When patients with chronic conditions receive care from multiple providers across different healthcare settings, fragmented services can lead to poor health outcomes, unmet needs, excessive service use and higher costs. On average across OECD countries, based on PaRIS data, only 59% primary care users living with chronic conditions reported good care co‑ordination, with results ranging from 22% in Wales (United Kingdom) to 81% in Switzerland. In response, many countries are developing new models of care to better integrate services – aiming to enhance population health, improve patient experience, reduce costs, support healthcare professionals’ well-being and promote health equity (OECD, 2023[1]).
Optimal integration across levels of care for patients with stroke and chronic heart failure (CHF) reduces unnecessary hospital readmissions and mortality, while improving adherence to appropriate prescribing (Barrenho et al., 2022[2]). Among patients discharged from hospital, indicators such as readmission rates, mortality and compliance with prescription guidelines serve as key measures of how effectively health systems deliver integrated care.
Figure 6.35 presents the share of patients experiencing adverse outcomes within one year of discharge for ischaemic stroke and CHF in 2023. There is substantial cross-country variation in both the level and type of post-discharge outcomes. For stroke patients, on average across OECD countries,15% died and 23% were readmitted within a year, resulting in a combined adverse outcome of 38%. The Netherlands (31%) and Iceland (33%) reported the lowest overall rates, while Czechia (54%) and Denmark (48%) recorded the highest, with particularly high share of mortality and readmissions unrelated to the initial stroke. In nearly all countries, readmissions for conditions other than the original diagnosis account for the largest proportion of post-discharge events.
For CHF, the burden of post-discharge adverse events is consistently higher than for stroke. Iceland reported the lowest overall rate at 24%. In contrast, Norway (71%) and Czechia (69%) recorded the highest, with both mortality and readmissions exceeding the OECD averages. These findings point to opportunities to strengthen transitional care pathways and enhance continuity in chronic disease management.
Between 2013 and 2023, the share of patients who died or were readmitted within a year after discharge declined in most countries for both CHF and stroke. On average across OECD countries, adverse outcome rates fell by about 6 p.p. for CHF and 5 p.p. for stroke. Iceland showed the greatest improvement in both, with CHF rates dropping from 32.6% to 23.1% and stroke rates from 35.3% to 23.2%. Switzerland also saw substantial declines. These trends suggest progress in post-discharge care, with most countries maintaining or improving performance. However, several countries experienced worsening trends, particularly in CHF outcomes. Norway saw a rise in all-cause mortality within one year of discharge – from 23.3% in 2017 to 27.8% in 2023. Canada and Czechia also reported modest but consistent increases in post-discharge mortality, raising concerns about care co‑ordination and primary care capacity.
Patients recovering from ischaemic stroke should receive antihypertensive and antithrombotic medications as part of secondary prevention after hospital discharge. Receiving at least one prescription within 18 months serves as an indicator of how well care is integrated between hospital and community settings (Barrenho et al., 2022[2]). Figure 6.36 shows wide variation in prescribing rates across countries: antihypertensives ranged from 68% in the Netherlands to 83% in Sweden, while antithrombotics ranged from 31% in OECD accession country Croatia to 94% in Sweden. Sweden’s strong performance is likely to reflect effective information transfer across care levels and comprehensive diagnosis documentation (Dahlgren et al., 2017[3]).
