Key points: Australia has a high lifetime prevalence of atopic dermatitis (AD) of around 32%. The country relies on regional Asia-Pacific guidelines for AD, which lack recommendations around the use of validated disease severity measures and quality-of-life measures. There are knowledge gaps among General Practitioners (GPs) around AD, but resources exist to fill those gaps. Australia has a mixed healthcare system that combines state-funded and private care, with active partnership between the two systems. 1 In 1984, Australia introduced a system of universal medical insurance, known as Medicare. 2 Three levels of government are responsible for providing care: the federal government offers funding and support to the states and healthcare professions, as well as subsidising primary care providers; states and territories have responsibility for public hospitals, ambulance services, community health services and mental health; and local authorities play a role in delivering community and preventive health programmes. 3 Indicator Score Use of quality of life measures 0 out of 2 Availability of multidisciplinary care Availability of psychological and emotional support Primary healthcare professional training and awareness programmes Patient advocacy and support groups 1 out of 2 1 out of 2 2 out of 2 2 out of 2 Very high: 3 Exceeds on good practice criteria High: 2 Good practice criteria met Moderate: 1 Good practice criteria partially met Low: 0 Good practice criteria not met Source: Atopic Dermatitis Scorecard; full explanation of the scores are available at the end of the article. Sponsored by: 1
Australia was assessed across 12 policy indicators on how well it manages atopic dermatitis (AD), a chronic skin disease that can have psychological impact on patients. The Economist Intelligence Unit created a 12-indicator Atopic Dermatitis Scorecard, which contains indicators of importance to the management of the disease, including the provision of care and support for patients and caregivers (see below for the full scorecard results for Australia). AD is a disease often misunderstood, according to a recent Economist Intelligence Unit EIU report, which analysed the complete scorecard. 3 Overall, Australia scored on the lower end of the eight countries analysed in meeting the 12 indicators, despite having the highest rate of lifetime prevalence in the scorecard countries. Guidelines lacked recommendations around the use of validated disease severity measures and quality-of-life measures. The country performed better in provision of primary healthcare professional training and awareness programmes, and in the availability of patient advocacy and support groups. Burden and lack of national guidelines Around 32% of Australia s population will have AD at some point in their life. In terms of morbidity and costs, a small 2004 Australian study found that 21% of a cohort of 85 people with AD felt embarrassed by their skin, 15% reported problems with treatments, and out-of-pocket costs for medical consultations ranged from zero to over A$800 (US$573) per individual. 5 A later 2015 study looking at childhood AD in the Asia Pacific region estimated that the direct costs of AD per patient per year ranged from US$199 in Thailand to US$4,842 in Australia. 6 Despite this high burden, Australia s health service uses regional guidelines developed in conjunction with the APAC rather than its own national evidence-based treatment guidelines. 7,8 The country s health providers also have no tools available for assessing the quality of life of AD patients, despite some studies that point to a clear impact on families with children suffering from the condition. 9 Meanwhile, in common only with Taiwan, Australia has no specific recommendations for the use of validated disease severity measures. Knowledge gaps Patients can see dermatologists directly without a GP referral, but under Medicare they will be billed for a non-referred consultation and will not be reimbursed by Medicare. 10 Median wait times for urgent specialist clinic appointments with dermatologists can be up to 30 days in some states of Australia. 11 Many patients with dermatology conditions in Australia are managed by General Practitioners (GPs) but GP knowledge varies significantly, according to an 2017 article in the Australian Family Physician. 12 One consequence, the article notes, is that the country s GPs have uneven knowledge about the use and safety profile of topical corticosteroids in treating AD, which can contribute to exaggerated risk messaging that reinforces misinformation and can directly affect treatment adherence. 13 This situation is further complicated by the fact that there is no financial reimbursement of many over-thecounter medicines to treat AD, with annual out-of-pocket costs to AD patients estimated at A$2,000 per year. 14 2
Support for patients and carers Australia scores in the middle of the scorecard countries for recommendations around psychological and emotional support for AD patients, as the APAC guidelines mention having psychologists as part of a multi-disciplinary team. The guidelines do not recommend specific interventions and a referral process. Research have shown there is a causal impact between AD and psychosocial problems 15 and that patients do better when they have access to psychological care. 16 Further professional training on AD for primary healthcare providers has been identified as a key factor in boosting patient outcomes and quality of life. 17 Australian primary health practitioners have good access to professional training and awareness programmes related to AD, according to the scorecard, with the country scoring 2 points out of 2. The Royal Australian College of General Practitioners has a Certificate of Primary Care Dermatology, including a module on eczema. Only the UK gains similar scoring on primary health training in the scorecard. Yet, the country does better in ensuring availability of patient advocacy and support groups, receiving the highest score for this category, with the Eczema Association of Australasia (EAA) committed to supporting patients, carers, and the wider community about the condition. 18 It provides free information about the condition, including links to videos, undertakes surveys of patients, and offers advice via the telephone. 3
Australia: results from the Atopic Dermatitis Scorecard Indicator Name Australia s Unit Domain 1: Epidemiology score 1.1 Lifetime prevalence 32% % of people within the population who will have atopic dermatitis at some point in their life 1.2 Currency of prevalence data 5-10 years 0=>15 years to 10 years; 1=<10 years to 5years; 2=<5 years old Domain 2: Monitoring and measuring 2.1 Use of validated disease severity measures 0 0=none recommended in guidelines; 1=non-validated measure recommended in guidelines; 2=validated measure recommended in guidelines 2.2 Use of quality of life measures 0 0=no; 1=yes, generic instrument recommended/used; 2=yes, AD-specific instrument recommended/used Domain 3: The provision of care 3.1 Presence of evidence-based treatment guidelines 3.2 Availability of multidisciplinary care 1 0=no guidelines; 1=region-specific guidelines; 2=country-specific guidelines; +1= guidelines developed within past 3 years 1 0=no recommendations about multidisciplinary care; 1=multidisciplinary care recommended; 2=multidisciplinary care and team make-up included in recommendations 3.3 Number of dermatologists 2.3 Reported as number of dermatologists per 100,000 population: figure does not distinguish between those in public and private practice Domain 4: Support for patients and carers 4.1 Assessment of wider impact of AD on families/carers 4.2 Availability of psychological and emotional support 0 0=no; 1=mentioned briefly in guidelines acknowledge that AD impacts on families/carers; 2=guidelines recommend one or more specific interventions and a referral process 1 0=no; 1=mentioned briefly in guidelines; 2=guidelines recommend one or more specific interventions and a referral process Domain 5: Awareness and advocacy 5.1 Primary healthcare professional training and awareness programmes 5.2 Patient/carer education programmes 5.3 Patient advocacy and support groups 2 0=no; +1=nationwide primary healthcare professional awareness schemes; +1=nationwide primary healthcare professional training schemes 0 0=no; +1=nationwide patient self-care education schemes; +1=nationwide parent/carer education schemes 2 0=no patient advocacy and/or support groups; +1=formal patient advocacy groups exist; +1=formal patient support groups exist 4
References 1 Available at: https://international.commonwealthfund.org/countries/australia/ 2 Available at: https://www.aph.gov.au/about_parliament/parliamentary_departments/parliamentary_library/ Publications_Archive/archive/medicare 3 Available at: https://international.commonwealthfund.org/countries/australia/ 4 The Economist Intelligence Unit. A misunderstood skin disease: Mapping the policy response to atopic dermatitis. October 2018, https://eiuperspectives.economist.com/sites/default/files/a%20misunderstood%20skin%20disease_ Mapping%20the%20policy%20response%20to%20atopic%20dermatitis.pdf 5 Jenner N et al. Morbidity and cost of atopic eczema in Australia. Australas J Dermatol. 2004 Feb;45(1):16-22. 6 Lee BW et al. Treatment of childhood atopic dermatitis and economic burden of illness in Asia Pacific countries. Ann Nutr Metab 2015;66(suppl 1):18-24 7 Rubel D et al. Consensus guidelines for the management of atopic dermatitis: An Asia Pacific perspective. Journal of Dermatology 2013; 40: 160 171 8 Thompson D. Atopic eczema management: it s hard to get consistent information!, Allergy & Anaphylaxis Australia, https://allergyfacts.org.au/allergy-anaphylaxis/eczema-atopic-dermatitis/management https://allergyfacts.org.au/ images/docs/atopic-eczema-management.pdf 9 Wolz MM et al. The itch scratch-cycle: quality of life assessment and management of atopic eczema in children. Pediatrics and Therapeutics. April 1, 2014. https://www.omicsonline.org/open-access/the-itchscratch-cycle-quality-oflife-assessment-and-management-of-atopic-eczema-in-children-2161-0665.1000198.php?aid=2606611 OECD State of Health in the EU: Italy Country profile, 2017. Available at: https://read.oecd-ilibrary.org/social-issues-migration-health/ italy-country-health-profile-2017_9789264283428-en#page3 10 Available at: https://www.cancer.org.au/content/about_cancer/ebooks/understanding%20skin%20cancer_booklet. pdf#_ga=2.117903498.2038775386.1540920735-454475630.1540920735 11 Victorian Health Services Performance: see https://performance.health.vic.gov.au/home/report. spx?reportkey=598 12 Smith SD et al. General practitioners knowledge about use of topical corticosteroids in paediatric atopic dermatitis in Australia. Australian Family Physician. 2017; 46(5): 335-340. https://www.racgp.org.au/afp/2017/may/generalpractitioners%e2%80%99-knowledge-about-use-of-topical-corticosteroids-in-paediatric-atopic-dermatitis-inaustralia/ 13 Ibid. 14 International Alliance of Dermatology Patient Organisations. Atopic Dermatitis: A collective global voice for improving care. February 2018, page 6. https://globalskin.org/images/publications/atopicdermatitis.pdf 15 Hammer-Helmich L et al. Mental Health Associations with eczema, asthma and hay fever in children: a cross-sectional survey. BMJ: 2016; Vol. 6 Issue 10 https://bmjopen.bmj.com/content/6/10/e012637 16 Leow MQH et al. Knowledge needs and coping with atopic dermatitis: perspectives of patients and healthcare professionals in Singapore. Australian Medical Student Journal, April 15, 2018 http://www.amsj.org/archives/6351 17 This is in the key findings of the white paper and is referred to in Atopic Dermatitis: A collective global voice for improving care, International Alliance of Dermatology Patient Organisations, February 2018, https://globalskin.org/ images/publications/atopicdermatitis.pdf. See also, The King s Fund. How can dermatology services meet current and future patient needs, while ensuring quality of care is not compromised and access is equitable across the UK? March 2014. 18 See profile page and referral page for management of AD: https://www.eczema.org.au/about-us/ and https://www. eczema.org.au/managing-eczema/ 5