Aura 2016: first Australian report on antimicrobial use and resistance in human health

1.4 Australian healthcare system context

Australia’s healthcare system is multifaceted, comprising public and private sector providers, settings and participants. Healthcare providers include medical practitioners, nurses, allied and other health professionals, hospitals, clinics, and government and nongovernment agencies. These providers deliver comprehensive and complex services, from public health and primary healthcare services in the community, to emergency and acute health services in hospitals, to rehabilitation and palliative care in both settings.

Public sector health services are provided by all levels of government: local, state and territory, and the Australian Government. Private sector health service providers include private hospitals, medical practices and pharmacies. Around 70% of total health expenditure in Australia is funded by governments, with the Australian Government contributing approximately 42%, and state and territory governments 27%. The remaining 30% is made up of contributions by patients (17%), private health insurers (8%) and accident compensation schemes (5%).¹⁰

Australia has a universal public health insurance scheme, Medicare, which provides all Australian citizens with access to free public hospital care, and to many diagnostic and pathology procedures.¹¹

The Australian Government’s Pharmaceutical Benefits Scheme (PBS) and Repatriation Pharmaceutical Benefits Scheme (RPBS) provide subsidised access to a wide range of medicines for all Australians. Under the PBS/RPBS, patient contributions towards medication costs at pharmacies are capped, and there is a Safety Net Scheme to protect people with high medication needs.

Although public hospitals are funded by the state, territory and Australian governments, they are managed by state and territory governments. These provide about 70% of all hospital care.

The private sector includes the majority of doctors (general practitioners and specialists), private hospitals and day hospitals, a large diagnostic services industry, pharmacists and private health insurance funds.¹¹ Private hospitals are increasingly providing more complex surgery in Australia.

Ownership of private hospitals is quite concentrated in Australia, with more than two-thirds of all private hospital beds owned by large for-profit or not-for-profit organisations.¹¹ General practitioners and pharmacists are largely self-employed and funded through a combination of government subsidies such as Medicare and the Practice Incentive Program, as well as payment from patients.

Health service providers seek to improve the overall safety and quality of health care through various improvement activities. The Commission leads and develops many AMR-related initiatives, focusing on infection control, antimicrobial stewardship and medication safety programs.

The Commission developed the National Safety and Quality Health Service (NSQHS) Standards to protect the public from harm and to improve the quality of health service provision. The NSQHS Standards provide a quality assurance mechanism that tests whether relevant systems are in place to ensure that minimum standards of safety and quality are met, and improve the quality of health care in Australia. The 10 NSQHS Standards were mandated by health ministers in 2011 and provide a nationally consistent statement about the level of care consumers can expect from health service organisations.

Standard 3: Preventing and Controlling Healthcare Associated Infections requires healthcare organisations to monitor patterns of AU locally, and use this information to guide antimicrobial stewardship practices, as well as meet infection control requirements.

1.5 Importance of surveillance

Comprehensive and coordinated surveillance is a critical requirement of efforts to control AMR.⁴ The information generated through surveillance of AU and AMR more accurately informs and supports strategies to prevent and contain AMR. Successive international and Australian reports on AMR have identified the effective coordination of national surveillance as a foundation for reducing the adverse impacts of AMR.

Box 1.1 What does surveillance do?

Surveillance of antimicrobial use (AU) and antimicrobial resistance (AMR):

measures the size, burden, relative importance and, where possible, impact of AMR

measures the level of exposure (use) and the appropriateness of AU

detects critical AMRs early to ensure that effective action can be taken

enables changes in AMR and AU to be monitored, and provides information on the effectiveness of measures to control AU and contain AMR.

Use of surveillance data can also result in earlier detection and response to critical AMRs, and has the potential to reduce overall population impact in an outbreak. Broader health system benefits can also be gained, through reduced length of stay and overall improvements in bed capacity.

At the local level, health services and practitioners can use surveillance data to develop guidance and protocols that maximise the appropriate, effective and efficient use of antimicrobials.

Timely access to relevant data on AMR and AU will more effectively inform policy decisions, such as development or revision of antimicrobial prescribing guidelines, and help identify priorities for public health action, such as education campaigns or regulatory measures.

Table 1.1 provides some examples of how surveillance data for AU and AMR can be used, and the expected outcomes.

Table 1.1 Uses and outcomes of national surveillance of antimicrobial use and resistance at different health system levels

Level	Use of surveillance data	Impact or outcome
Global	Inform strategies to prevent and contain antimicrobial resistance, including the response to the Global Action Plan on Antimicrobial Resistance	Coordinated efforts internationally: avoidance of duplication of effort and inefficient use of resources
National	Inform policy and program development Develop and revise guidelines Inform public health priorities Inform regulatory decisions Coordinate, where necessary, the response to critical antimicrobial resistances	Coordinated and integrated efforts across Australia Increased awareness of antimicrobial resistance and One Health approach
State and territory	Inform policy and program development Develop and revise guidelines Inform public health priorities Inform regulatory decisions Detect and respond to critical antimicrobial resistances and outbreaks	Improved knowledge of local antimicrobial resistance profiles Timely response to emerging resistance Appropriate and effective use of antimicrobials
Healthcare services	Inform clinical practice Inform policy development Develop local strategies to improve antimicrobial stewardship Detect and respond to outbreaks of resistant organisms	Appropriate and effective use of antimicrobials Improved capacity for timely response to emerging resistance
Individual	Raise awareness of appropriate use in the community	Appropriate use of antimicrobials as prescribed Decreased complications from unnecessary or inappropriate antimicrobial therapy

A lack of surveillance and effective reporting can lead to misdirected and inefficient policies and programs, and poor use of limited resources through inappropriate or inefficient therapy. Importantly, these deficits can also lead to increased morbidity and mortality if patients are given ineffective or inappropriate medicines.¹²

Box 1.2 Antimicrobial stewardship

Antimicrobial stewardship (AMS) involves a multidisciplinary approach to implementing a suite of strategies to improve the appropriate and safe use of antimicrobials by health services.¹³

Effective AMS strategies are comprehensive in approach and incorporate the AMS Clinical Care Standard. Key strategies include:

educating and assessing competence of prescribers

reviewing antimicrobial prescribing and providing feedback to clinicians regarding their prescribing practices

establishing an antimicrobial formulary that includes restriction rules and approval processes

ensuring that clinicians have ready access to current, evidence-based Australian therapeutic guidelines

developing point-of-care interventions to improve appropriate prescribing

measuring the performance of AMS programs

ensuring that the clinical microbiology laboratory uses selective reporting of susceptibility testing results, consistent with health service antimicrobial treatment guidelines.

AMS is a core criterion under the National Safety and Quality Health Service Standard 3: Preventing and Controlling Healthcare Associated Infections. AMS is critical to improving patient outcomes, reducing adverse effects relating to antimicrobial treatment and containing the spread of antimicrobial resistance. Implementing an AMS program requires an understanding of the rates of antimicrobial prescribing within the service. Programs in Australia – such as the National Antimicrobial Prescribing Survey, and the National Antimicrobial Utilisation and Surveillance Program – can provide this type of data, and the Antimicrobial Use and Resistance in Australia project will offer further opportunities to report across these programs.