2.1.4 Indicators
Many aspects of human and animal health related to AMR can be measured, but not all these measures are informative and useful. An
Most indicators are not directly observed and have to be calculated from the values of other variables. In special circumstances, such as the emergence of a new type of AMR, the observation of a single instance of AMR in one patient or animal might comprise an indicator that triggers an alert or response. However, in most cases, indicators are defined for facility-level data units such as hospitals, or geographic regions such as provinces or countries. This enables comparisons over time, over different geographic areas and across population groups.
Given their importance in supporting decision-making, indicator variables are required to have SMART characteristics:
- Specific: Indicators should measure a precise, operationally relevant target for improvement, monitoring or achievement. For example, rate of MRSA carriage in surgical inpatients should not exceed a particular threshold.
- Measurable: Indicators must be able to be precisely and accurately measured using validated, standardised instruments. For example, standard, internationally comparable units of measurement of AMR and AMU are important for constructing indicators.
- Achievable and attributable: Changes in the key outcomes that the indicator measures must be possible – an indicator that will not vary over time, and will not respond to interventions is not a good indicator. Additionally, changes in the outcome must be causally related (attributable) to changes in the indicator. For example, a decline in MRSA carriage should be attributable to improved preoperative screening and decolonisation of surgical patients.
- Relevant and realistic: When indicators are used as ‘benchmarks’ or ‘standards’, it must be possible that the desired outcomes can be reached. For example, an indicator measuring the number of weeks with zero resistant infections across the entire community in a year would not be relevant, because it is practically impossible that no resistant infections at all will occur.
- Time-bound: Changes in the indicator must be achievable within a relevant time frame. For example, indicators included in a
National Action Plan on AMR (NAP) should be expected to show change within the time period covered by the plan (most often three or five years). An indicator that refers to AMU or AMR in, say, 2050 would not be much help for evaluating a NAP.
Activity 7: SMART indicators of AMR
Return to the example dataset (Table 4). (Hint: go through all the characteristics to make sure the indicator you select is SMART.)
| PatientID | DOB | Age | Gender | Date sample | Sample | Species | Methicillin |
|---|---|---|---|---|---|---|---|
| 1234 | 01/01/1960 | 60.8 | 1 | 01/02/2020 | Blood culture | S. aureus | R |
| 1235 | 01/01/1970 | 50.8 | 2 | 02/02/2020 | Nasal swab | Staphylococcus aureus | S |
Answer
One example of an indicator is the percentage of hospital inpatients who develop MRSA blood infections in a calendar year. Here’s why it is a SMART indicator:
- Specific: This indicator could be measured for a single hospital ward, the whole hospital, a region or a country, and be used to evaluate progress against targets in these settings.
- Measurable: It can be measured using standard protocols for sampling, bacterial identification and AST.
- Achievable and attributable: It is a measure of the quality of infection prevention and control in healthcare settings – hospitals with a higher percentage of patients developing MRSA infections can be targeted with interventions to improve infection prevention and control practices.
- Relevant and realistic: MRSA is associated with increased length of hospital stay, more severe disease and increased risk of death – therefore, this is an important indicator of patient outcomes, which might vary between hospitals, regions or countries.
- Time-bound: The time period for monitoring this indicator (one calendar year) is clearly specified.
2.1.3 Datasets
