronologies of illness and care for ambulatory chronic conditions.

6. Learning from other health systems? Perspectives from the Bahamas

“For health, the previous century largely relied on the technology-driven medical model to combat communicable diseases. With NCDs now the biggest killers worldwide, this century must be an era where prevention receives at least as much priority as cure”.

Director WHO – Margaret Chan 67TH World Assembly address

Why does the Bahamas need CTC-HCW? As the rural communities around the World become more open and are exposed to more fluent societal determinants of health, where education along with individuals taking responsibility for their health are going to be the most positive pivotal factors to transform and sustain healthy communities. The Commonwealth of the Bahamas owing to the archipelagic nature of the islands which are scattered across one hundred thousand square, extending from the United States to its North and Cuba to its South, has sparsely populated rural areas that are separated by masses of water; with very particular healthcare delivery challenges as a Developing Country. The changing cultural influences in the communities have brought about the introduction of processed modern “fast foods” rich in high carbohydrates and fats. Along with less active lifestyles have resulted in an exponential rise in chronic Non-Communicable Diseases (Cardiovascular Diseases, Obesity, Diabetes and Cancers – NCD's). The models of healthcare delivery at this pivotal juncture must change to positively impact these rural communities which will require allied healthcare practitioners to infiltrate these communities with CTC-HCW (Close To Community Health Care Workers) to bridge the gaps in healthcare which can improve the quality of life among affected populations. As the Bahamas is in the process of introducing Universal Health Care (UHC) by January, 2016 the opportunity to involve these new emerging categories of allied healthcare workers will be significant to ensuring equity and accessibility to vulnerable communities in a cost-effective manner. This will optimize already limited resources that is a typical feature of developing countries.

Who could these CTC-HCW be? The CTC-HCW in the Bahamas, namely Home Care Providers and Patient Clinical technicians are two categories that are being trained in certificate courses, with specific limited healthcare skills, to serve the needs of the elderly and economically challenged individuals so they can become active participants in ambulatory care (out of institutional care) which will have considerable benefits to improving client satisfaction and the overall adherence/compliance in NCD's management in the long term. In order to implement the new models of healthcare delivery inclusive of modifying the protocols (e.g. Heart Failure Treatment) and therapies that are being researched and changed to determine the most simplified evidence-based, efficient and effective approaches to be utilized in these rural communities. The “Family Islands” as they are called in the Bahamas context are ideal research environments. The opportunities to conduct collaborative research with other communities across the globe such as the rural communities in Australia are welcomed because the collaborative work would enrich the knowledge pool and unravel areas of synergy, with tangible benefits, relevant to “tool” healthcare leaders with knowledge of commonalities in delivery systems that are applicable in similar healthcare settings for optimal quality outcomes.

7. Conclusions

“A hospital bed is a parked taxi with the meter running.”

--Groucho Marx

For CTC-HCW to succeed it has to be relevant to the current and future health system needs. It has to address at the core social determinants of health, through multisystem collaboration and backed by a viable business model with a sound flexible curriculum. Unfortunately the need also arises because of a gap in health services. This gap also involves the poor and marginalized However if we are to bridge gaps in health care it is important that there are standards behind the CTC-HCW model. It is also important we delineate their roles primarily as a case manager who can bridge client-health care deficits due to distance, culture and other reasons. Their ability to take on additional roles should be considered a bonus. We would encourage some universal method to standardize this and define the scope and breadth of practice. Where practice is targeted certificates may suffice; where practice is broad a diploma or degree. Regardless, it would appear that a communication bridge between the traditional source of health delivery and expertise, tertiary health centers, would see CTC-HCW actually deliver more care and assume more roles as there is unhindered communication and free flow of knowledge and information.

Authors contribution

Dr Iyngkaran prepared the manuscript. Dr Bidarrgardi prepared the section on technology. Dr Beneby prepared the section on Learning from other health systems. All authors reviewed the manuscripts, offered suggestions and corrections.

Disclosures/competing interests

None declared. All co-authors have won independent and governmental research funding. Several members provide counsel to pharmaceuticals. None pose a conflict of interest for this review. Dr Iyngkaran is supported by the Heart Foundation Health Professional Scholarship (100309). Article choices were weighted in favor of Australian public health systems and regional relevance to reflect the need for regional solutions. We acknowledge there may be similar perhaps larger international studies for some of the areas presented.