Short Communication

Significant healthcare resource utilisation in the management of skin and soft tissue infections in the Torres Strait, Australia


name here
#Haylee Fox
1 PhD, Postdoctoral Research Officer

name here
#Allison Hempenstall
2 FACRRM, Adjunct Associate Professor *

name here
Pelista Pilot
2 (Torres Strait Islander) Indigenous Research Officer

name here
Emily Callander
3,4 PhD, Health Economist

name here
Simon Smith
5 FRACP, Staff Specialist

name here
Malcolm I McDonald
6 PhD, Adjunct Professor

name here
Josh Hanson
7 PhD, Staff Specialist, Senior Research Associate

#Contributed equally


*Assoc Prof Allison Hempenstall


1 School of Nursing and Midwifery, Griffith University, 1 Parklands Drive, Gold Coast, Qld 4215, Australia

2 Thursday Island Hospital, Torres and Cape Hospital and Health Service, 165 Douglas St, Thursday Island, Qld 4875, Australia

3 School of Public Health, University of Technology Sydney, 15 Broadway, Ultimo, NSW 2007, Australia

4 College of Medicine and Dentistry, James Cook University, 1/14-88 McGregor Rd, Smithfield, Qld 4878, Australia

5 Cairns Hospital, Cairns Hospital and Hinterland Health Service, 165 The Esplanade, Cairns, Qld 4870, Australia

6 College of Public Health, Medical and Vet Sciences, James Cook University, 1/14-88 McGregor Rd, Smithfield, Qld 4878, Australia

7 The Kirby Institute, University of New South Wales, Cnr High St and Botony St, Kensington, NSW 2052, Australia


18 April 2024 Volume 24 Issue 2


RECEIVED: 8 July 2023

REVISED: 18 January 2024

ACCEPTED: 18 January 2024


Fox H, Hempenstall A, Pilot P, Callander E, Smith S, McDonald MI, Hanson J.  Significant healthcare resource utilisation in the management of skin and soft tissue infections in the Torres Strait, Australia. Rural and Remote Health 2024; 24: 8572.


This work is licensed under a Creative Commons Attribution 4.0 International Licence


Introduction:  Aboriginal and Torres Strait Islander Peoples (First Nations Australians) living in remote communities are hospitalised with skin and soft tissue infections (SSTIs) at three times the rate of non-First Nations Australians. The Torres Strait in tropical northern Australia has a highly dispersed population mainly comprising First Nations Australians. This study aimed to define the health service utilisation and health system costs associated with SSTIs in the Torres Strait and to improve the quality of regional healthcare delivery.
Methods: The research team conducted a retrospective, de-identified audit of health records for a 2-year period, 2018–2019. The aim was to define health service utilisation, episodes of outpatient care, emergency department care, inpatient care and aeromedical retrieval services for SSTIs.
Results: Across 2018 – 2019, there were 3509 outpatient episodes of care for SSTIs as well as 507 emergency department visits and 100 hospitalisations. For individuals with an SSTI, the mean outpatient clinic episode cost $240; the mean emergency department episode cost $400.85, the mean inpatient episode cost $8403.05 while an aeromedical retrieval service cost $18,670. The total costs to the health system for all services accessed for SSTI management was $6,169,881 per year, 3% of the total annual health service budget.
Conclusion: Healthcare costs associated with SSTIs in the Torres Strait are substantial. The implementation of effective preventative and primary care interventions may enable resources to be reallocated to address other health priorities in the Torres Strait.


Australia, health economics, Indigenous Australians, infectious skin diseases.

full article:


Skin and soft tissue infections (SSTIs) include cellulitis, wound infections, boils and abscesses. They are common in Aboriginal and Torres Strait Islander Peoples (hereafter respectively referred to as First Nations Australians) living in remote Australian communities1. The burden of SSTIs in First Nations communities is compounded by higher rates of comorbidities, including obesity and type 2 diabetes mellitus. The social determinants of health are critical contributors2,3. In Australia, SSTIs are managed predominantly in outpatient settings. But, for First Nations Australians living in northern Australia, hospitalisation rates for SSTIs are three times that of non-First Nations Australians4. These infections are more likely to be complicated by sepsis and more commonly necessitate intensive care unit admission5,6.

SSTIs present a substantial financial burden on Australia’s health system: a single episode of hospitalisation for SSTIs costs at least $670 per day7. Cellulitis alone accounts for 250 554 hospital bed days and 11% of all potentially preventable hospitalisations. Individuals living in rural and remote Australia often require aeromedical retrieval service to access emergency department and inpatient care; this represents a sizeable financial cost8.

The Torres Strait is a body of water bounded by mainland Papua New Guinea to the north and Cape York, Queensland to the south (Fig1). The 18 inhabited Australian islands9 of the Torres Strait have a population of close to 4500 people, the majority (about 2800) of whom live on Waiben (Thursday Island), the administrative and commercial centre of the Torres Strait region and location of the referral hospital. The Torres and Cape Hospital and Health Service (TCHHS) is the main, publicly funded health service in the Torres Strait. The hospital on Waiben is closely linked to 16 primary healthcare centres on outer islands. TCHHS also services Cape York with an additional three hospitals and 14 primary healthcare centres10. Approximately 64% of the population serviced by the TCHHS identify as Aboriginal and/or Torres Strait Islander, as compared to 3.3% represented in the whole Australian population11. The proximity to Papua New Guinea provides additional challenges for local clinicians and broadens the differential diagnoses for SSTI presentations12.

There are few published studies highlighting the financial expenditure and health economic impact of SSTIs in Australia’s First Nations communities. The aim of this study was to define the health service utilisation and health system costs associated with SSTIs in the Torres Strait in order to identify ways of improving the quality of regional healthcare delivery. 

table image Figure 1: Map of the Torres Strait, Queensland, Australia.


Data collection

Episodes of outpatient care, emergency department visits, inpatient care and aeromedical retrieval services for patients with SSTIs were collected from TCHHS health service electronic medical records for the 2-year period between 1 January 2018 and 31 December 2019. This period coincided with a year-long observational study evaluating the safety, effectiveness and community acceptance of outpatient treatment of SSTIs across the Torres Strait region in 20191. Demographic data included gender, age, ethnicity and residential address. Costs for inpatient and emergency department use were derived from the Australian Refined Diagnosis Related Groups (AR-DRG) and Urgency Related Group (URG) codes for each inpatient and emergency department occasion of service respectively. This information was combined with the mean costs reported by the National hospital cost data collection public sector report 2018–201913. Each outpatient service was assigned a cost based upon Tier-2 number 40.13 (Wound Management). Patients with SSTIs who resided outside of Waiben and who required inpatient or emergency department care were transferred by the aeromedical retrieval services. The cost of an aeromedical retrieval in the Torres Strait was sourced from Queensland Health. Outer islands were defined as any inhabited island other than Waiben.

Individual data were de-identified, aggregated and entered into an electronic spreadsheet (Microsoft Excel). The demographic characteristics of people accessing health services for SSTIs in the Torres Strait were reported by health service type including outpatient clinic, emergency department and inpatient. The individuals accessing health services were disaggregated by outpatient clinic, emergency department, inpatient and retrieval services. Of those who accessed health services, we recorded the mean number of episodes for each type of health service accessed. The mean costs per healthcare episode for individuals with SSTIs were reported and the total number of health service episodes were reported. Total costs associated with SSTIs were disaggregated by health service type (outpatient clinic, emergency department, inpatient and retrieval services); these were calculated by multiplying the number of episodes per year by the mean cost per episode in that year. All health service utilisation and cost results were reported for the years 2018 and 2019.

Ethics approval

The Far North Queensland Human Research and Ethics Committee provided ethics approval for the study (HREC/2018/QCH/44535). As data was retrospective, aggregated, and de-identified in nature, the committee waived the requirement for informed consent.


Between 2018 and 2019 there were 3509 episodes of SSTI care in outpatient clinics, 507 episodes of SSTI care in the emergency department and 100 inpatient admissions (Table 1). Most outpatient presentations were from outer island residents (2313/3509 (65%)), whereas most presentations to the emergency department were from Waiben residents (331/507 (66%)). Of those admitted to hospital on Waiben, 55/100 (55%) were from outer islands.

A total of 2529 individuals accessed health care for SSTIs, 2307/2529 (91%) presented to an outpatient clinic, 396/2529 (16%) to an emergency department, 92/2529 (4%) were admitted as an inpatient and 163/2529 (6%) were retrieved by air (Table 2). A mean outpatient clinic episode cost $240.00, an emergency department episode cost $400.85 and an inpatient episode cost $8403.05. A retrieval service cost $18,670.00 for individuals with an SSTI (Table 3).

The largest contributor to total cost was retrieval services, a mean of $4,303,435 per year. The total cost to the health system for SSTI management was $6,169,881 (Table 3). The mean annual amount of funding for TCHHS between 2018 and 2019 was $216,482,295. These amounts cover the Torres Strait (population close to 4500) and all the towns and communities of Cape York (approximate population 7500). This SSTI management in the Torres Strait accounts for 3% of the total annual TCHHS health service budget.

Table 1: Demographic characteristics of people assessing health care for skin and soft tissue infections across the Torres Strait, 2018–2019table image

Table 2: Number of individuals accessing different types of health care for skin and soft tissue infections across the Torres Strait and mean number of episodes for individuals who did access care, 2018–2019>table image

Table 3: Estimated mean health systems costs per episode and total costs for individuals with skin and soft tissue infections across the Torres Strait, 2018–2019table image


SSTIs in the Torres Strait are a substantial financial burden for the health system. The yearly number of individuals accessing the health service for SSTI management was 2529, a staggering 56% of the total local population. SSTI management in the Torres Strait alone accounts for 3% of the total health service budget for the Torres Strait and Cape York. This burden of SSTIs highlights the need for greater upstream preventative intervention measures. This should reduce the burden on the healthcare system and help to prevent other complications, including sepsis, long-term disability, recurrent cellulitis and possible acute rheumatic fever and acute post-streptococcal glomerulonephritis14-17.

Most outpatient presentations for SSTIs were in the outer islands, compared with emergency department presentations, which were mostly by Waiben residents. This reinforces the value of the primary healthcare centres in remote communities, which are typically staffed by remote area nurses and Aboriginal and Torres Strait Islander Health Workers. Ensuring adequate primary care resources on Waiben would also reduce the burden of unnecessary SSTI presentations to the emergency department.

Over a third of emergency department episodes and over half of inpatient episodes were from outer island residents. For both emergency department and inpatient episodes, patients required aeromedical retrieval or commercial flight transfer from their outer island home to hospital on Waiben. This is a huge additional financial impost on an already-stretched healthcare system. A hospital-in-the-home (HITH) or telehealth service may represent a more cost-effective healthcare model. In other Australian metropolitan and regional settings, home-based care has proven to be safe and highly cost-effective18-20.

Previous community-driven skin health promotional activities have improved skin health knowledge; however, greater investment of resources is required21,22 Strengthening of primary care services might expedite the earlier treatment of SSTIs while also potentially reducing the burden of comorbidities that drive the high incidence of SSTIs in the region. The savings from reduced retrieval, emergency and inpatient costs could be used to support other health priorities in the region including metabolic syndrome, macrovascular disease, dementia and chronic kidney disease3,23,24. Improving housing and addressing overcrowding remain priorities in this region and across northern Australia and are critical in preventing SSTIs and other infectious diseases25,26.

This study has several limitations. First, we were unable to obtain complete demographic details from some of the healthcare settings. Second, this study did not examine indirect costs of SSTIs such as work and school absenteeism, relocation away from home and family for SSTI treatment and mental health. It is time for a multicentred prospective study exploring these indirect costs – and how we might avoid them – while providing highest quality care. Finally, mean hospital costs were based on national data and we acknowledge that there is large variability in these costs between national and state-based estimates.


The management of SSTIs in the Torres Strait places a substantial resource and financial burden on local health services and the regional health system. Preventative and primary care measures such as skin health promotion programs, expanded telehealth, a HITH service and the addressing of comorbidities that drive the incidence of SSTIs have the potential to reduce their impact in this region. This may also enable the reallocation of necessarily finite resources to other local health priorities.


We acknowledge all the Torres and Cape Hospital and Health Service staff who assisted in patient enrolment and project support. We thank Peter Horne for assistance with the production of Figure 1.


This research was funded by the Emergency Medicine Foundation (grant number EMJS-300R30-2018-HEMPENSTALL), the Australian National Health and Medical Research Council (grant numbers 1046812, 1098337 and 1131932; the HOT NORTH initiative), One Disease and James Cook University. All researchers were independent from the funding bodies and had full access to all the data in this study.

Conflicts of interest

The authors declare no conflicts of interest.


1 Hempenstall A, Pilot P, McDonald M, Smith S, Hanson J. Community antibiotic management of skin infections in the Torres Strait. Australian Journal of Primary Health 2022; 29(1): 91-98. DOI link, PMid:36265549
2 Quinn EK, Massey PD, Speare R. Communicable diseases in rural and remote Australia: the need for improved understanding and action. Rural and Remote Health 2015; 15(3): 3371. DOI link, PMid:26391139
3 Li M, McDermott R. High absolute risk of severe infections among Indigenous adults in rural northern Australia is amplified by diabetes – A 7 year follow up study. Journal of Diabetes and Its Complications 2016; 30(6): 1069-1073. DOI link, PMid:27179750
4 Australian Commission on Safety and Quality in Health Care and Australian Institute of Health and Welfare. The Third Australian Atlas of Healthcare Variation. Canberra: Australian Commission on Safety and Quality in Health Care and Australian Institute of Health and Welfare, 2018.
5 Hanson J, Smith S, Brooks J, Groch T, Sivalingam S, Curnow V, et al. The applicability of commonly used predictive scoring systems in Indigenous Australians with sepsis: An observational study. PLoS One 2020; 15(7): e0236339. DOI link, PMid:32697796
6 Nguyen ADK, Smith S, Davis TJ, Yarwood T, Hanson J. The efficacy and safety of a shortened duration of antimicrobial therapy for group A Streptococcus bacteremia. International Journal of Infectious Diseases 2023; 128: 11-19. DOI link, PMid:36529371
7 Kameshwar K, Karahalios A, Janus E, Karunajeewa H. False economies in home-based parenteral antibiotic treatment: a health-economic case study of management of lower-limb cellulitis in Australia. Journal of Antimicrobial Chemotherapy 2016; 71(3): 830-835. DOI link, PMid:26702920
8 Franklin RC, King JC, Aitken PJ, Elcock MS, Lawton L, Robertson A, et al. Aeromedical retrievals in Queensland: A five‐year review. Emergency Medicine Australasia 2021; 33(1): 34-44. DOI link, PMid:32633088
9 Torres Shire Council. About the Torres Strait. 2023. Available: web link (Accessed 19 January 2024).
10 Queensland Health, Torres and Cape Hospital and Health Service. Hospitals and health centres. 2023. Available: web link (Accessed 19 January 2024).
11 Australian Institute of Health and Welfare. Australia’s Welfare: Profile of Indigenous Australians. Canberra: Australian Institute of Health and Welfare, 2023.
12 Hempenstall A, Smith S, Hanson J. Leprosy in Far North Queensland: almost gone, but not to be forgotten. Medical Journal of Australia 2019; 211(4): 182. DOI link, PMid:31231806
13 Independent Health and Aged Care Pricing Authority. National hospital data collection public hospitals report 2018–2019. Canberra: Independent Health and Aged Care Pricing Authority, 2019.
14 Wyber R, Noonan K, Halkon C, Enkel S, Cannon J, Haynes E, et al. Ending rheumatic heart disease in Australia: the evidence for a new approach. Medical Journal of Australia 2020; 213(S10): S3-S31. DOI link, PMid:33190287
15 Hempenstall A, Howell E, Kang K, Chau KWT, Browne A, Kris E, et al. Echocardiographic screening detects a significant burden of rheumatic heart disease in Australian Torres Strait Islander children and missed opportunities for its prevention. American Journal of Tropical Medicine and Hygiene 2021; 104(4): 1211-1214. DOI link, PMid:33432909
16 Guthridge I, Smith S, Law M, Binotto E, Hanson J. Efficacy and safety of intravenous lincosamide therapy in methicillin-resistant Staphylococcus aureus bacteremia. Antimicrobial Agents Chemotherapy 2021; 65(9): e0034321. DOI link, PMid:34125589
17 Kang K, Chau KWT, Howell E, Anderson M, Smith S, Davis TJ, et al. The temporospatial epidemiology of rheumatic heart disease in Far North Queensland, tropical Australia 1997–2017; impact of socioeconomic status on disease burden, severity and access to care. PLoS Neglected Tropical Diseases 2021; 15(1): e0008990. DOI link, PMid:33444355
18 Grayson ML, McDonald M, Gibson K, Athan E, Munckhof WJ, Paull P, et al. Once‐daily intravenous cefazolin plus oral probenecid is equivalent to once‐daily intravenous ceftriaxone plus oral placebo for the treatment of moderate‐to‐severe cellulitis in adults. Clinical Infectious Diseases 2002; 34(11): 1440-1448. DOI link, PMid:12015689
19 Levine DM, Ouchi K, Blanchfield B, Saenz A, Burke K, Paz M, et al. Hospital-level care at home for acutely ill adults. Annals of Internal Medicine 2020; 172(2): 77. DOI link, PMid:31842232
20 Bryant PA, Katz NT. Inpatient versus outpatient parenteral antibiotic therapy at home for acute infections in children: a systematic review. Lancet Infectious Disease 2018; 18(2): e45-e54. DOI link, PMid:28822781
21 Wapau C, Pilot P, Kris E, McDonald M, Hempenstall A. Healthy Skin, Healthy Mepla: A skin health promotional event for children in the Torres Strait. Health Promotion Journal of Australia 2022; 33(3): 736-739. DOI link, PMid:34923714
22 McRae T, Leaversuch F, Sibosado S, Coffin J, Carapetis JR, Walker R, et al. Culturally supported health promotion to See, Treat, Prevent (SToP) skin infections in Aboriginal children living in the Kimberley region of Western Australia: a qualitative analysis. Lancet Regional Health Western Pacific 2023; 35: 100757. DOI link, PMid:37424680
23 Riddell J, Hempenstall A, Nakata Y, Gregson S, Hayes R, Smith S, et al. The high burden of comorbidities in Aboriginal and Torres Strait Islander Australians living with chronic hepatitis B in Far North Queensland, Australia, and the implications for patient management. PloS ONE 2023; 18(4): e0284151. DOI link, PMid:37023060
24 Hempenstall AJ, Smith S, Stanton D, Hanson J. Melioidosis in the Torres Strait Islands, Australia: exquisite interplay between pathogen, host, and environment. American Journal of Tropical Medicine and Hygiene 2019; 100(3): 517-521. DOI link, PMid:30675834
25 Gramp P, Gramp D. Scabies in remote Aboriginal and Torres Strait Islander populations in Australia: A narrative review. PLoS Neglected Tropical Diseases 2021; 15(9): e0009751. DOI link, PMid:34591843
26 Ralph AP, Noonan S, Wade V, Currie BJ. The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease. Medical Journal of Australia 2021; 214(5): 220-227. DOI link, PMid:33190309