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General information about the indicator set

The indicators in this set are intended for population-level quality assessment across Nordic macrosocial units (regions and countries). Applications for quality improvement purposes requires setting appropriate target levels, which may vary across population groups (e.g., age) or medications assessed.
For each indicator, the preference towards higher or lower share or ratio across macrosocial units (countries, regions) is indicated, if applicable.
However, if target levels are set, they should not be set to 100% or 0%. Register data only allows measuring broad care patterns deemed appropriate or inappropriate for most. Many individual-level characteristics (e.g., contraindications, laboratory test results, risk factors, primary care diagnoses or visits) cannot be reliably observed from registers in all Nordic countries. In clinical practice, appropriateness of pharmacotherapy is to be defined based on individual-level factors.
When an indicator contains several sub-measures, appropriate sub-measure, or combination of sub-measures is to be chosen depending on the purpose of the assessment, and the time period and regions/countries compared.
The need for further stratification or standardisation by age and sex should be considered depending of the purpose and scope of comparison.

Indicators were selected through a process initiated by searches of the international scientific literature and Nordic grey literature.
To be selected, the indicators needed to be calculable by explicit rules using structured data in the registries available in the Nordic countries (patient registries of secondary care contacts with ICD-coded diagnoses, prescription registries of dispensed pharmaceuticals, pharmaceutical sales registries, population registries, causes of death registries).
The searches were followed by initial ranking and operationalisation by the MultiMed study team consisting of Nordic experts in register-based research, prescribing and healthcare quality assessment, and qualitative and quantitative research methods.
The pre-selected set was rated, commented and revised in an eDelphi study. Invitations to the eDelphi panel were shared by the study team to multiple stakeholders from all Nordic countries, including healthcare professionals, methodological experts and potential users of the indicators (e.g., representatives of bodies responsible for national and regional healthcare quality assessment and steering). The eDelphi panellists remained anonymous to each other.
The final set contains [final N will be added at the end of the study] indicators that were rated as relevant, actionable and content and face valid with consensus.
The eDelphi study was pre-registered at OSF registries. https://doi.org/10.17605/OSF.IO/2QMF7

Further research is needed to confirm predictive and concurrent validity of the indicators.
Further methodological studies are needed to evaluate the robustness of indicator definitions across register datasets deriving from different time points, countries and regions.
Further applications include following adherence/persistence to pharmacotherapy over time using observation periods of different lengths.
Limitations related to each data are to be acknowledged and reported when interpreting results of empirical applications of the indicators.

List of indicators

Secondary prevention

Acute care

Chronic care

Safety