People living with chronic conditions often face poor-quality, fragmented care due to the need for multiple interactions with different providers and levels of care. Addressing this requires a shift to people‑centred health systems that deliver seamless, integrated care across settings (OECD, 2021[1]). Countries are testing various levels of integration in organisational structures and services to better manage complex health needs, aiming to improve population health, patient experiences, reduce costs, enhance working conditions of health professionals, and promote health equity. However, inconsistent data and varying definitions of “integrated care” make it difficult to inform policy and benchmark progress, despite taxonomies developed by organisations such as the WHO and the EU (OECD, 2023[2]).
Policies promoting integrated care can improve patient outcomes and experiences. They also hold the potential to increase value‑for-money by reducing duplicative and unnecessary care. Key actions to advance integrated care include strengthening the governance of care delivery, developing interoperable information systems and aligning financial incentives across providers.
Stressing the need to link electronic health records, the OECD is collecting data to compare post-hospital care performance across countries. Indicators such as mortality rates, readmission rates and medication prescriptions post-hospitalisation offer insight into the effectiveness of care co‑ordination between hospital and community settings, particularly when assessed over longer periods following the initial event (Barrenho et al., 2022[3]). Readmissions are a key metric for evaluating integrated care, with higher rates indicating poorer outcomes.
Figure 6.11 shows mortality and readmission outcomes in the year after discharge following a hospitalisation for ischaemic stroke or chronic heart failure (CHF). On average, among patients admitted with ischaemic stroke in 2021, 59% had survived and were not readmitted to hospital care, 22% had survived but were readmitted to hospital during this period (4% for stroke‑related and 18% for other reasons) and 19% had died. For CHF patients admitted the same year, 41% who survived were not readmitted, while 32% survived but were readmitted (10.4% for CHF-related reasons and 21.3% for other reasons), and 27% died.
For stroke patients, one‑year mortality ranged from below 14% in Slovenia, Sweden and the Netherlands to more than 23% in Estonia, Latvia and Croatia. For CHF patients, one‑year mortality varied from below 20% in Slovenia and Lithuania to above 30% in Czechia, Malta and Latvia. Hospital readmissions within one year of stroke ranged from 2% in Lithuania up to 5% in Latvia for stroke‑related reasons, and from 12% in Italy to 27% in Malta for other causes. For CHF patients, one‑year readmission rates varied from 5% in Latvia to 18% in Slovenia for CHF-related causes and from 15% in Italy to 33% in Malta for other causes.
Approximately one in seven ischaemic stroke survivors will experience a second stroke after one year. Clinical guidelines recommend that ischaemic stroke patients receive medications to reduce hypertension and prevent blood clots (antihypertensive and antithrombotic prescriptions) to reduce greatly the risk of future vascular events. The presence of at least one prescription for these medicines within 18 months post-discharge can show appropriate follow up care after discharge for these patients (Barrenho et al., 2022[3]). Figure 6.12 shows that the prescription rate for antihypertensives for patient discharged after an ischaemic stroke ranged from 63% in Austria to 82% in Sweden, while the prescription rate for antithrombotics varied from 33% in Latvia to 94% in Sweden. Comprehensive diagnosis recording practices for stroke has been identified as one of the driving causes of the Swedish good performance in stroke secondary prevention (Dahlgren, 2017[4]).
