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How much do superbugs cost Australian hospitals? An evidence-based open-access tool

  • Teresa M. Wozniak
    Correspondence
    Corresponding author. Queensland University of Technology, 60 Musk Ave, Kelvin Grove, Brisbane Queensland, Australia.
    Affiliations
    Centre for Research Excellence in Reducing Healthcare Associated Infections, Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
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  • Nicholas Graves
    Affiliations
    Centre for Research Excellence in Reducing Healthcare Associated Infections, Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
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  • Adrian G. Barnett
    Affiliations
    Centre for Research Excellence in Reducing Healthcare Associated Infections, Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
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Open AccessPublished:November 24, 2017DOI:https://doi.org/10.1016/j.idh.2017.11.002

      Highlights

      • Economic burden of superbugs is not known in Australia.
      • Innovative tools are needed to inform health policy and planning.
      • The ResImpact tool estimates Australia-specific cost of superbugs.

      Abstract

      Drug resistant “superbugs” are on the rise and pose a considerable threat. Little is known of their impact on health outcomes and costs to health services at a country-level. Local and relevant estimates that are realistic and derived with a transparent method can stimulate and inform policy responses.
      We describe an innovative online open-access tool, ResImpact that provides estimates of the national cost of common drug-resistant infections in Australia. Users are able to modify the proportion of five resistant organisms and be presented with an estimate of the associated healthcare costs. By translating complex economic data into a practical and user-friendly output, policy makers and other health professionals can improve their policy response for the Australian healthcare system.

      Keywords

      Introduction

      Drug-resistant infections are an issue of significant importance for healthcare in Australia [
      • Australian Commission on Safety and Quality in Health Care (ACSQHC)
      AURA 2017: second Australian report on antimicrobial use and resistance in human health.
      ] and worldwide [

      O'Neill J. Review on antimicrobial resistance: tackling a crisis for the health and wealth of nations London 2014. Available from: https://amr-review.org/sites/default/files/AMR%20Review%20Paper%20-%20Tackling%20a%20crisis%20for%20the%20health%20and%20wealth%20of%20nations_1.pdf.

      ]. Australia has an established National Strategy and Implementation plan [
      ] both of which align with current global efforts to curb the effects of drug-resistance [
      • OPGA/WHO/FAO/OIE Joint News Release
      High-level meeting on antimicrobial resistance [press release].
      ]. As part of the Australian Government's response to this global threat, the Australian Commission on Safety and Quality in Health Care was funded to establish and coordinate a national surveillance system for Antimicrobial Use and Resistance in Australia (AURA) [

      Australian Commission on Safety and Quality in Health Care. Antimicrobial Use and Resistance in Australia (AURA), Sydney, ACSQHC. Available from: https://www.safetyandquality.gov.au/antimicrobial-use-and-resistance-in-australia/2017-report/.

      ]. This system is now in place and is expanding the data collected and analysed to provide reports that will inform policy and practice.
      However, despite significant important efforts already in place in Australia, we still have a limited understanding of the impact that resistant organisms have on the health of the Australian population and cost to our healthcare system. Such data are necessary to report against both the National Strategy and Implementation plan, as well as for other professional wishing to address this challenge.
      We have developed an online open-access estimation tool. It is a population-based economic model of five common drug-resistant infections in Australia [

      Health Economic Modelling of Antimicrobial Resistance in Australia (HEMAA) Study. Brisbane, Queensland: Centre of Research Excellence- Reducing Healthcare Associated Infections (CRE-RHAI). Available from: http://www.cre-rhai.org.au/projects/health-economic-modelling-of-antimicrobial-resistance-in-australia–-hemaa.

      ]. The tool aims to promote evidence-based methods in epidemiology and to provide a comprehensive framework for communicating complex information to policy makers and practitioners.

      What is drug resistance?

      Drug resistance occurs when organisms such as bacteria, viruses, fungi and parasites change in ways that render the medications used to cure the infections they cause ineffective. When these pathogens become resistant to most therapies they are often referred to as “superbugs” and this is a major concern because a resistant infection may kill, spread to others, and imposes significant costs to people and the economy [
      • Cosgrove S.E.
      • Carmeli Y.
      The impact of antimicrobial resistance on health and economic outcomes.
      ,
      • ECDC/EMEA
      The bacterial challenge: time to react.
      ,
      • Centres for Disease Control and Prevention, US Department of Health and Human Services
      Antibiotic resistance threats in the United States.
      ].

      Health and economic burden of drug resistance

      Significant efforts have been made to estimate the health and economic impact of drug resistance. The most notable being the UK government commissioned ‘Review of antimicrobial resistance’ report that forecast a global cost of USD$100 trillion and 10 million extra deaths by 2050, if resistance continues to rise [

      O'Neill J. Review on antimicrobial resistance: tackling a crisis for the health and wealth of nations London 2014. Available from: https://amr-review.org/sites/default/files/AMR%20Review%20Paper%20-%20Tackling%20a%20crisis%20for%20the%20health%20and%20wealth%20of%20nations_1.pdf.

      ]. In 2016, the Australian Institute of Health and Welfare released the most recent Burden of Disease report [
      • AIHW
      Australian burden of disease study: impact and causes of illness and death in Australia 2011.
      ] with “infections” causing 1.6% of the total disease burden, measured by disability-adjusted life years. However, there are no such reports specifically focussing on resistant infections or their impact on the health of the population. Similarly, we have a limited understanding of the economic burden of drug resistance in Australia. To our understanding, the only published Australian estimates of AUD$250 million per year, are more than a decade old and are based on international data [
      • Expert Advisory Group on Antimicrobial Resistance (EAGAR)
      A comprehensive integrated surveillance program to improve Australia's response to antimicrobial resistance.
      ]. Both the O'Neil and the Australian-equivalent report made important progress in this area, but are limited in providing the context-specific information to inform policy and current planning in Australia.

      ResImpact tool in practice

      ResImpact, is an open-access tool based on a validated and transparent economic model developed as part of the Health and Economic Modelling of Antimicrobial resistance in Australia (HEMAA) project [

      Health Economic Modelling of Antimicrobial Resistance in Australia (HEMAA) Study. Brisbane, Queensland: Centre of Research Excellence- Reducing Healthcare Associated Infections (CRE-RHAI). Available from: http://www.cre-rhai.org.au/projects/health-economic-modelling-of-antimicrobial-resistance-in-australia–-hemaa.

      ]. The model uses a prevalence-based approach to estimate the additional burden to the Australian healthcare system. The tool currently covers five common pathogenic bacteria: ceftriaxone-resistant Escherichia coli and Klebsiella pneumoniae; ceftazidime -resistant Pseudomonas aeruginosa; vancomycin-resistant Enterococcus faecium; and methicillin-resistant Staphylococcus aureus.
      It includes the additional cost of antibiotic treatment of drug-resistant infections and associated morbidity and mortality (Diagram 1). We performed a Monte Carlo simulation with 10,000 samples to account for parameter uncertainty. We used gamma probability distributions to represent the excess length of hospital stay associated with each infection and log-normal distributions for two contrasting bed-day values – the accounting and the opportunity cost. To estimate the annual hospital costs of each infection, these costs were multiplied by the expected number of infections using prevalence densities calculated in the analysis. Rather than describe the model in detail the aim for this paper is to show the model's results and how they are made available using the ResImpact tool.
      Figure thumbnail gr1
      Diagram 1Pictorial representation of the economic model used to estimate the cost of drug resistant infections in Australia.
      ResImpact allows a user to input their own epidemiological data of drug resistance probability by site of infection and be presented with a range of measures to estimate the additional cost of resistant infections. The interface and layout is designed in recently launched Shiny web application framework (https://shiny.rstudio.com/), to facilitate use by policy makers and public health professionals who are not necessarily familiar with economic modelling and or the Monte Carlo methods of uncertainty analysis. Moreover, this tool provides a standardised and flexible method which can be manipulated as new, and urgently needed evidence, becomes available.
      Since June 2016, the pilot version of ResImpact is available via open-access https://aushsi.shinyapps.io/costresistantecoli/.

      Conclusion

      We present an innovative resource for policy makers and other interested professionals to use for valuing the economic impact on resource allocation and disease management. ResImpact adds to the national capacity in burden of disease analysis and provides a relevant resource to enable efficient and timely ongoing updates.
      We believe this tool can enable more effective communication between researchers and end-users including policy makers and practitioners, by providing an interactive and user-friendly display. It is an important step forward in providing a transparent and evidence-based framework for impact analysis across drug-resistant infections and ultimately to improve patient safety and future health policy. We plan to update ResImpact as new data comes to light and encourage feedback from researchers and policy makers.

      Ethics

      Not applicable.

      Authorship statement

      TW and AB developed the online tool. TW conceptualised and wrote the manuscript, NG and AB revised and critiqued the final manuscript.

      Conflict of interest

      The authors declare no conflict of interest.

      Funding

      This work is supported by the Centre of Research Excellence in Reducing Healthcare Associated Infections, which is funded by the National Health and Medical Research Council (NHMRC) grant GNT1030103. This research presented in this article is solely the responsibility of the authors and does not reflect the views of the NHMRC.

      Provenance and peer review

      Not commissioned; externally peer reviewed.

      References

        • Australian Commission on Safety and Quality in Health Care (ACSQHC)
        AURA 2017: second Australian report on antimicrobial use and resistance in human health.
        ACSQHC, Sydney2017
      1. O'Neill J. Review on antimicrobial resistance: tackling a crisis for the health and wealth of nations London 2014. Available from: https://amr-review.org/sites/default/files/AMR%20Review%20Paper%20-%20Tackling%20a%20crisis%20for%20the%20health%20and%20wealth%20of%20nations_1.pdf.

      2. National antimicrobial resistance strategy 2015–2019. Australian Department of Health, Canberra2015 (Report No: 978-76007-191-2 Contract No. February 2017)
        • OPGA/WHO/FAO/OIE Joint News Release
        High-level meeting on antimicrobial resistance [press release].
        General Assembly of the United Nations, 2016
      3. Australian Commission on Safety and Quality in Health Care. Antimicrobial Use and Resistance in Australia (AURA), Sydney, ACSQHC. Available from: https://www.safetyandquality.gov.au/antimicrobial-use-and-resistance-in-australia/2017-report/.

      4. Health Economic Modelling of Antimicrobial Resistance in Australia (HEMAA) Study. Brisbane, Queensland: Centre of Research Excellence- Reducing Healthcare Associated Infections (CRE-RHAI). Available from: http://www.cre-rhai.org.au/projects/health-economic-modelling-of-antimicrobial-resistance-in-australia–-hemaa.

        • Cosgrove S.E.
        • Carmeli Y.
        The impact of antimicrobial resistance on health and economic outcomes.
        Clin Infect Dis. 2003; 36: 1433-1437
        • ECDC/EMEA
        The bacterial challenge: time to react.
        European Center for Disease Prevention and Control, Stockholm2009
        • Centres for Disease Control and Prevention, US Department of Health and Human Services
        Antibiotic resistance threats in the United States.
        CDC, Atlanta2013
        • AIHW
        Australian burden of disease study: impact and causes of illness and death in Australia 2011.
        Australian Institute of Health and Welfare, Canberra2016 (2016. Report No.: ISSN 2204–4108 Contract No: Cat. no. BOD 4)
        • Expert Advisory Group on Antimicrobial Resistance (EAGAR)
        A comprehensive integrated surveillance program to improve Australia's response to antimicrobial resistance.
        National Health and Medical Research Council, Canberra, Australia2006