Saq065 amrau report Internal V11

4.4 Strategic options and assumptions for national coordination

To maximise the utility and effectiveness of an Australia-wide coordination of AMR and antibiotic usage surveillance and reporting, a clear set of high-level objectives must be established and articulated. We drew on the stated objectives of existing systems (as detailed in Section 3.2) to make a list of potential objectives for a national system. We then prioritised the list:

1. 
   Strengthen the capacity of states and territories to conduct effective AMR surveillance activities and improve the flow of surveillance information.
   
2. 
   Integrate bacterial isolate and resistance data from multiple databases to provide standardised reporting, and comparative and validated information sets.
   
3. 
   Improve the use of information to detect changes in resistance patterns over time, and between geographical areas and institutions.
   
4. 
   Improve the use of information to support rapid detection and response to emerging threats.
   
5. 
   Provide guidance to public health authorities in responding to community and hospital outbreaks of resistant organisms.
   
6. 
   Monitor the impact of interventions undertaken to reduce the levels of AMR.
   
7. 
   Evaluate the impact of therapy and infection control interventions on infection rates and cure rates.
   
8. 
   Strengthen laboratory capacity and performance through quality activities and review of reporting.
   
9. 
   Provide timely AMR data that constitutes a basis for policy decisions at both state and national levels.
   
10. 
    Provide the capacity to link AMR data from healthcare settings with information from other systems associated with antibiotic use, and veterinary and food industries.
    
11. 
    Initiate, foster and complement scientific research in Australia in the field of AMR.
    
12. 
    Provide advice to regulatory authorities on the availability and accessibility of antimicrobials based on the potential for resistance selection.
    

To develop a national system, the following assumptions are made:

• 
  Existing systems and databases will be examined for their potential to feed data to a national system.
  
• 
  Systems developed will be capable of future integration with other relevant data, information and analysis relating to AMR surveillance of food and animal sources.
  
• 
  Proposals will build on the previous work of JETACAR and EAGAR.
  
• 
  A national coordinating centre with the responsibility for the development and implementation of strategies is essential.
  

To determine the best way forward for future national coordination of AMR and antibiotic usage surveillance and reporting, two high-level strategic options are considered:

• 
  Enhance – use existing systems and processes as the basis for a national platform, and develop these systems to achieve national objectives.
  
• 
  Construct – design a new national system ‘from the ground up’, and consider the desirable attributes of Australian and international systems discussed in Section 3.
  

 

These strategic options were selected to stimulate high-level consideration of enablers and barriers to the development of a national AMR surveillance system. By using a combination of real examples and generic information, it is hoped that a discussing a range of options and solutions will lead to a focuses and achievable outcome.

4.5 Enabler and barrier analysis

Table 10 presents commentary on formative enablers and barriers relevant to the ‘enhance and construct’ options in Section 4.4. These enablers and barriers have been developed after analysing the examples in Section 3 and discussing options with members of AMRSC.

Table 10: Formative enablers and barriers relevant to ‘enhance’ and ‘construct’ options

Attribute	Enhance		Construct
	Enabler	Barrier	Enabler	Barrier
Technical Nonclinical aspects Design and construction	Many aspects already developed Proof of concepts available Advantages and deficiencies are known Pre-existing investment in design, construction and testing	Not tested in national context Not sufficiently comprehensive in current form Not currently integrated to desired extent	Can be designed with intelligence derived from experience No hindrance of legacy programming and design	Novel systems frequently yield a gap between expectations and delivery All aspects of system must be developed and operationalised
Scientific Clinical aspects Data	Shown to work with existing laboratory processes, networks and datasets Works with existing standards Has the confidence of existing users Has a public profile; is known nationally	Ability to work with data from networks not currently participating can only be inferred	Can be designed to accommodate known issues with the incorporation of laboratory data and processes	Practicalities of data submission and handling will not be known until during proof of concept and rollout No existing proof of concept in Australian environment
Operational Operating environment Management Governance	Might be undertaken via expansion in situ, or by transfer to a new operating and development environment System demands and requirements are known	Transfer to new governance arrangements and/or operating environment requires satisfactory negotiation and capacity	Can take advantage of the latest programming and operating platforms, potentially adding to efficiency and flexibility of the solution	System requirements and demands can be estimated, but cannot be tested until proof of concept stage Inherent risks regarding suitability and capacity of untested operating environment
Financial Funding	Current costs of development and operation can be ascertained Costs of further development and operation can be reasonably estimated Likely lower cost than the ‘construct’ option Opportunity for public–private partnership	Agreement is needed to fund improvement Limited fiscal resources to support unplanned cost imposts	Opportunity for public–private partnership	Potential for significant variance between cost estimates and delivery cost Limited fiscal resources to support unpredictable cost scenario
Governance and policy Jurisdictional influence Stakeholder interests Government and nongovernment	Opportunity for tangible interaction and evaluation by all stakeholders and decision makers Broad support at a national level for a national approach Visibility of existing systems	Potential for non-user ‘not invented here’ bias Perception that existing users and owners will be advantaged compared to new adopters New adopters can perceive loss of the advantages of their legacy systems	Can seek to address the concerns and interests of all stakeholders Broad support at a national level for a national approach	Key stakeholders can find it difficult to commit to an intangible concept Periods of negotiation and design can be extended in trying to appease all parties and reach agreement to proceed
Background JETACAR EAGAR	JETACAR and EAGAR reports accepted by previous governments contain references to the evolution of existing Australian systems as a suitable solution for AMR surveillance	Of the existing recommendations, some remain valid and other not valid	Previous reviews and committees recommend a national approach	No reference to new construction in recommendations of previous reviews and committees

 

Other considerations that are equally relevant to either approach include:

Funding	adequate sources of funding must be secured funding must support design and construction phases, and ongoing operation and development		Data	data privacy, security, confidentiality and ownership concerns must be negotiated and resolved evolving legislative issues and differing jurisdictional environments need to be considered
Resourcing	advancing key established resources such as the enterprise data warehouse to support the new national system		Engagement	mechanisms to ensure widespread participation and data contribution by pathology providers must be developed
Scientific	standardisation of laboratory processes to ensure comparability of data is necessary		Design	traditional CDC-like system is not particularly politically favoured

Nominated representatives of key Australian stakeholders were asked about perceived enablers and barriers to the success of proposed models executed in an Australian context. Several themes have emerged in the stakeholder survey to date.

Important features identified by respondents towards implementing a successful Australian program comprise:

• 
  recognising AMR containment as a national health priority with a long-term commitment to improving surveillance
  
• 
  establishing clear roles and responsibilities for national coordination (including clarifying the role of state and territory organisations)
  
• 
  establishing effective national leadership to coordinate decisions and agreement among key sectors
  
• 
  confirming availability of dedicated government (public) funding.
  

Adequate funding and resourcing (including education and equipment) were considered necessary to support the participation of competing laboratories financially, and to develop protocols for identification and timely processing of isolates. Stakeholders believed agreement must be reached on key organisms and parameters for surveillance. Other aspects of a successful program in Australia were considered to be the effective coordination and collaboration among contributing laboratories, adoption and expansion of existing laboratory information systems, and the use of pharmacy systems to submit hospital-based and community-based consumption data to a national database. The accessibility of data to hospitals and the public is important to inform policy and guidelines.